Letters to Editor
Gurcharan Singh, G. Archana
Department of Dermatology and STD, Sri Devaraj Urs Medical
College, Tamaka, Kolar-563 101, India
Address for correspondence: Dr. Gurcharan Singh, 108, A, Jal Vayu
Vihar, Kamanahalli, Bangalore-560 043, India.
E-mail: drsinghgs@gmail.com
REFERENCES
1. Pareek A, Khopkar U, Sacchidanand S, Chandurkar N,
Naik GS. Comparative study of efficacy and safety of
hydroxychloroquine and chloroquine in polymorphic light
eruption: A randomized, double-blind, multicentric study.
Indian J Dermatol Venereol Leprol 2008;74:18-22.
2. Nyberg F, Hasan T, Puska P, Stephansson E, Hkkinen M,
Ranki A, et al. Occurrence of polymorphous light eruption in
lupus erythematosus. Br J Dermatol 1997;136:217-21.
3. Murphy GM, Hawk JL.The prevalence of antinuclear
antibodies in patients with apparent polymorphic light
eruption. Br J Dermatol 1991;125:44851.
4. Yam JC, Kwok AK. Ocular toxicity of hydroxychloroquine.
Hong Kong Med J 2006;12:294-304.
5. Jones. SK Ocular toxicity and hydroxychloroquine: Guidelines
for screening. Br J Dermatol 1999;140:3-7.
Spider nevi: A presenting feature
of chronic liver disease
Sir,
The vascular spider, arterial spider or spider angioma is the
most classical vascular lesion that is sometimes a presenting
sign of chronic liver disease. Spider telangietasia occur
in up to 15% of normal individuals and may also be seen
in pregnant women. The main vessel of the spider is an
arteriole represented by a red point from which numerous,
small, twisted vessels radiate. Application of pressure on the
central arteriole with the head of a pin or a match stick causes
blanching of the whole lesion. We report here a case with
profusion of spider nevi predating the onset of liver disease.
A 36 year-old, non-alcoholic man presented to the
Dermatology OPD for evaluation of multiple, eight months
old, erythematous, asymptomatic macules distributed
mainly over the front of the chest, with a few on the upper
arm and back [Figure 1]. The rash was earlier diagnosed as
an allergic reaction and was treated with antihistamines by a
general physician. Six months after the patient presented to
us, he developed jaundice and was investigated and found
to have chronic liver disease.
Indian J Dermatol Venereol Leprol | July-August 2008 | Vol 74 | Issue 4
Figure 1: Spider nevi
Dermatological examination showed hundreds of
erythematous macules 25 mm in size, mainly over the
front of the chest, upper abdomen and a few on the upper
arm and back [Figure 1]. The central body and the vessels
radiating from it, could be seen clearly in a few lesions;
mucous membranes were spared. There was no other
dermatological evidence of chronic liver disease.
Hematological investigations revealed thrombocytopenia:
1,25,000 (Normal = 1,50,0004,50,000); prothrombin time
= 17 s (control: 13 s ) and activated partial thromboplastin
time = 36 s (control: 26 s) were prolonged. Viral markers for
hepatitis were all absent. Total estrogen level was 85.7 pg/
mL (normal < 56 pg/mL) and the total testosterone level was
218 mg/dL (normal: 2451836 mg/dL). Tests for antinuclear
antibody and alpha fetoprotein were also negative. Liver
function tests showed elevated bilirubin (total 4.3 mg/dL)
and elevated enzyme levels (ALT: 93 IU/L, ALP: 328 IU/L)
(expand abbreviations). Blood sugar and renal parameters
were normal. An ultrasound of the whole abdomen showed
a shrunken liver with a coarse and nodular echo texture,
suggestive of chronic liver disease, splenomegaly and
ascites. A liver biopsy was not done as the patient was
unwilling to have it done. Based on the above findings, a
diagnosis of cryptogenic cirrhosis was made.
Spider angioma or nevus araenus is a dilatation of preexisting
vessels under several circumstatnces.[1] Common causes of
spider nevi are listed in Table 1.
Spider nevi are commonly distributed over the face,
necklace area, forearms, hands and the upper part of chest,
i.e., mainly over the region drained by the superior vena
cava.[2] Vascular spiders have been attributed to excessive
levels of estrogen because estrogens cause blood vessels to
enlarge and dilate.[3] Serum estradiol and total testosterone
397
Letters to Editor
Table 1: Causes of spider nevi
1015% normal adults and young children
Pregnancy
Familial
Chronic liver disease
Thyrotoxicosis
Estrogen therapy for rheumatoid arthritis
Oral contraceptive pills
levels are altered particularly in male patients with cirrhosis
and spiders. Serum estradiol levels are increased and the
total free testosterone level is reduced, thus leading to
high estradiol/free testosterone ratios in male patients with
spiders. Regression of spiders in patients with liver disease
is possible with an improvement in the underlying condition
although persistence of these spiders is more likely.[4]
Morphological studies and reconstruction methods
demonstrated that spiders represent an arteriole and an
organ with five separate parts:
1. A cutaneous arterial net,
2. A central spider arteriole,
3. A subepidermal ampulla
4. A star-shaped arrangement of afferent spider vessels,
and
5. Capillaries[5]
Awareness of the association of spider nevi with systemic
illnesses is essential to determine the underlying pathology.
This case is presented for two reasons: 1. As spider nevi can
precede liver diseases, it would be advisable to screen the
patients with spider nevi for liver disease as early detection
could prove to be beneficial to the patient, 2. The presence
of spider nevi is also considered to be one of the physical
findings predicting the presence of esophageal or gastric
varices in patients with advanced liver disease.[6] It could
therefore be cost-effective to screen and identify a group of
patients who would most benefit from endoscopic screening
for varices.
Maya Vedamurthy, Amar Vedamurthy
Department of Dermatology, Apollo Hospitals, Chennai, India
Address for Correspondence: Dr. Maya Vedamurthy, AB-76, I street,
Annanagar, Chennai-600 040, India.
E-mail: mayavedamurthy@yahoo.com
REFERENCES
1. Robin AC GrahamBrowne, Rathbone B, Marks J. The skin
and disorders of the alimentary tract. In: Freedberg IM,
Eisen AZ, Austen KF, Goldsmith LA, Katz SI et al, editors.
398
Dermatology in internal medicine. 5th ed. New York:
McGrowHill; 1999. p. 190929.
2. Champion RH. Disorders of blood vessels. In: Champion
RH, Burton JL, Ebling FJ, editors. Rook / Wilkinson / Ebling
Textbook of Dermatology. 5th ed. Oxford: Blackwell science
Publishers; 1992. p. 182749.
3. Akiyama M, Inamoto N. Arteriovenous haemangioma in
chronic liver disease clinical and hisopathologic features
of four cases. Br J Dermatol 2001;144:6049.
4. Whiting DA, Kallmeyer JC, Simson IW. Widespread arterial
spiders in a case of latent hepatitis with resolution after
therapy. Br J Dermatol 1970;82:326.
5. Requena L, Sangueza OP. Cutaneous vascular anomalies Part
I, Hamartomas, malformation and dilation of preexisting
vessels. J Am Acad Dermatol 1997;37:52349.
6. Zaman A, Hapke R, Flora K, Rosen HR. Bennerk in Factors
predicting the presences of esophageal or gastric varices in
patients with advanced liver disease. Am J Gasteroenterol
1999;95:32926.
Fanconis anemia
Sir,
Fanconi described a fatal disorder in three brothers, that was
characterized by pancytopenia, bone marrow hypoplasia
and congenital anomalies.[1] Although rare, the disorder is
sufficiently common that an international study group has
been established to register clinical experience.[2] The disorder
is characterized by a variable clinical picture consisting of
pancytopenia, skeletal abnormalities, neurological and
endocrine disorders, chromosomal instability, and an
increased risk of leukemia and other tumors.
A seven year-old female child born to nonconsanguineous
parents was brought to our out patient department for
three year-old pigmentary changes on the trunk and
limbs. There was no similar history in the family. General
examination revealed gross pallor, while cutaneous
examination revealed hypo- and hypopigmented macules
0.11 cm in size, distributed on the neck, trunk, and the
dorsae of the hands and feet. Axillae, groins and palms and
soles were also involved. A single caf-au-lait macule was
present on the chest. The left thumb showed syndactyly.
Hemoglobin (Hb) was 3.5 g%; sickling test was negative
while Hb electrophoresis showed the presence of HbA and
HbF (15.7%). An X-ray of the left hand showed syndactyly of
the left thumb. Ultrasonography of the abdomen showed
a mild echogenic center in the liver. Bone marrow biopsy
revealed a hypoplastic marrow of moderate degree.
Histopathological examination of the skin showed a mild
Indian J Dermatol Venereol Leprol | July-August | Vol 74 | Issue 4