Severe Intravascular Hemolysis Associated With Brown Recluse Spider Envenomation:A Report of Two Cases and Review of the Literature

Abstract

Envenomation by the brown recluse spider (loxoscelism) is classically associated with a necrotic ulcer. Systemic manifestations occur in a minority of cases, but are generally mild and self-limited. The hematologic complications of brown recluse spider bite range from mild hemolysis to fulminant intravascular hemolysis with or without evidence of disseminated intravascular coagulation. Intravascular hemolysis is a rare but occasionally lethal complication of brown recluse spider envenomation. This article presents two cases of severe hemolysis associated with loxoscelism occurring in two young women in Memphis, Tennessee. The second documented death in an adult from severe hemolysis due to a brown recluse spider bite is reported. A review of the literature emphasizing the pathogenic mechanisms of spider bite hemolysis is also included.

Successful Use of Plasma Exchange for Profound Hemolysis in a Child With Loxoscelism

“…1 Although most of the reported clinical manifestations are limited to dermo-necrotic effects, severe systemic loxoscelism has been reported with fulminant intravascular hemolysis, disseminated intravascular coagulopathy, and multiorgan system failure. [2][3][4][5][6] In almost all cases, supportive care with red blood cell (RBC) transfusions, intravenous fluids, and local wound care are sufficient to provide full recovery. 1,7,8 In more severe cases, hyperbaric oxygen, 9 dapsone, 10,11 and antivenom 12,13 have been used with variable success.…”

Brown Recluse Spider Bites

“…They speculated that the resulting lysis of the red blood cells was accomplished through an interaction between this component and complement factors contained in human serum. Conclusive evidence of the lytic activity of brown recluse venom on human red blood cells was described by Forrester et al 27 Wtlliams and coworkers 28 …”

Loxoscelism: Old obstacles, new directions

“…59,65 From 1958 to 1995, only 39 cases of hemolysis were found, with 6 of those cases resulting in death. 69 However, in Peru, Chile, and the Santa Catarina state of Brazil, the presence of viscerocutaneous loxoscelism is higher. 4 This difference exists because L reclusa, the predominant species in the United States, seldom causes the systemic illness that L laeta, the predominant South American species, does.…”

“…However, the systemic illness soon progresses, with diarrhea, vomiting, coagulopathies, disseminated intravascular coagulation, 7,66 hemolysis, petechia, 1,8,67 thrombocytopenia, and urticaria. 14,22,23,37,58,68,69 Oliguria and dark urine are suggestive of the resultant intravascular hemolysis 2,4,69 and rhabdomyolysis, 52 which can cause profound anemia and acute renal failure. Although most authors believe this occurs 48 to 72 hours after envenomation, it has occurred as early as 24 hours.…”

“…Although most authors believe this occurs 48 to 72 hours after envenomation, it has occurred as early as 24 hours. 14,23,69,70 The prevalence of viscerocutaneous loxoscelism ranges from 0.7% to 27% and varies geographically ( Table 2). In North America, the systemic illness is rare, with a low incidence of mortality.…”