Article, Cardiology

Myocarditis after black widow spider envenomation

Case Report

Myocarditis after black widow spider envenomation Abstract

The black widow spider (BWS), which is a member of

the arthropod family, is widely distributed on earth. Black widow spider bites can cause a wide variety of signs or symptoms in humans, but the cardiovascular manifesta- tions are relatively rare except hypertension/hypotension and bradycardia/tachycardia. We report on a 65-year-old man who experienced myocarditis after BWS envenoma- tion, which is extremely rare. He complained of chest pain after the BWS bite, and Electrocardiography was consistent with a 0.5-mm ST-segment elevation in leads II, aVF, and V3 through V6 and accompanying augmentation in T-wave amplitude in leads V3 through V6 without reciprocal changes. Creatine kinase-MB, tropo- nin-I, and aspartate aminotransferase levels peaked at 98 IU/L, 6.1 ng/mL, and 62 U/L, respectively. His ECG readings and cardiac enzymes returned to normal with supportive treatment, and he was discharged with Complete recovery. To the best of our knowledge, the present case is the third in the literature reporting myocarditis and the first reporting ST-segment elevation and accompanying augmentation in T-wave amplitude after BWS envenomation. In addition to usual measures, we recommend ECG and cardiac-specific enzyme follow- up for every patient envenomated by BWS for potentially fatal cardiac involvement.

The black widow spider (BWS) is a member of the arthropod family and is widely distributed on earth, being especially numerous in China, Middle Asia, North and South America, India, Australia, and Southern Europe. It usually emerges between April and November, and its venom is quite toxic [1-5]. In cases of BWS bites, the sensation is typical, and the adults tolerate the bites worse than children. Bitten individuals may exhibit cramps at the large muscle groups; headache; dyspnea; and severe abdominal, back, and trunk pains. In addition, hypertension, diaphoresis, vomiting, diarrhea, photophobia, and dyspnea may be observed.

Spiders are natural enemies of insects; however, in humans, spiders can cause variable clinical scenarios from local damage to very Serious conditions including death.

Detailed description of the clinical features of human widow spider bites have been reported, but cardiovascular manifes- tations are relatively rare [1-3]. Here, in the present article, we report a case of myocarditis after BWS envenomation.

A 65-year-old man was bitten by a spider while working in a farm field. He suddenly felt a bite on his left foot and then saw a black spider on the ground. Half an hour later, he felt dizziness, nausea, and strong headache. His son and the local veterinarian, who saw the spider, confirmed that it was a Latrodectus, commonly known as BWS.

On presentation to the emergency department (ED) approximately 2 hours after the spider bite, he was anxious and diaphoretic. He had vomited repeatedly and was complaining of nausea and strong headache. His vital signs were as follows: blood pressure, 115/75 mm Hg; pulse rate, 101/min; respiratory rate, 18/min; and temperature,

37.7?C. The result of his physical examination was within normal limits. The result of his Electrocardiography was normal except sinus tachycardia. The chest radiograph was normal. Laboratory findings were within normal limits. Approximately half an hour after admission to the ED, the patient started to complain of chest pain. His second ECG revealed 0.5-mm ST-segment elevation in leads II, aVF, and V3 through V6 and accompanying augmentation in T-wave amplitude in leads V3 through V6 without Reciprocal changes (Fig. 1). The patient was transferred to the coronary care unit. Creatine kinase-MB, troponin-I, and aspartate aminotransferase levels peaked at 98 IU/L, 6.1 ng/mL, and

62 U/L, respectively. His Echocardiographic examination result was normal. Coronary angiography revealed Normal coronary arteries. He was given supportive treatment, and approximately 12 hours after admission to the coronary care unit, his symptoms subsided. During follow-up, ST elevations and increase in T-wave amplitude returned to normal within 4 hours. His blood chemistry returned to the normal limits within 12 hours, and he was discharged without any complications.

Myocardial involvement after a scorpion bite has been well described, but it is extremely rare after a spider bite [6,7].The present article reports a very rare case of myocarditis caused by BWS envenomation.

Detailed descriptions of the clinical features of BWS bites have been reported, but Cardiovascular manifestations are relatively rare except hypertension/hypotension and bradycardia/tachycardia [1-3,8]. So far, only 2 cases of

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Fig. 1 Second ECG of the patient after he had complained of chest pain. Note 0.5-mm ST-segment elevation in leads II, aVF, and V3 through V6 and accompanying augmentation in T-wave amplitude in leads V3 through V6 without reciprocal changes. His first ECG on admission to the ED was normal.

myocardial involvement associated with BWS envenoma- tion have been reported. In the first one, a transient and resolved case of myocarditis after a BWS bite had been reported from Italy in a 16-year-old patient [9]. In the second one, a 19-year-old woman died because of myocarditis after BWS bite, which was reported from Greece [10]. To the best of our knowledge, our case is the third in the literature.

The major component of the venom is ?-latrotoxin, which is thought to be a protein causing Catecholamine release at adrenergic nerve endings and depleting acet- ylcholine at motor nerve endings [5,10]. Although ?– latrotoxin mostly affects the nervous system, it can also affect a variety of organs, including the heart. The exact mechanism of myocarditis after BWS envenomation is not known; however, catecholamine surge, direct toxic effect of the ?-latrotoxin, and hypersensitivity reaction could be among possible mechanisms, as discussed previously [3,5,8-10].

Although BWS is found widely almost all over the world, 2 previously reported cases of myocarditis and our

case after BWS envenomation are all from the Southern Europe region. This is interesting because there may be a difference in the structure of ?-latrotoxin depending of the region where the BWS lives, therefore designating the major target organ of the venom in the victim. In our case, the main clinical manifestations of the BWS bite were associated with Cardiovascular complaints rather than systemic complaints such as cramps at the large muscle groups; dyspnea; and severe abdominal, back, and trunk pains. This is important because although unlikely, myocardial involvement may be the only complication of a BWS bite, necessitating physicians to be aware of this possibility.

electrocardiographic abnormalities, which can be observed after BWS envenomation, vary, including slurring of the QRS with ST- and T-segment depression, prolonged QT interval, and atrial fibrillation [8,10]. However, as stated in our article, ST-segment elevation in leads II, aVF, and V3 through V6 and accompanying augmentation in T-wave amplitude in leads V3 through V6 without reciprocal changes has not been reported previously.

Case Report

Treatment of BWS-envenomated patients, whether cardi- ovascular manifestations are present or absent, is supportive

References

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and uses antivenom in selected cases. In our case, the patient was treated with supportive measures because antivenom is not available in our country. Luckily, he recovered with supportive treatment, which ended with death in a recently presented case [10].

In conclusion, to the best of our knowledge, the present case is the third in the literature reporting myocarditis and the first reporting ST-segment elevation and accompanying augmentation in T-wave amplitude after BWS envenoma- tion. In addition to usual measures, we recommend ECG and cardiac-specific enzyme follow-up for every patient enve- nomated by BWS for potentially fatal cardiac involvement.

Ibrahim Sari MD Suat Zengin MD Vedat Davutoglu MD Cuma Yildirim MD Nurullah Gunay MD

Departments of Cardiology and Emergency Medicine Gaziantep University School of Medicine

Gaziantep TR-27310, Turkey E-mail address: [email protected]

doi:10.1016/j.ajem.2007.09.012

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