Atypical systemic and dermatologic loxoscelism in a non-endemic region of the USA

A previously healthy 27 year-old male presented to an emergency department (ED) in central Virginia two hours after a LR envenomation to his left proximal arm. He was treated with diphenhydramine and discharged on oral methylprednisolone for a 5-day taper. On post-bite Days 1 and 2, the patient developed subjective fevers, chills, arthralgias, and myalgias, followed by a blanching, pruritic, morbilliform rash throughout his trunk and lower extremities. Post-bite Day 3, the patient presented to the ED again because of marked erythema of face and the right lateral thigh, and posterior and anterior trunk. Vital signs and laboratory analysis were generally unremarkable. The patient was observed overnight, and discharged with a prescription for prednisone 60 mg per day. On post-bite Day 7, the patient noted a petechial rash on the palms and soles and returned to the ED with a fever of 102.6 °F, a heart rate of 130 beats per minutes, and systolic blood pressure ranging 80-90 mmHg. After considering this may be an atypical presentation of LX, corticosteroids were increased to methylprednisolone 1 mg/kg IV every 6 h. The patient's condition slowly improved and he was discharged on post-bite Day 10. On post-bite Day 24, he had nearly complete resolution of skin findings.LR envenomation can cause a variety of dermatological and systemic manifestations of toxicity. It is critical for toxicologists to be aware of the variety of presentations and findings to appropriately assess and treat LX.