A 27-year-old male patient with a history of alcoholism (a liter of daily rum) and polydrug use (cocaine, base paste and cannabis).
ventral hernia in the Urgency Department of Luis Tisné Hospital (HLT) due to a 20-hour skin lesion secondary to a spider bite in the proximal third of the right forearm.
The examination revealed a central plaque, associated with edema, erythema and pain in the forearm and lower two thirds of the arm.
An entrance door of 4 mm with signs of necrosis in the forearm was evident.
On admission, the patient was normotensive, tachycardic, with normal oxygen saturation, eupneic and axillary temperature of 37.5°C. Among laboratory tests at admission, there was a predominance of normal CRP serum levels,
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Volume was started with saline 0.
9% to 120 cc/h i.v., and therapy with ceftriaxone 2 g/day i. v., metronidazole 500 mg c/8 h i.v., c.mizole iv.
Initially located and subfebrile up to 37.4°C and without changes in urine color.
At 32 h of evolution, he presented macroscopic hematuria and increased edema of the right upper extremity, with the appearance of a flictena approximately 6 mm in diameter ventral bite site of the forearm on the face.
Generous volume and IV fluid administration were maintained.
Chlorphenamine 4 mg c/8 h was started and ceftriaxone was switched to cefazolin 1 g c/8 h i.v., remaining with metronidazole.
Analgesia was optimized with paracetamol 1 g c/8 h vo and tramadol 200 mg IV in continuous infusion pump.
Laboratory tests revealed impaired renal and hepatic function and increased LDH.
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Due to renal failure, the patient was referred to an Intermediate Treatment Unit (ICU) after 44 hours of evolution, highlighting the appearance of multiple blisters in the right forearm.
The patient persisted in the ICU with malaise, respiratory or hemodynamic compromise, with clearer urine output.
A decrease in local swelling and heat of the affected limb was observed in the skin, with rupture of the filthene.
Laboratory parameters were normalized 60 h after the bite.
On the fourth day of evolution, due to the clinical and laboratory improvement, she went to a medical ward, where the patient got away from the hospital, despite the beginning of the polyaddiction and alcoholism therapy.
She was treated with antihistamines, corticosteroids, and antibacterials for four days.
On the sixth day of the bite, the patient consulted again in the Emergency Department due to pain in the extremity, highlighting improvement of the edema, pigmentation in the right forearm, and flictenas healing
The patient again leaked without consulting the HLT.
