Tennessee Poison Center, Nashville, TN, USA.
Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
Clin Toxicol (Phila). 2020 Dec;58(12):1297-1305. doi: 10.1080/15563650.2020.1739701. Epub 2020 Mar 18.
Brown recluse spider (BRS) () envenomation can cause local dermonecrotic lesions, constitutional symptoms, and potentially fatal hemolysis (i.e., cutaneous-hemolytic loxoscelism). As the incidence of hemolysis is low and the spider habitat is limited, little is known regarding the clinical course of cutaneous-hemolytic loxoscelism. We performed a retrospective observational study of patients following BRS envenomation over an eight-year period. Demographics, clinical course, laboratories, and interventions were assessed. Wilcoxon rank-sum tests and Pearson chi-square tests were used in the univariate analyses. Logistic regression assessed the independent contribution of symptoms in a multivariate analysis. Of the 97 patients, 40.2% ( = 39) developed hemolysis; the majority (66.7%) were 18 years old or younger. Univariate analysis revealed that constitutional symptoms were associated with hemolysis, but multivariate analysis showed only myalgia (aOR: 7.1; 95% CI: 2.2-22.7; < .001) and malaise (aOR: 12.76; 95% CI: 1.4-119.9; = .026) were independently associated with hemolysis. The median time to hemolysis onset was 1.0 days (IQR: 1.0-2.5) and all occurred within a week of envenomation. Hemolysis durations were longer in patients DAT positive for IGG antibodies (7.5 vs. 4.0 days; = .042). Most (76.9%) of hemolyzing patients received blood. In patients with cutaneous-hemolytic loxoscelism, hematuria occurred in 32.4%, rhabdomyolysis occurred in 60.9%, and elevated transaminases with normal hepatic synthetic function occurred in 29.4% but all of these patients developed rhabdomyolysis. Hemolysis was both intravascular and extravascular. Complications (hyperkalemia, INR ≥2.0, metabolic acidosis requiring bicarbonate, hypotension requiring vasopressors, and hypoxia requiring intubation) occurred only in patients with profound hemolytic anemia (hemoglobin <4 g/dL); one patient died. Constitutional symptoms occur in both cutaneous and cutaneous-hemolytic loxoscelism, although they occur more frequently in patients who develop hemolysis. Children may be at a higher risk of hemolysis after envenomation. Renal involvement (as evidenced by hematuria) and rhabdomyolysis may occur more frequently than has been previously reported. Hemolysis was both intravascular and extravascular.
棕色遁蛛（BRS）螫伤可导致局部皮肤坏死性病变、全身症状和潜在致命的溶血性贫血（即皮肤溶血性罗索利马中毒）。由于溶血性贫血的发生率较低，且蜘蛛栖息地有限，因此对于皮肤溶血性罗索利马中毒的临床过程知之甚少。我们对 8 年来 BRS 螫伤患者进行了回顾性观察性研究。评估了人口统计学、临床过程、实验室和干预措施。单变量分析采用 Wilcoxon 秩和检验和 Pearson 卡方检验。多变量分析采用 logistic 回归评估症状的独立贡献。97 例患者中，40.2%（39 例）发生溶血性贫血；大多数（66.7%）患者为 18 岁或以下。单变量分析显示，全身症状与溶血性贫血相关，但多变量分析仅显示肌痛（OR：7.1；95%CI：2.2-22.7； < .001）和不适（OR：12.76；95%CI：1.4-119.9； = .026）与溶血性贫血独立相关。溶血性贫血发病的中位时间为 1.0 天（IQR：1.0-2.5），所有患者均在螫伤后 1 周内发病。DAT 对 IGG 抗体呈阳性的患者溶血性贫血持续时间较长（7.5 天 vs. 4.0 天； = .042）。大多数（76.9%）发生溶血性贫血的患者接受了输血。在发生皮肤溶血性罗索利马中毒的患者中，血尿发生率为 32.4%，横纹肌溶解症发生率为 60.9%，正常肝合成功能的转氨酶升高发生率为 29.4%，但所有这些患者均发生横纹肌溶解症。溶血性贫血既有血管内也有血管外。仅在严重溶血性贫血（血红蛋白 <4 g/dL）患者中出现并发症（高钾血症、INR ≥2.0、需要碳酸氢盐治疗的代谢性酸中毒、需要升压药治疗的低血压和需要插管治疗的缺氧），有 1 例患者死亡。全身症状发生在皮肤和皮肤溶血性罗索利马中毒患者中，但在发生溶血性贫血的患者中更常见。儿童在螫伤后可能有更高的发生溶血性贫血的风险。肾脏受累（表现为血尿）和横纹肌溶解症的发生率可能高于以往报道。溶血性贫血既有血管内也有血管外。
