ILLUSTRATIVE CASE
Recognition and Successful Treatment of Priapism and Suspected Black Widow Spider Bite With Antivenin Sheila Choudhury Goel, MD, FAAP,*† Mouhammad Yabrodi, MD,† and James Fortenberry, MD, FAAP† Abstract: Priapism, although uncommon in preadolescent children, is considered a true emergency. Envenomation by a black widow spider bite has been reported to induce priapism as a manifestation of its toxicity. Early recognition and timely administration of antivenin have been reported to be effective in relieving priapism. Clinicians who care for children need to be aware of this unusual presentation. The diagnosis is traditionally from either direct observation of a spider bite or capture of a spider. We report a case of a previously healthy 2-year-old boy who presented with severe irritability, leg cramps, and stomachache. The diagnosis of a likely black widow spider envenomation was made on the basis of clinical suspicion and suggestive physical findings in absence of demonstrated exposure. This case highlights the importance of early recognition and successful resolution of symptoms with administration of antivenin and supportive care. Key Words: spider bites, priapism, antivenins (Pediatr Emer Care 2014;30: 723–724)
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riapism is defined as a potentially painful condition in which penile erection occurs and does not return to a flaccid state despite the absence of physical and psychosocial stimulation.1 Priapism, although uncommon in preadolescent children, is considered a true emergency.2 Rapid assessment and treatment of priapism are important to minimize sequelae. The differential diagnosis of priapism in children includes hematological illnesses (sickle cell anemia, leukemia, and thalassemia), spinal shock, penile trauma, and drugs adverse effect (α-blockers, cocaine, phosphodiesterase type 5 inhibitors, etc).3 Envenomation from a black widow spider (BWS) Latrodectus mactans has been reported to induce priapism as a manifestation of its toxicity.4–6 Timely administration of antivenin has been reported to be effective in relieving priapism in patients with observed BWS bites confirmed by capture of the spider or direct observation of the spider bite.6–8 We report recognition of likely BWS envenomation, on the basis of clinical suspicion and suggestive physical findings in the absence of demonstrated exposure, and successful treatment with BWS antivenin. We also report delayed complications of antivenin administration.
CASE A previously healthy 2-year-old boy with penile erection for 9 hours that was associated with abdominal pain was brought to an outside emergency department (ED). His parents reported that he had complained of pain in his diaper area after returning from walking with his father in the woods. He had also been unobserved in an outhouse on the family property. Initially, his mother noticed a red rash with some scrotal swelling. In the ED, he received intravenous fluids and 1 dose of diphenhydramine. From the *Department of Pediatric Emergency Medicine, Children’s Healthcare of Atlanta and †Emory University School of Medicine, Atlanta, GA. Disclosure: The authors declare no conflicts of interest. Reprints: Sheila Choudhury Goel, MD, Emory University, 1405 Clifton Road, Atlanta, GA 30322 (e‐mail:
[email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 30, Number 10, October 2014
A testicular ultrasound was also performed and revealed no evidence of torsion or abnormality. The patient was discharged home with pain medications. After returning home, the child's penile and abdominal pain worsened, and he also developed headache and vomiting. Nine hours after initial symptoms, he was brought by his parents to the ED at Children's Healthcare of Atlanta for a second assessment. On presentation to the ED, the patient was afebrile, tachycardic, and hypertensive, with a heart rate of 140 beats per minute and a blood pressure of 140/70 mm Hg. Physical examination revealed an irritable, crying, alert child with neck stiffness without other meningeal signs, abdominal wall rigidity, and swelling of both feet. He had an erect penis with significant tenderness to palpation. His perineal area and lower abdomen were tender with an erythematous macular rash. In addition, 2 puncture marks approximately 4- to 5-mm apart were noted along with a ringlike surrounding erythema (Fig. 1). His complete blood cell count as well as differential and serum electrolytes were normal. He was given morphine for pain relief, diazepam for anxiolysis, and intravenous fluids. These interventions did not provide any improvement in the priapism. Pediatric urology was consulted and did not recommend surgical intervention. The finding of priapism in the absence of other etiology together with the puncture wounds discovered on his back suggested the possibility of a BWS bite. The patient was admitted to the pediatric intensive care unit. The state Poison Control Center was consulted and concurred with recommendations for antivenin therapy because of the failure of symptomatic treatment. Risks and benefits of antivenin were discussed with the family who gave consent for treatment. Antivenin for L mactans (Merck Pharmaceuticals, Whitehouse Station, NJ) was administered after pretreatment with diphenhydramine. Within 60 minutes of antivenin administration, the patient's priapism resolved. His abdominal pain, rash, and headache resolved for the next 3 hours. The patient was discharged home symptom-free 14 hours after admission to the pediatric intensive care unit. The patient returned to the ED 5 days later with a generalized nonpruritic blanching urticarial exanthem. His symptoms were considered consistent with mild serum sickness and were treated with oral diphenhydramine. His rash persisted, and at follow-up visit, he received prednisolone and ranitidine with complete resolution.
DISCUSSION Priapism in young boys is quite uncommon.1 Priapism occurs when there is either unregulated arterial inflow to the penis or persistent obstruction of venous outflow. As a result, priapism can be classified as high flow (nonischemic) or low flow (ischemic). The latter represents most cases and is most commonly seen in boys with sickle cell disease. Low-flow priapism is a consequence of the sickling of erythrocytes within the venous sinusoids of the corpus cavernosum and is considered a medical emergency. In high-flow (nonischemic) priapism, the penis www.pec-online.com
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to 7%.13 However, acute hypersensitivity reactions can occur and be potentially life-threatening. Two reports of death in adults have been documented after BSW antivenin administration.5,6,14 In spite of these reports, antivenin is still considered to be safe and effective in rapidly relieving symptoms in cases of severe envenomation.7 Pretreatment or therapy with antihistamines and corticosteroids has been recommended to blunt hypersensitivity reactions.8 Our patient demonstrated symptoms of mild serum sickness but responded well to treatment.
CONCLUSIONS
FIGURE 1. Two puncture marks approximately 4-5 mm apart with surrounding erythema were noted on lower back.
typically is neither fully rigid nor painful and does not require emergency medical attention.9 The BWS is common in many regions of North America. Black widow spider envenomation has been considered very dangerous and even deadly, especially among children. The venom is a neurotoxin, with affected humans most commonly manifesting symptoms such as severe skeletal muscle pain, abdominal pain, cramping, and autonomic disturbances such as diaphoresis and hypertension. Children and the elderly are considered at high risk for mortality and are typically more symptomatic than other age groups. Supportive treatment of BWS envenomation with opiates and benzodiazepines for pain has shown some benefit in mild to moderate cases. Calcium gluconate previously was considered the mainstay of therapy but is no longer recommended after being shown to be ineffective.5 Priapism is a symptom uncommonly reported with BWS envenomation.5 The mechanism of priapism induced by the BWS has not been clearly described but is believed to be secondary to effects of venom on neurotransmitters affecting blood flow within the penis.4,10 Parenteral opioids and L mactans antivenin are considered to be the most effective therapies for severe cases of priapism to eliminate intractable pain and to improve other signs and symptoms from BWS envenomation including priapism.5,11 A small number of case reports have been published previously reporting priapism in children secondary to BWS bites, which were successfully treated with antivenin infusion.4,6,12 All cases reported resolution of symptoms without adverse reactions. Our patient demonstrated similarly rapid resolution of erection within 60 minutes, suggesting a proximate cause of relief. Black widow spider antivenin is derived from the blood serum of healthy horses immunized against the venom of BWSs.11 Most reports show that BSW antivenin is well tolerated, particularly in the pediatric population. Delayed allergic reactions, including serum sickness, are rare because of the low volume of foreign protein infused during BSW antivenin administration. In 1 Australian study using antivenin to the red black spider (Latrodectus hasselti), the incidence of serum sickness was 1%
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We report a case of a patient with a likely BWS bite whose diagnosis was suggested by the presence of priapism. Despite the absence of observation of a spider bite, a suggestive history of being in a wooded area as well as physical signs of priapism and abdominal pain associated with findings suspicious for bite marks led to the diagnosis of a likely BWS bite, treatment with BWS antivenin, and rapid resolution of symptoms. Awareness of potential serum sickness with serum sicknesslike reaction with BWS antivenin is important. REFERENCES 1. Pitetti RD, Nangia A, Bhende MS. Idiopathic priapism. Pediatr Emerg Care. 1999;15:404–406. 2. Jesus LE, Dekermacher S. Priapism in children: review of pathophysiology and treatment. J Pediatr (Rio J). 2009;85:194–200. 3. Burnett AL, Bivalacqua TJ. Priapism: current principles and practice. Urol Clin North Am. 2007;34:631. 4. Stiles AD. Priapism following a black widow spider bite. Clin Pediatr (Phila). 1982;21:174–175. 5. Clark RF, Wethern-Kestner S, Vance MV, et al. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. 1992;21:782–787. 6. Hoover NG, Fortenberry JD. Use of antivenin to treat priapism after a black widow spider bite. Pediatrics. 2004;114:e128–e129. 7. Offerman SR, Daubert GP, Clark RF. The treatment of black widow spider envenomation with antivenin Latrodectus mactans: a case series. Perm J. 2011;15:76–81. 8. Clark RF. The safety and efficacy of antivenin Latrodectus mactans. J Toxicol Clin Toxicol. 2001;39:125–127. 9. Aboseif SR, Lue TF. Hemodynamics of penile erection. Urol Clin North Am. 1988;15:1–7. 10. AT Tu. Venoms: Chemistry and Molecular Biology. New York, NY: John Wiley and Sons; 1977:490–496. 11. Daly FF, Hill RE, Bogdan GM, et al. Neutralization of Latrodectus mactans and L. hesperus venom by redback spider (L. hasseltii) antivenom. J Toxicol Clin Toxicol. 2001;39:119–123. 12. Quan D, Ruha AM. Priapism associated with Latrodectus mactans envenomation. Am J Emerg Med. 2009;27:759.e1–759.e2. 13. Sutherland SK, Trinca JC. Survey of 2144 cases of red-back spider bites: Australia and New Zealand, 1963–1976. Med J Aust. 1978;2:620–623. 14. Murphy CM, Hong JJ, Beuhler MC. Anaphylaxis with Latrodectus antivenin resulting in cardiac arrest. J Med Toxicol. 2011;7:317–321.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.