A 31-year-old female presents with complaints of generalized weakness and progres sively worsening pain in her left arm. Patient reports sustaining a bite on her left arm 5 days previously. On review of systems, patient admits having dark colored urine for the last 3 days. Physical examination reveals pallor and erythematous patch on the lateral aspect of her left arm with two blood-filled vesicles. Laboratory workup reveals leukocyte count of LJ2,500/,LLL, hemoglobin LJ g/dl, and platelet count 1 LJ1 ,000/,LLL. Reticulocyte count is elevated. Direct antiglobin test is positive for both lgG and com plement. LDH is 2,080 U/L, total bilirubin 9.1 mg/dl. and indirect bilirubin 8.2 mg/dl. Coagulation parameters are normal. Peripheral blood smear and left arm bite is shown below.
What is the most likely explanation of her presentation?
- Idiopathic immune hemolytic anemia
- Loxoscelism
- Paroxysmal nocturnal hemoglobinuria
- Spherocytosis
- G6PD deficiency-associated hemolysis
Medicine
B. Peripheral slide demonstrates spherocytosis and increased reticulocytes. Leukocytes exhibit toxic granulation and vacuolation. Loxoscelism is a syndrome produced by the bite of Loxosceles reclusa, the brown recluse spider. Hematologic manifestations include disseminated intravascular coagulation and both intravascular and extravascular hemolysis with positive direct antiglobin test. Treatment is mainly supportive with red blood cell transfusions and corticosteroids (Transfusion. 2004;44(11):1543, J Pediatr. 2010;156(1):155, Lancet. 2011;378(9808):2039, Cutis. 2004;74(6):341, Am l Med Sci. 1992;304(4):261, Am J Clin Pathol. 1995;104(4):463).
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