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CASE REPORT
J Res Med Sci 2018,  23:28

Misdiagnosis of spider bite in a 3-year-old child


1 Department of Pediatric, Medical Toxicology Center, Imam Reza Hospital, Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran
2 Department of Clinical Toxicology, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
3 Department of Pediatric Nephrology, Dr. Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
4 Clinical Research Development Unit, School of Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Submission03-Feb-2016
Date of Decision07-May-2016
Date of Acceptance02-Jul-2016
Date of Web Publication27-Mar-2018

Correspondence Address:
Dr. Anoush Azarfar
Mashhad University of Medical Sciences, Mashhad
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1735-1995.228585

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  Abstract 

Abdominal pain is a common complaint among children with a vast differential diagnosis. Hip pain is also a nonspecific sign. Here, we present a case of a 3-year-old boy with a complaint of abdominal pain and pain in both hips, much on the right one. After evaluations, the diagnosis was a spider bite.

Keywords: Abdominal pain, children, spider bite


How to cite this article:
Alizadeh A, Vahabzadeh M, Azarfar A, Ravanshad Y. Misdiagnosis of spider bite in a 3-year-old child. J Res Med Sci 2018;23:28

How to cite this URL:
Alizadeh A, Vahabzadeh M, Azarfar A, Ravanshad Y. Misdiagnosis of spider bite in a 3-year-old child. J Res Med Sci [serial online] 2018 [cited 2018 Dec 11];23:28. Available from: http://www.jmsjournal.net/text.asp?2018/23/1/28/228585




  Introduction Top


Abdominal pain is a common complaint in children which has a vast differential diagnosis. Hip pain is also a nonspecific sign.

Spider bite is one of the differential diagnoses. Since the time of Aristotle, spiders were known. One of the most dangerous types is black widow spider or Latrodectus tredecimguttatus. Typically, the female is larger and more dangerous than male. After a spider bite, sharp pain as a pinprick occurs in the bite site, and then the pain spreads contiguously, for example, from the hand to the arm. Other signs and symptoms include generalized myalgia, pain on the back, chest, and abdomen, and vomiting and head ache. In addition, muscle rigidity and cramp are common. Abdominal wall may be severe and may be confused with surgical problem, especially in children.

Here, we present a case of a 3-year-old boy with a chief complaint of abdominal pain and pain on both hips, much on the right side, who was misdiagnosed at the beginning.


  Case Report Top


A 3-year-old boy (from Torbat-e Jam, Khorasan, Iran) with a chief complaint of abdominal pain and pain in both hips, much on the right side, was presented to the Pediatric Emergency Department of Imam Reza Hospital in Mashhad, Iran. The patient was examined in the Pediatric Emergency Unit. He had mild fever and severe tremor, and on examination, abdominal distention and severe sweating were overtly observed. His vital signs were respiratory rate = 32/min, pulse rate = 89/min, blood pressure = 139/93 mmHg, and temperature = 36.8°C. The history was negative for trauma, use of drugs, previous diseases, or fever. The initial examination of the hip and abdomen had no important clinical symptoms except for abdominal distention. Generalized tremor and abdominal pain continued. Imaging was performed, and the chest and abdominal radiography showed generalized ileus. Sonography of the abdomen and hip was normal. Laboratory analysis was also performed, and the urine analysis was normal. Further laboratory data are shown in [Table 1].
Table 1: Laboratory evaluations of the patient on arrival to the emergency department

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Given the high prevalence of  Brucellosis More Details in Iran, an evaluation utilizing Wright and 2ME standard tests was performed which was negative. The abdominal pain continued, so abdominal sonography was performed and the result was normal. The imaging for kidney, urine, and bladder was normal too. Therefore, according to the laboratory data and imaging, several nondigestive causes of abdominal pain in children such as pneumonia, hydronephrosis, psoas abscess, pelvic osteomyelitis, and pyelonephritis were ruled out. Pediatric surgical consult was requested for the patient and the surgical problems were also ruled out.

Due to the ongoing symptoms such as severe abdominal distention and tremor, a toxicology counseling was requested. On a second history taking from the parents, we found that the patient's father was a farmer and the boy was in the farm with his father prior to the onset of the symptoms. There was also a hesitant history of sudden burning sensation on the right malleoli, hence the diagnosis was made based on the history and symptoms as a spider bite. After the use of acetaminophen and midazolam with appropriate dose, pain was recovered, and the patient discharged without any complaint after 4 days.


  Discussion Top


L. tredecimguttatus, also known as red back spider or black widow spider, has a neurotoxin named α-latrotoxin which triggers a cascade of events including intracellular activation and exocytosis of norepinephrine, dopamine, neuropeptides, acetylcholine, glutamate, and gamma-aminobutyric acid.[1]

According to numerous publications, following the widow spider (Latrodectus sp.) envenomation, local pain, erythema, abdominal pain, rigidity, hypertension, and diaphoresis can be observed.[2],[3] The regional lymph nodes often become swollen and tender within 30 min. General effects include nausea, vomiting, and sweating, but coma and respiratory failure scarcely happen.[3]

Based on a study conducted on this type of envenomation in children, during summer and afternoon, 74% were poisoned by the spider at home, and the anatomical areas mostly affected were arms, hands, and thorax. The common signs and symptoms in the infants were irritability, constant crying, hypersalivation, agitation, erythema on wounded areas, and seizures. Among elementary school children and teenagers, signs of envenomation included local pain in the envenomation area, abdominal and thoracic muscle spasms, fine tremor, and residual signs.[4]


  Conclusion Top


Diagnosis of latrodectism must be made based on the clinical and epidemiological data. Other diagnosis such as surgical acute abdomen, renal colic, meningitis, tetanus, or opioids withdrawal would entail an incorrect treatment. Increasing the knowledge about the symptoms of spider bite among health-care providers is essential.[5],[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Riley BD, Pizon AF. SNAKES and other reptiles. In: Nelson LS, Levin LA, Howland MA, Hoffman Rs, Goldfrank L R, Flomenbaum N, et al., editors. Goldfrank's Toxicologic Emergencies. 9th ed. Under the united state copyright: McGraw-Hill; 2011. p. 1562-3.  Back to cited text no. 1
    
2.
Nordt SP, Clark RF, Lee A, Berk K, Lee Cantrell F. Examination of adverse events following black widow antivenom use in California. Clin Toxicol (Phila) 2012;50:70-3.  Back to cited text no. 2
[PUBMED]    
3.
Monzavi SM, Dadpour B, Afshari R. Snakebite management in Iran: Devising a protocol. J Res Med Sci 2014;19:153-63.  Back to cited text no. 3
    
4.
Goel SC, Yabrodi M, Fortenberry J. Recognition and successful treatment of priapism and suspected black widow spider bite with antivenin. Pediatr Emerg Care 2014;30:723-4.  Back to cited text no. 4
    
5.
Yaman M, Mete T, Ozer I, Yaman E, Beton O. Reversible myocarditis and pericarditis after black widow spider bite or Kounis syndrome? Case Rep Cardiol 2015;2015:768089.  Back to cited text no. 5
    
6.
Levine M. Pediatric envenomations: Don't get bitten by an unclear plan of care. Pediatr Emerg Med Pract 2014;11:1-12.  Back to cited text no. 6
    



 
 
    Tables

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