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Abstract
Spider angiomas are cutaneous manifestations usually described with liver disease. They result from dilatation of an arteriole with multiple radiating vessels emerging from it. Pressure on the central arteriole can make the entire lesion disappear which reappears once it is released. The lesions are typically seen in the territory of superior vena cava. The number of lesions varies but more than a couple must prompt concern about underlying liver disease. Histologically, it consists of central arteriole with radial branching of telangiectasia in the periphery. Different theories have advocated increased levels of vascular endothelial growth factor, basic fibroblast growth factor, estrogen/testosterone ratio and substance P as reason for their development. Usually they remain asymptomatic in a majority of subjects and do not need therapy. If treatment is needed for cosmetic purposes, it may include electrocoagulation or laser. These lesions may disappear with improvement in underlying hepatic disease or after liver transplantation. Keywords: spider angioma; cirrhosis; alcoholic liver disease; viral hepatitis; liver
Received: April 3, 2012; Accepted: April 13, 2012; Published online: May 3, 2012
Introduction
Skin is often believed to provide a peep into the human body and careful examination of skin may yield important diagnostic and prognostic information. Perhaps nowhere else is this aphorism better suited than in respect to the spider angiomas and their relation to hepatic diseases [1]. Hepatic disease can have a number of cutaneous findings (Table 1) [2]. Spider angiomas are peculiar manifestations usually described with liver disease and have been variably named as spider nevus, vascular spider, nevus araneus, arterial spider tche http://www.intermedcentral.hk/
stellaire, etoile vasculair or merely as spiders [1, 3]. First described by Erasmus Wilson, the lesions were described in detail by William Bennett Bean [3].
Clinical diagnosis
Spider angiomas are so described for their resemblance to legs of a spider (Figure 1). The lesions result from dilatation of an arteriole with multiple radiating vessels emerging from the central arteriole. Pressure on the central arteriole, typically with a pinhead, can make the entire lesion disappear while the lesion reappears once
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Spider angioma the pressure is released (Figure 2)[4].Occasionally a central pulsation can be noted. The lesions are typically seen in the territory of superior vena cava although the reason is not entirely clear. Therefore the locations usually are the face, neck, and upper part of the trunk, and arms[1]. Other locations from where the lesions have been reported include pleural and sub-pleural locations[5]. Another report has reported esophageal spider naevi in hepatitis C virus related cirrhosis[6]. They have also been reported in the stomach and colon[7, 8]. A report indicated that they may not occur in the retina[9]. Unusual locations like at the knees and distribution like unilateral only distribution have also been reported[10, 11]. The bleeding occuring from Dieulafoys lesion in cirrhotics has also been explained to be a result of bleeding from an underlying spider [8]. Interestingly, even the pulmonary abnormalities that accompany cirrhosis and manifest as hepatopulmonary syndrome have been blamed on pulmonary spider like lesions and described as hepato-pulmonary-cutaneous syndrome [12].The number of lesions vary but more than a couple of lesion must prompt concern about underlying liver disease [4]. Some indicate that even up to five spiders can occur in a normal population [13]. Histologically the lesions consist of central arteriole with radial branching of telangiectasia in the periphery [14]. pregnancy. A higher estradiol/testosterone ratio has been noted in plasma of patients with cirrhosis. This was primarily due to lower free testosterone levels in those cirrhotic patients who had spiders [19]. The increased peripheral conversion of androgens to estrogens may also play a role. In another study of patients with cirrhosis, a higher estradiol/testosterone ratio was noted in patients vis--vis healthy controls [20]. It is believed that relative estrogen excess mediates vasodilatation and results in these vascular lesions. However another study refuted these findings and reported a normal hormonal profile. This study also noted an increased level of substance P in those patients who had spiders [21]. As circulating plasma substance P is partially inactivated in liver, the increase levels may be due to increasing hepatic dysfunction. Substance P might be responsible for the genesis of vascular spiders by causing vasodilatation[21].
Table 1. Cutaneous manifestations and the related liver disease
[2]
Skin pigmentation Biliary Cirrhosis Papular acrodermatitis (Gianotti Crosti Syndrome) Scarring Paper money skin Palmar Erythema Purpura, Bleed Viral infections like HCV, HBV Porphyrea cutanea tarda Usually chronic liver disease Usually chronic liver disease Coagulopathy HCV Palpable purpura cryoglobulinemia Muhercke Nails[42] Terry Nails/Leukonychia[42] Hypoalbuminemia Cirrhosis Cirrhosis, Hepatopulmonary Clubbing syndrome Azure lunulae [42] Caput medusa [43] Wilson Portal hypertension related
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Spider angioma
Figure 2.
Spider naevi disappear when pressure is applied at the centre and reappear at release of pressure
Figure 3.
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Spider angioma
parameters including aspartate aminotransferase/platelet ratio [37]. Spider naevi have also been reported as a reliable clinical sign for underlying cirrhosis [4]. In patients with hepatic C infection, the presence of spider naevi indicated both the presence of inflammation and fibrosis [38].
References
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Cruveilhier-Baumgarten syndrome with caput medusae. N Z Med J 2011; 124(1347): 89-90 Copyright: 2012 Vishal Sharma, et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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