Troponin elevation after black widow spider envenomation

Abstract

Black widow spider envenomation generally results in selflimiting pain that can be treated in the emergency department (ED) with analgesics and benzodiazepines, usually with no further intervention. Occasionally, a patient has to be admitted or treated with antivenom for refractory pain or a venom-induced complication. We present the case of an 84-year-old man who presented to our ED with chest pain and dyspnea after being bitten on the foot by a western black widow spider (Lactrodectus hesperus). His initial cardiac troponin I (cTnI) was elevated at 0.07 ng/ml and continued to rise to a peak of 0.17 ng/ml. He also had rhabdomyolysis, another uncommon complication of black widow envenomation. An elevated cTnI generally signifies myocardial injury and is rarely seen after black widow envenomation. We discuss the possible etiologies for an elevated cardiac biomarker, in this context, and review potentially serious complications of widow spider envenomation presenting with chest symptoms and an elevated cardiac biomarker. RÉSUMÉL'envenimement par piqûre de veuve noire entraîne généralement une douleur qui tend à disparaître spontané-ment et qui peut se traiter au service des urgences (SU) par des analgésiques et des benzodiazépines, habituellement sans autre intervention. Il arrive toutefois que des patients soient hospitalisés ou soient traités par des antivenins pour des douleurs rebelles ou pour des complications causées par le venin. Sera exposé ici le cas d'un homme de 84 ans qui a consulté au SU pour des douleurs thoraciques et de la dyspnée après une piqûre de veuve noire (Lactrodectus hesperus) au pied. Le taux de troponine I cardiaque (t. Ic) à l'arrivée s'élevait à 0,07 ng/ml et a continué d'augmenter pour atteindre un pic de 0,17 ng/ml. Le patient a également souffert de rhabdomyolyse, une autre complication peu fréquente de l'envenimement par piqûre de veuve noire. Une élévation du taux de t. Ic signe généralement une lésion myocardique, et le phénomène s'observe rarement à la suite d'un envenimement par piqûre de veuve noire. Il sera question ici des causes possibles de l'élévation du taux de biomarqueur cardiaque dans le contexte, ainsi que des complications potentiellement graves de l'envenimement par piqûre de veuve noire, qui produit des symptômes de type thoracique et une élévation du taux de biomarqueur cardiaque.

Black Widow Spider Envenomation with Elevated Troponin I Levels

“…It is believed that cardiac effects are induced by the activation of the adrenergic system by latrotoxin, the most dominant component of the venom (5,10). Inflammatory cell infiltrates and cytokine activation cause elevated troponin I levels that leads to myocarditis (11). The troponin I levels increased up to 3.01 ng/mL in the follow-ups of our patient.…”

Widow spiders in the New World: a review on Latrodectus Walckenaer, 1805 (Theridiidae) and latrodectism in the Americas

“…Although ECG changes may be present, damage to the myocardium is uncommon and cardiac manifestations are considered rare. In these uncommon cases, the concentration of troponin is increased, and echocardiographic changes are reported in all studies, but vary according to the report [61,[102][103][104][105]. Cardiogenic pulmonary edema that required mechanical ventilation has also been described [103].…”

“…Rhabdomyolysis is another uncommon condition that can be observed from Latrodectus bites [102,107]. It may be a consequence of generalized hypercontraction and intense muscle cramps that are typical of this envenomation; as a result, renal damage (oliguria and anuria) can occur.…”

“…They suggest that the exhaustion of the noradrenaline after its intense release compromises penile detumescence. Additionally, the increase in acetylcholine from cholinergic nerves causes smooth muscle relaxation and the synthesis of nitric oxide from non-adrenergic and non-cholinergic nerves that promote vasodilation [102,111]. Figure 2 summarizes the symptoms of Latrodectus envenomation.…”