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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, Figure 1: Spider nevi
Ranki A, et al. Occurrence of polymorphous light eruption in
lupus erythematosus. Br J Dermatol 1997;136:217-21. Dermatological examination showed hundreds of
3. Murphy GM, Hawk JL.The prevalence of antinuclear erythematous macules 25 mm in size, mainly over the
antibodies in patients with apparent polymorphic light front of the chest, upper abdomen and a few on the upper
eruption. Br J Dermatol 1991;125:44851. arm and back [Figure 1]. The central body and the vessels
4. Yam JC, Kwok AK. Ocular toxicity of hydroxychloroquine. radiating from it, could be seen clearly in a few lesions;
Hong Kong Med J 2006;12:294-304. mucous membranes were spared. There was no other
5. Jones. SK Ocular toxicity and hydroxychloroquine: Guidelines
dermatological evidence of chronic liver disease.
for screening. Br J Dermatol 1999;140:3-7.

Hematological investigations revealed thrombocytopenia:


1,25,000 (Normal = 1,50,0004,50,000); prothrombin time
Spider nevi: A presenting feature = 17 s (control: 13 s ) and activated partial thromboplastin
time = 36 s (control: 26 s) were prolonged. Viral markers for
of chronic liver disease 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
Sir,
antibody and alpha fetoprotein were also negative. Liver
The vascular spider, arterial spider or spider angioma is the
function tests showed elevated bilirubin (total 4.3 mg/dL)
most classical vascular lesion that is sometimes a presenting
and elevated enzyme levels (ALT: 93 IU/L, ALP: 328 IU/L)
sign of chronic liver disease. Spider telangietasia occur
(expand abbreviations). Blood sugar and renal parameters
in up to 15% of normal individuals and may also be seen were normal. An ultrasound of the whole abdomen showed
in pregnant women. The main vessel of the spider is an a shrunken liver with a coarse and nodular echo texture,
arteriole represented by a red point from which numerous, suggestive of chronic liver disease, splenomegaly and
small, twisted vessels radiate. Application of pressure on the ascites. A liver biopsy was not done as the patient was
central arteriole with the head of a pin or a match stick causes unwilling to have it done. Based on the above findings, a
blanching of the whole lesion. We report here a case with diagnosis of cryptogenic cirrhosis was made.
profusion of spider nevi predating the onset of liver disease.
Spider angioma or nevus araenus is a dilatation of preexisting
A 36 year-old, non-alcoholic man presented to the vessels under several circumstatnces.[1] Common causes of
Dermatology OPD for evaluation of multiple, eight months spider nevi are listed in Table 1.
old, erythematous, asymptomatic macules distributed
mainly over the front of the chest, with a few on the upper Spider nevi are commonly distributed over the face,
arm and back [Figure 1]. The rash was earlier diagnosed as necklace area, forearms, hands and the upper part of chest,
an allergic reaction and was treated with antihistamines by a i.e., mainly over the region drained by the superior vena
general physician. Six months after the patient presented to cava.[2] Vascular spiders have been attributed to excessive
us, he developed jaundice and was investigated and found levels of estrogen because estrogens cause blood vessels to
to have chronic liver disease. enlarge and dilate.[3] Serum estradiol and total testosterone

Indian J Dermatol Venereol Leprol | July-August 2008 | Vol 74 | Issue 4 397


Letters to Editor

Dermatology in internal medicine. 5th ed. New York:


Table 1: Causes of spider nevi
McGrowHill; 1999. p. 190929.
1015% normal adults and young children
2. Champion RH. Disorders of blood vessels. In: Champion
Pregnancy RH, Burton JL, Ebling FJ, editors. Rook / Wilkinson / Ebling
Familial Textbook of Dermatology. 5th ed. Oxford: Blackwell science
Chronic liver disease Publishers; 1992. p. 182749.
Thyrotoxicosis 3. Akiyama M, Inamoto N. Arteriovenous haemangioma in
Estrogen therapy for rheumatoid arthritis chronic liver disease clinical and hisopathologic features
Oral contraceptive pills of four cases. Br J Dermatol 2001;144:6049.
4. Whiting DA, Kallmeyer JC, Simson IW. Widespread arterial
levels are altered particularly in male patients with cirrhosis spiders in a case of latent hepatitis with resolution after
and spiders. Serum estradiol levels are increased and the therapy. Br J Dermatol 1970;82:326.
5. Requena L, Sangueza OP. Cutaneous vascular anomalies Part
total free testosterone level is reduced, thus leading to
I, Hamartomas, malformation and dilation of preexisting
high estradiol/free testosterone ratios in male patients with vessels. J Am Acad Dermatol 1997;37:52349.
spiders. Regression of spiders in patients with liver disease 6. Zaman A, Hapke R, Flora K, Rosen HR. Bennerk in Factors
is possible with an improvement in the underlying condition predicting the presences of esophageal or gastric varices in
although persistence of these spiders is more likely.[4] patients with advanced liver disease. Am J Gasteroenterol
1999;95:32926.
Morphological studies and reconstruction methods
demonstrated that spiders represent an arteriole and an
organ with five separate parts:
1. A cutaneous arterial net,
Fanconis anemia
2. A central spider arteriole,
3. A subepidermal ampulla Sir,
4. A star-shaped arrangement of afferent spider vessels, Fanconi described a fatal disorder in three brothers, that was
and characterized by pancytopenia, bone marrow hypoplasia
5. Capillaries[5] and congenital anomalies.[1] Although rare, the disorder is
sufficiently common that an international study group has
Awareness of the association of spider nevi with systemic been established to register clinical experience.[2] The disorder
illnesses is essential to determine the underlying pathology. is characterized by a variable clinical picture consisting of
This case is presented for two reasons: 1. As spider nevi can pancytopenia, skeletal abnormalities, neurological and
precede liver diseases, it would be advisable to screen the endocrine disorders, chromosomal instability, and an
patients with spider nevi for liver disease as early detection increased risk of leukemia and other tumors.
could prove to be beneficial to the patient, 2. The presence
of spider nevi is also considered to be one of the physical A seven year-old female child born to nonconsanguineous
findings predicting the presence of esophageal or gastric parents was brought to our out patient department for
varices in patients with advanced liver disease.[6] It could three year-old pigmentary changes on the trunk and
therefore be cost-effective to screen and identify a group of limbs. There was no similar history in the family. General
patients who would most benefit from endoscopic screening examination revealed gross pallor, while cutaneous
for varices. examination revealed hypo- and hypopigmented macules
0.11 cm in size, distributed on the neck, trunk, and the
Maya Vedamurthy, Amar Vedamurthy dorsae of the hands and feet. Axillae, groins and palms and
Department of Dermatology, Apollo Hospitals, Chennai, India
soles were also involved. A single caf-au-lait macule was
Address for Correspondence: Dr. Maya Vedamurthy, AB-76, I street, present on the chest. The left thumb showed syndactyly.
Annanagar, Chennai-600 040, India. Hemoglobin (Hb) was 3.5 g%; sickling test was negative
E-mail: mayavedamurthy@yahoo.com
while Hb electrophoresis showed the presence of HbA and
HbF (15.7%). An X-ray of the left hand showed syndactyly of
REFERENCES
the left thumb. Ultrasonography of the abdomen showed
1. Robin AC GrahamBrowne, Rathbone B, Marks J. The skin a mild echogenic center in the liver. Bone marrow biopsy
and disorders of the alimentary tract. In: Freedberg IM, revealed a hypoplastic marrow of moderate degree.
Eisen AZ, Austen KF, Goldsmith LA, Katz SI et al, editors. Histopathological examination of the skin showed a mild

398 Indian J Dermatol Venereol Leprol | July-August | Vol 74 | Issue 4