Acute Generalized Exanthematous Pustulosis and Coombs‐Positive Hemolytic Anemia in a Child Following Loxosceles reclusa Envenomation

Abstract

Previously reported cases of acute generalized exanthematous pustulosis secondary to brown recluse spider bite have been questioned due to lack of identification of the spider or because of the concomitant administration of antibiotics. We report a 9-year-old boy who arrived at the emergency department with a confirmed Loxosceles reclusa bite to the neck. On the third day of hospitalization, he developed hundreds of monomorphous, sterile pustules, initially in intertriginous areas. The eruption disseminated and was followed by pinpoint desquamation typical for acute generalized exanthematous pustulosis. During this he also developed late onset Coombs-positive hemolytic anemia and systemic loxoscelism. Sphingomyelinase in Loxosceles venom induces the production of interleukin-8 and granulocyte-macrophage colony-stimulating factor, cytokines involved in the pathogenesis of acute generalized exanthematous pustulosis, providing a mechanism by which Loxosceles reclusa bite may trigger acute generalized exanthematous pustulosis. We suggest that this case adds Loxosceles envenomation to the spectrum of agents that can trigger acute generalized exanthematous pustulosis.

Defining the complex phenotype of severe systemic loxoscelism using a large electronic health record cohort

“…This suggests that although adults suffer from envenomation from brown recluse spiders more frequently (which was also seen in our data), children are subject to a much more severe reaction. Prior literature shows more frequent case reports of systemic loxoscelism occurring in pediatric individuals[4, 24–26], and this large retrospective review corroborates that children are at greater risk for systemic loxoscelism.…”

TCTP from Loxosceles Intermedia (Brown Spider) Venom Contributes to the Allergic and Inflammatory Response of Cutaneous Loxoscelism

“…Clinical symptoms of envenomation include histamine-related responses; although they are less frequent, there are reports of hypersensitivity or even allergic reactions after spider bites [9,10]. The presence of histamine in the envenomation site of Loxoscelism can cause edema and endothelial changes such as increased vascular permeability and vasodilation, which contribute to the systemic dispersion of venom components and exacerbate the inflammatory response triggered by the bite [7,8].…”

“…Negative control mice were injected with the same volume of PBS (30 µL). Edema was evaluated by examining changes in paw thickness using a calibrated digital micrometer (Digimess, São Paulo, SP, Brazil) at the following time points: immediately after subcutaneous injection (t zero), 5,10,20,30,60,120,240,360, and 720 min after injection. Results are shown as mean ± s.e.m of one representative experiment from three independent biological replicates.…”

“…TCTP proteins are known as histamine releasing medium with 10% FCS. After 16 h, cells were washed, and the medium was replaced by Tyrode's buffer containing LiRecTCTP (10,50, and 100 µg/mL) with or without cromolyn (10 µM), total venom of L. intermedia (10,50, and 100 µg/mL), 48/80 compound (100 µg/mL) (positive control), and PBS or the recombinant toxin LiRecDT1H12A (100 µg/mL) (as negative controls) for 2 h at 37 • C in a humidified 5% CO 2 incubator. From each experimental sample to be quantified, five aliquots (10 µL) of the supernatants were taken as pentaplicates to another microwell plate.…”

Laboratory Testing in Monitoring the Effects of Brown Recluse Spider Bites

“…One study suggested that interleukin-8, the factor that attracts neutrophils, and granulocyte-macrophage colony stimulating factor, the cytokine that stimulates granulocyte production, might be involved in this process. 3,12,13 For patients requiring blood products, packed red blood cells should be used in place of fresh frozen plasma or cryoprecipitate, since both contain complement and may worsen hemolysis. 7…”