Marys Medicine

Effect of built environment on tsunami related injuries

Dinamithra NP et al AMJ 2013, 7 (1)
Open Access
Introduction
Throughout history, envenoming by animal toxins has
fascinated humans. Animal toxins have made a vast
contribution to enhancing knowledge in human
physiology and pharmacology. Information on the nature
and mechanism of action of these toxins has enabled a
more scientific approach to the treatment of their
intoxications. Early and specific treatment is frequently
required after envenoming and often includes life support
and maintenance of vital functions by mechanical
ventilation, intra venous fluid and drug therapy. Spider
Figure 1 A. Visible muscle spasms (indicated by arrow),
bites are associated with a mortality of 1-17% in Chile, B. Disappearance of muscle spasms one hour after
Brazil(1), the Mediterranean region, Israel, North Africa intravenous calcium gluconate therapy
and some regions in the former Soviet Union. Most spiders have neuroactive substances in their venom(2), other systemic symptoms. He had taken 2 tablets (1 gram) which are characterized by different affinities by a series of paracetamol orally to relieve the pain. of different receptors and ionic neuronal channels(3). Twenty four hours after the incident he developed painful During the predation, spiders inject neurotoxins which are muscle spasms over right upper arm which made him to able to cause paralysis of their prey due to the blocking get admitted to the hospital. On admission he was in pain actions at the neuromuscular junctions and/or at the with visible muscle spasms over right tricep region, his central nervous system (CNS); generally the voltage- pulse rate was 40 beats / minute, respiratory rate 18 cycles gated sodium (Nav) and voltage-gated calcium (Cav) / minute, and blood pressure was 120/80 mmHg. He was channels constitute the most common targets of these treated with 1 gram of paracetamol and 4 miligram of toxins(3,4). Spider bites are mostly accidental and usually Chlopheniramine oraly . His symptoms were subsided they do not attack animals larger than themselves, some after 4hours of the onset (28 hours the bite). have aggressive behavior and will attack when After 4 hours (28 hours the bite) he again complained of approached by larger animals. Most spider bites on severe abdominal pain mainly over epigastric region humans are unintentional and happen when they press up where visible muscle spasms was obvious. (Figure 2 against spiders and receive a defensive bite. We report on A).Then he was treated with slow bolus of intravenous a 19-year-old boy with visible muscle spasms admitted to 10% calcium gluconate 10 milliliter over 10 minutes. He the hospitals 24 hours after spider bite. made a good recovery after 1hour followed by a few short lasting episodes of right triceps, right calf and rectus abdominis muscle spasms which were not as severe as the previous. On physical examination all the systems were normal except bradycardia of 40/minute revealed as a sinus bradycardia on 12 lead ECG. Blood investigations Alanine Transaminase(ALT)- 20, Asparate Transaminase (AST)- 29,WhiteBlood Count (WBC)-7000,Haemoblobin (Hb)-13gram/deciliter, (MCV) -86 Femto liter, Platelets -328,000/micro liter, Blood Urea 22milligram/deciliter, Serum Na-144, K-4.7, 9.10milligram/deciliter (8.10-10.40) with normal Urine Figure 2 Offending spider Sri-Lankan
Ornamental Tarantula Poecilotheria fasciata
After treatment (at 28 hours after the bite ) with single dose of intravenous Calcium gluconate and oral calcium Case presentation
lactate 300 milligram thrice daily , the patient improved A 19-year old boy from Karainagar (9° 44' 53.07"N 79° rapidly (Figure 2 B)and was discharged from hospital 52' 58.38"E) in Jaffna District admitted with right upper after 24 hours of admission (48 hours of the bite ) with arm pain and spasms of tricep muscle after 24 hours of a calcium lactate 300mg thrice daily for three days. spider bite to right foot. He was bitten by the spider at about 4 p.m.at home garden while he was trying to take a Discussion
photograph of the spider. Offending spider was identified The clinical presentation and treatment modalities of by the experts with the help of the photographs brought Poecilotheria fasciata bite is not well documented in by the patient (Figure 1)(5,6). Just after the bite he noticed medical literature and there is no specific treatment for a severe pain at the site with local swelling without any Anuradhapura Medical Journal 2013 Volume 07 Issue 01 Page 11
Dinamithra NP et al AMJ 2013, 7 (1)
Open Access
that. Antivenoms are available for Latrodectus, Atrax and Signs and symptoms occurring within hours to 36 hours Loxosceles bites in many countries. These species are not post envenomation are typically abdominal pain, nausea, reported in Srilanka. Exact mechanisms of muscle spasms vomiting, fever, often > 39 to 40°C, myalgia and after Poecilotheria fasciata spider bite is yet to be artheralgias, headaches, fatigue, and weakness.Most identified. Pain and muscle spasms caused by spider bites spider bites are harmless, and require no specific are refractory to standard treatments but are relieved by treatment. Treatment of bites may depend on the type of intra venous calcium(7). Effectiveness of calcium spider; thus, capture of the spider—either alive, or in a gluconate is challenged in some studies[8]. Although well-preserved condition, is useful. calcium gluconate has been considered the first-line Treatment for non-poisonous spider bites include washing treatment of spider bite it is ineffective for pain relief the bite with soap and water and ice to reduce compared with a combination of intravenous opiods and inflammation (10). Analgesics and antihistamines may be benzodiazepines(8). Tarantula toxins inhibit activation of used, however antibiotics are not recommended unless voltage-activated potassium (Kv) channels by interacting there is also a bacterial infection present (10) There have with their voltage-sensing domains.They might cause the been reports of significant bites by Poecilotheria species, disturbance of skeletal muscle excitability responsible for occasionally resulting in hospitalization. Symptoms the tonic muscle spasms that have been described. include localized pain and swelling, exhaustion, moderate Possibly most relevant to our case of Poecilotheria to severe muscle cramping, labored breathing and fever, fasciata bite. It is postulated that the tonic spasms were sometimes delayed days after the initial bite. the result of a direct effect of venom neurotoxins acting on voltage-gated sodium and/or calcium channels in the Conclusion
victim's muscles(9). Our patient had a total plasma Ca2+ Although no specific treatment exists in Srilanka, it has concentration of 9.10milligram/deciliter (8.10-10.40) been suggested that calcium supplements may be after intravenous Calcium Gluconate which was towards beneficial to relieve the muscle spasms. Our patient made the lower end of the normal range, hinting that Ca2+ a full recovery with calcium supplements suggesting the might have entered the muscle fibres under the influence treatment with calcium is beneficial in relieving the pain of the putative spasm-producing toxin.Our patient had a and muscle spasms caused by Sri-Lankan Ornamental heart rate of around 40 beats per minute all throughout his Tarantula (Poecilotheria fasciata). hospital stay as well as two weeks review which we However, there is little documented clinical evidence of attributed to his normal heart rate. the effects of this (Poecilotheria fasciata ) spider bite in The clinical presentation depends on many variables, humans, so firm conclusions about the level of danger including the amount of venom injected. There is usually posed by this spider cannot be drawn. only one bite, which may cause cutaneous or systemic manifestation or both. Other organs may be involved, including the gastrointestinal system. The pancreas, renal, pulmonary, and cardiovascular systems are less commonly affected (10, 11). Competing Interests
None
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