Caracterización clínica y epidemiológica de 200 pacientes con loxoscelismo cutáneo y cutáneo visceral / Loxoscelism: experience in 200 patients

Background: Loxoscelism is an important public health problem in Chile and South America, due to the higher rate of cutaneous-visceral involvement. The diagnosis of loxoscelism is mostly clinical without established diagnostic criteria. There is little evidence to support any treatment used in this condition. Aim: To characterize the clinical features and epidemiology of loxoscelism among patients consulting at the Emergency and Dermatology Services of a clinical hospital between 2013 and 2017. Material and Methods: Review of medical records of patients registered in the electronic clinical record system with a confirmed diagnosis of loxoscelism. Epidemiological, clinical, laboratory tests and treatment variables were analyzed. Results: We reviewed data from 200 patients. Ninety-four percent presented cutaneous loxoscelism and 5.5% cutaneous-visceral loxoscelism. Systemic symptoms were present in 73% of patients with cutaneous-visceral loxoscelism. Patients who developed systemic symptoms had an 18 times higher risk of developing cutaneous-visceral loxoscelism. Laboratory abnormalities were more common in patients with cutaneous-visceral loxoscelism. Not all patients with hematuria had cutaneous-visceral loxoscelism. Most patients required analgesia. Anti-loxosceles serum was not used in any patient. Conclusions: Many questions remain to be answered regarding the diagnosis and treatment of the disease. Studies are required to validate diagnostic criteria for loxoscelism, predictors for visceral involvement and response to treatment.

Experiencia en loxoscelismo cutáneo y cutáneo visceral de manejo hospitalario: clínica, evolución y propuesta terapéutica / Experience in visceral cutaneous and cutaneous loxoscelism of hospital management: clinical, evolution and therapeutic proposal

Resumen Introducción: El loxoscelismo es una patología frecuente en nuestro medio con un amplio espectro de presentaciones y diagnósticos diferenciales, con complicaciones potencialmente graves, e incluso con riesgo de muerte. A la fecha no existe un tratamiento estándar para estos pacientes. Objetivo: Describir las manifestaciones clínicas, principales complicaciones, manejo terapéutico y evolución de pacientes internados por loxoscelismo en un hospital terciario en Chile. Pacientes y Método: Se analizaron todos los pacientes consultantes e internados por loxoscelismo en el Hospital Clínico de la Pontificia Universidad Católica de Chile entre los años 2014 y 2017, evaluados en interconsulta por Dermatología. Revisión de los registros clínicos incluyendo semiología, imágenes, informes de laboratorio y tratamientos efectuados. Resultados: Se registraron 17 casos de loxoscelismo de manejo hospitalario, cuya presentación responde al patrón epidemiológico nacional. La mayoría de los casos fue manejada con antimicrobianos, corticosteroides sistémicos, antihistamínicos y dapsona. De ellos, 11,8% correspondieron a loxoscelismo cutáneo visceral, manejados exitosamente con medidas de soporte, corticosteroides sistémicos y antihistamínicos. El 59% presentó resolución de las lesiones al mes de tratamiento, con cicatriz residual leve o hiperpigmentación postinflamatoria, sin mortalidad en nuestra serie. Discusión: La mayoría de los casos de loxoscelismo cutáneo presentó excelente respuesta y rápida resolución del cuadro tras el tratamiento asociado de corticosteroides sistémicos, antimicrobianos y dapsona, sugiriendo que el uso de estas terapias podría detener la progresión de la necrosis cutánea y prevenir las complicaciones asociadas al loxoscelismo.

Background: Loxoscelism is a common pathology in our environment with a broad spectrum of differential diagnoses and presentations, with potentially serious complications, even to the point of death. To date, there is no standard treatment for these patients. Aim: To describe the clinical manifestations, main complications, therapeutic management, and evolution of loxoscelism in an inpatient setting from a tertiary hospital in Chile. Methods: All patients consulting and hospitalized in the hospital of the Pontificia Universidad Católica de Chile with diagnosis of loxoscelism between 2014 to 2017 and evaluated by dermatologist were included. Review of clinical files, including symptoms, images, laboratory parameters and treatment. Results: We evaluated seventeen inpatient with loxoscelism, whose presentation responds to the national epidemiological pattern. Most cases were managed with antibiotics, systemic corticosteroids, antihistamines, and dapsone. From these, 11.8% corresponded to viscerocutaneous loxoscelism, successfully managed with supportive measures, systemic corticosteroids and antihistamines. Fifty-nine percent healed their cutaneous lesions after one month of treatment, with slight residual scarring or post inflammatory hyperpigmentation, without associated mortality in our series. Discussion: Most cases of cutaneous loxoscelism presented excellent response and rapid resolution of the disease after combined therapy with systemic corticosteroids, antibiotics and dapsone, suggesting that the use of these therapies could stop the progression of cutaneous necrosis and prevent complications associated with loxoscelism.

de araña marrón (Loxosceles laeta). presentación de un caso / Brown spider (Loxosceles laeta) bite. presentation of a case

Se presentó un caso tratado en la Unidad Básica de Salud del poblado Pedras municipio Matoes Do Norte estado Maranhao Brasil, de una gestante de 32.4 semanas con lesión necrótica en la cara interna del muslo derecho provocado por la picadura de una araña marrón. Con el propósito de informar un caso de lesión producida por la picadura de este insecto y revisar la literatura médica se presentó este reporte sobre una gestante de 19 años donde el diagnóstico se estableció mediante estudio epidemiológico y características de la lesión siendo diagnosticada finalmente de loxoscelismo cutáneo, lesión producida por la picadura de araña marrón(AU)

It was presented a case in the Basic Health Unit of Pedras municipality Matoes Do Norte Maranhao Brazil, from a pregnant woman of 32.4 weeks with a necrotic lesion on the inner side of her right thigh caused by the bite of a brown spider. In order to report a case of injury caused by the brown spider bite and review the medical literature, this report is presented on a pregnant woman of 19 years where the diagnosis was established by epidemiological study and characteristics of the lesion being the final diagnosis of Loxoscelism cutaneous lesion produced by the brown spider bite(AU)

Infrared thermography to diagnose and manage venomous animal bites and stings

Abstract INTRODUCTION Infrared imaging (IR) is a noninvasive technique that quantifies body surface temperature, producing a digital color image. IR has been used to study diseases in which skin temperature can reflect the presence of inflammation. METHODS This was an observational pilot study of eight patients envenomed by snakes, spiders, and scorpions. All patients were examined using a thermal camera. RESULTS In all cases, we obtained infrared images that corroborated clinical findings indicating localized effects of venom, specifically inflammation. CONCLUSIONS IR has potential for use as a research, diagnostic, and monitoring tool for localized effects of animal venoms.

Acidente loxoscélico / Loxoscelic accident

Os acidentes com aranhas do gênero Loxosceles podem apresentar variadas evoluções clínicas, dificultando a realização do diagnóstico e a escolha correta de uma medida terapêutica. Este artigo de revisão tem como objetivo abordar os mais importantes mecanismos de evolução, principais desfechos e os tratamentos de escolha para o acidente loxoscélico (AU)

Accidents with Loxosceles genus spiders may have different clinical outcomes, hindering the diagnosis and the correct choice of a therapeutic measure. This review article aims to address the main mechanisms of evolution, main outcomes and treatments of choice for loxoscelic accident (AU)

Aspectos clínicos y epidemiológicos del loxoscelismo en un hospital de primer nivel / Clinical and epidemiological aspects of loxoscelism in a first level hospital

Objetivo. Determinar las características clínicas y epidemiológicas del loxoscelismo en un hospital de primer nivel. Material y Métodos. En un estudio descriptivo y retrospectivo se evaluaron un total de 12 casos con diagnóstico de loxoscelismo en el Hospital I Edmundo Escomel, en el periodo comprendido entreenero de 2008 a abril de 2012. resultados. El 67% de los casos correspondió al sexo femenino, el grupo etario mas afectado fue el de 41-60 años (42%), y el lugar de procedencia fue de la zona urbana en el 58% de los casos. La forma clínica más común fue la cutánea (92%), la ubicación topográfica más común fue en las extremidades (inferiores 33% y superiores 25%), el tiempo transcurrido entre la mordedura y la ayuda médica fue en el 67% de los casos entre las 24 y 48 horas. Las manifestaciones locales más frecuentes fueron edema y eritema en el 100% de casos. El 92% de los pacientes estudiados presento hemoglobinuria. En el tratamiento se utilizó antibióticos (75%), esteroides (100%), bloqueadores H1 (75%) y bicarbonato (83%). Conclusión. El loxoscelismo produce una lesión altamente sugestiva y la suma de los hallazgos clínicos y epidemiológicos pueden establecer el diagnóstico, inclusive si la araña no es identificada o capturada.

Objective. To determine the clinical and epidemiological characteristics of loxoscelism in a first level hospital. Material and Methods. A retrospective and descriptive study was done on 12 cases of loxoscelism in the Hospital I EsSalud Edmundo Escomel, between January 2008 and April 2012. results. 67% of cases where female, the group age most affected was between 41 to 60 year-old (42%), the most frequent locations were areas around the city (58%). The most common lesion was cutaneous (92%). The majority of lesions were in extremities (lower 33% and upper 25%) The disease time until to arrive to the hospital was within the first 24 to 48 hours (67%), the most frequent local manifestations were erythema and edema (100%). Hemoglobinuria was found in 92%. As treatment, it was used antibiotics (75%), steroids (100%), H1 blockers (75%) and sodium bicarbonate (83%). Conclusion. Loxoscelism produce a highlysuggestive lesion and the sum of the epidemiologic and clinical features could establish the diagnosis, even the spider is not identified or captured.

Loxoscelismo cutáneo: revisión narrativa de un problema actual / Cutaneous loxoscelism: narrative review of a current problem

The endemic presence of Loxosceles laeta species in Chile determines a constant validity of loxoscelism in clinical practice. Among their clinical scope, cutaneous loxoscelismis the most common presentation and it usually requires surgical management. The objective of this article is to review basic knowledge, epidemiologic data, clinical and therapeutic knowledge and advances in this disease based on the available evidence. Evidence does not support the routinary use of any pharmacological agent in cutaneous loxoscelism. General therapeutic measures, adequate analgesia, the delimitation of thedermonecrotic area and in cases if needed a conservative surgical approach are recommended. The use of antibiotics should be restricted to cases of concomitant infection. Emphasis should be on prevention of these injuries, stressing the importance of early consultation in the emergency service, and monitoring for signs and symptoms of the systemic compromise. A conservative surgical approach minimizes unnecessary morbidity.

Loxoscelismo cutáneo. A propósito de un caso clínico / Skin loxoscelism. A clinical case report

Loxosceles laeta es una araña de distribución mundial y la necrosis cutánea caracteriza a su mordedura. Las formas sistémicas son de baja frecuencia pero alta mortalidad. El diagnóstico es de sospecha ante una lesión intensamente dolorosa o por la identificación del arácnido. La recomendación para la utilización de suero antiloxosceles no es uniforme. En este artículo reportamos un caso de loxoscelismo a forma cutáneo necrótica que requirió cirugía de debridamiento temprano y con buena evolución. El objetivo es concientizar a los pediatras de la existencia de esta entidad que sólo será diagnosticada tempranamente si pensamos en ella, lo que permitirá el oportuno y adecuado abordaje del paciente.

Accident caused by Centruroides testaceus (DeGeer, 1778) (Scorpiones, Buthidae), native to the Caribbean, in Brazilian airport / Acidente causado por Centruroides testaceus (DeGeer, 1778) (Scorpiones, Buthidae), nativo do Caribe, em aeroporto brasileiro

Describes the case of a 6-year-old girl who was stung by a Centruroides testaceus, a scorpion native to the Lesser Antilles, in the Guarulhos International Airport, São Paulo, Brazil, as she disembarked from a flight coming from the Caribbean. The patient presented only local symptoms (a small area of erythema and pain at the sting site), which were resolved after a few hours with analgesics, without the need for antivenom. Physicians who treat patients stung by scorpions should be alert to the possibility of such accidents being caused by non native species, especially those cases that occur near airports or ports.

Descreve-se um caso de menina de 6 anos de idade picada por um Centruroides testaceus, escorpião nativo das Antilhas, no interior do Aeroporto Internacional de Guarulhos, São Paulo, Brasil, após ter desembarcado de um vôo vindo do Caribe. A paciente apresentou apenas sintomas locais (pequena área de eritema e dor no local da picada), resolvidos em algumas horas com uso de analgésicos, não necessitando receber soro antiveneno. Os médicos que tratam pacientes picados por escorpiões devem estar precavidos quanto à possibilidade dos acidentes serem causados por espécies não-nativas, especialmente nos que ocorrem próximos a aeroportos ou portos.

Imagem / Imagem

Bombeiro, 31 anos, relata ter calçado bota pela manhã e trabalhado por aproximadamente 12 horas seguidas. Ao final desse período, começou a sentir dor progressivamente mais forte, em queimação, no pé direito. Ao retirar a bota e a meia, observou a lesão mostrada na imagem.

Scorpion stings in Turkey: epidemiological and clinical aspects between the years 1995 and 2004 / Picadas de escorpião na Turquia: aspectos epidemiológicos e clínicos entre os anos de 1995 e 2004

The most important health-threatening scorpions found in Turkey are; Androctonus crassicauda, Leiurus quinquestriatus, Mesobuthus gibbosus and M. eupeus species, all of which belong to the Buthidae family. The epidemiological and clinical findings of scorpion stings in Turkey were evaluated between the years 1995 and 2004 based on data recorded in the National Poison Information Center (NPIC). A total of 930 cases were recorded. The cases mostly occurred in the month of July. The gender distribution was 50.22 percent female and 45.48 percent male. It was shown that the 20-29 age group presented more scorpion stings. Most of the stings occurred in Central Anatolia and Marmara regions of Turkey. Patients at the hospital showed signs of localized (pain, hyperemia, edema and numbness) and systemic effects (hyperthermia, nausea and vomiting, tachycardia, shivering and lethargy) but no lethality was notified. According to records, 33 percent of the poisoned patients were treated with antivenin in healthcare facilities.

Os mais importantes escorpiões que comprometem a saúde na Turquia são: Androctonus crassicauda, Leiurus quinquestriatus, Mesobuthus gibbosus e M. eupeus, todos eles pertencentes à família Buthidae. Os achados clínicos e epidemiológicos da picada de escorpiões na Turquia foram avaliados no período entre os anos de 1995 a 2004 baseados em dados do Centro Nacional de Informações de Envenenamentos (NPIC). Foram registrados 930 casos que ocorreram principalmente no mês de julho. A distribuição por sexo foi 50,22 por cento femininos e 45,48 por cento masculinos. Demonstrou-se que o grupo etário de 20 a 29 anos apresentou maior número de picadas de escorpião. A maior parte das picadas ocorreu na Anatólia Central e na região de Marmara, na Turquia. Os pacientes hospitalizados mostraram sinais localizados (dor, hiperemia, edema e confusão mental) e sistêmicos (hipertermia, náusea e vômitos, taquicardia, arrepios de frio e letargia), mas não houve notificação de letalidade. De acordo com os prontuários 33 por cento dos pacientes foram tratados com antiveneno nas unidades de saúde.

Acidente por Rhopalurus agamemnon (Koch, 1839) (Scorpiones, Buthidae) / Accident caused by Rhopalurus agamemnon (Koch, 1839) (Scorpiones, Buthidae)

Acidentes escorpiônicos constituem um sério problema de saúde pública no Brasil. Rhopalurus agamemnon é um grande escorpião do bioma Cerrado, muito abundante em diversas localidades do Brasil Central. A espécie utiliza ambientes campestres e savânicos, sendo comum no interior de cupinzeiros. Entretanto, desaparece de locais onde o cerrado é removido. Os acidentes relatados apresentam sintomas de envenenamentos moderados, mas são baseados em identificações discutíveis. Aqui apresentamos o relato de um acidente seguramente causado por esta espécie. Concluímos que os poucos relatos disponíveis não permitem avaliar a gravidade dos acidentes e o eventual risco deste escorpião para a saúde pública.

Accidents caused by scorpions are a serious public health problem in Brazil. Rhopalurus agamemnon is a large scorpion found in the Cerrado (savanna) biome, and it is very abundant in many localities in central Brazil. The species inhabits open savanna environments, and is common inside termite mounds. However, it disappears from places where the native vegetation has been removed. The accidents reported present moderate symptoms of envenoming, but are based on questionable identifications. Here, we present a report on an accident that was certainly caused by Rhopalurus agamemnon. We conclude that the few reports available do not make it possible to evaluate the severity of such accidents and the possible risk to public health from this scorpion.

Loxoscelismo: revisión de la epidemiología, clínica, diagnóstico y tratamiento actuales / Loxoscelism: a review of the epidemiology, diagnosis and current clinical treatments

Spiders of the genus Loxosceles have a wide world distribution. In Chile, the brown recluse spider Loxosceles laeta, commonly called the "corner spider", is one of the species which causes the clinical syndrome known as loxoscelism, poisoning by the accidental bite of this arachnid. Loxoscelism is characterized by dermonecrotic lesions (cutaneous loxoscelism), which in more severe cases (systemic loxoscelism) may be accompanied by intravascular hemolysis of erythrocytes and renal insufficiency with a high associated mortality. Treatment requires the precocious application of anti-venom, along with complementary measures based on the use of antihistamines, corticoids and antibiotics. The diagnosis, which currently is eminently clinical, should be accompanied by the identification of the spider when possible, due to the lack of diagnostic methods of rapid response applicable at the level of emergency clinics. The introduction of new tools based on recombinant proteins of highly immunogenic components present in the venom is a recently explored alternative. Preventive methods based on avoidance of contact with the spider continue to be the principal mechanism to avoid an endemic pathology with high risk of death in our region. The objective of this revision is to bring up to date fundamental aspects of loxoscelism, especially its epidemiology, diagnosis and clinical treatment.

Las arañas del género Laxosceles, tienen una amplia distribución mundial. En Chile, Laxosceles laeta (comúnmente conocida como “araña de los rincones”) es una de las especies causante del cuadro clínico conocido como loxoscelismo, envenenamiento por la mordedura de este arácnido por accidente. El loxoscelismo se caracteriza por lesiones dermonecróticas (loxoscelismo cutáneo), que en los casos más graves (loxoscelismo sistemáticos), se puede acompañar con hemólisis intravascular de los eritrocitos e insuficiencia renal con elevada mortalidad asociada. El tratamiento requiere la aplicación precoz del antisuero, junto a mediadas complementarias basada con el uso del antihistamínicos, corticoides y antibióticos. El diagnóstico, en la actualidad eminentemente clínico, debe ser acompañado por la identificación de los ejemplares, cuando es posible, ante la falta de métodos diagnóstico de respuesta precoz aplicable a nivel asistencial de urgencia. La introducción de nuevas herramientas basadas en proteínas recombinantes de componentes altamente inmunogénicos presentes en el veneno, es una alternativa explorada recientemente. Las medidas de prevención basadas en evitar el contacto con la araña, sigue siendo los principales mecanismos para evitar una patología endémica y con elevado riesgo de muerte en nuestra región. El objetivo de la presente revisión es actualizar aspectos fundamentales del loxoscelismo, especialmente sobre su epidemiología, clínica, diagnóstico y tratamiento.

Loxoscelismo: epidemiología y clínica de una patología endémica en el país / Loxoscelism: epidemiology and clinical aspects of an endemic patology in the country

Loxosceles es una araña de distribución mundial con características sinantrópicas. Su picadura se caracteriza por necrosis cutánea que, en un bajo porcentaje de casos, se acompaña de manifestaciones sistémicas. En los cuadros sistémicos lamortalidad puede ser elevada. No existen métodos de laboratorio para el diagnóstico asistencial, que se realiza por los signos clínicos y la identificaciónde los ejemplares. El tratamiento específico es la aplicación del antiveneno. El objetivo de esta presentación es brindar una actualización sobre las características de este envenenamiento, su diagnóstico y tratamiento dirigidos hacia el paciente pediátrico.

Loxosceles is a global distribution spider with synanthropic characteristics. It is responsible for skin necrosis that in a low percentage is accompanied by systemic manifestations. Mortality can be high when systemic manifestationsare present. There is no laboratory methods available for diagnostic. Clinical signs and identification of individuals lead to it. The applicationof antivenom is the specific treatment.The objetive of this presentation is to update on the characteristics of this poisoning, its diagnosis and treatment directed toward the pediatric patient.

Asymmetric pulmonary edema after scorpion sting: a case report / Edema pulmonar assimétrico após picada de escorpião: relato de caso

A 12-year-old boy was referred with acute asymmetric pulmonary edema (APE) four-hour after scorpion sting to Emergency department. On admission, the main clinical manifestations were: dyspnea, tachypnea, and tachycardia. Chest x-ray revealed APE predominantly on the right hemithorax. The patient was treated with oxygen, intravenous frusemide and digoxin and discharged on the sixth hospital day in a good condition. This case report emphasizes the occurrence of asymmetric pulmonary edema after severe scorpion envenomation within few hours immediately after the sting.

Menino de 12 anos foi internado no Pronto Socorro, com edema pulmonar assimétrico agudo (APE), quatro horas após picada de escorpião. À admissão, as principais manifestações clínicas foram: dispnéa, taquipnéa e taquicardia. Raio X do pulmão revelou APE predominantemente no hemitórax direito. O paciente foi tratado com oxigênio, frusemida intravenosa e digoxina e teve alta no sexto dia de internação, em boas condições. Este relato de caso enfatiza a ocorrência de edema pulmonar assimétrico algumas horas após a picada.