Complete detumescence followed within 3 hours. On later examination, the patient achieved partial erection with manipulation and spontaneous resolution. Edema of the foot was improved, as well as the abdominal signs and he was discharged from the hospital without symptoms two days after admission.

Discussion

The BWSE syndrome usually involves a pinprick sensation at the bite site, which is brief in duration. Severity of envenomation depends on the size of the spider, depth of the bite, and the age and size of the victim. Children, the elderly, and persons with cardiovascular disease are considered at high risk for serious complications and worse symptomatology.⁴

Approximately 30 to 60 minutes after envenomation, proximal muscle cramping occurs particularly of the chest, abdomen and back. Symptoms can progress to waxing and waning muscle rigidity and severe pain. Findings can often be confused with an acute abdomen, especially in children. Autonomic nervous system stimulation by venom produces nausea, vomiting, sweating, hypertension, and tachycardia.

Treatment is generally supportive, and only those patients who require repeated doses of medication to relieve symptoms warrant hospital admission. Treatment is primarily symptomatic, with the use of opiates and benzodiazepines for the management of pain and muscle spasms. Calcium gluconate was previously recommended as the treatment of choice, especially in patients who arrived 3 hours after being bitten.⁴

Antivenin should be administered only in a location where anaphylaxis can be treated, such as an emergency department or intensive care unit. Priapism is a pathologic condition of penile erection that persists beyond or is unrelated to sexual stimulation.

Peak incidence in children is from ages 5 to 10 years and is usually associated with sickle-cell disease or some others hemoglobinopathy.⁵ Priapism is thought to occur because of a disturbance in the regulatory mechanisms that maintain penile flaccidity.

Priapism can be separated into 2 distinct hemodynamic forms: low flow (ischemic) or high flow (no ischemic).⁶ Low-flow priapism results from a decrease in venous outflow from the penis and is characterized by venous stasis and penile ischemia. It is usually a painful, rigid erection characterized clinically by absent cavernous blood flow.

Low flow priapism beyond 4 hours results in a compartment syndrome and requires emergent medical o surgical intervention. High-flow priapism results from increased arterial flow into the cavernosal sinusoids, which overwhelms venous outflow, leading to persistent erection. High-flow priapism is often caused by groin or straddle trauma that results in injury to the internal pudenda artery or its branches.⁶ Priapism with BWSE has only rarely been noted.

In 1982 by Stiles reported treatment with antivenin for presumed BWSE in a 4-year-old with distress, muscle rigidity, hypertension, and priapism.⁷ Symptoms were consistent with BWSE, but no spider exposure ousting puncture wound was documented. The patient had dramatic improvement in his muscle rigidity and discomfort within 30 minutes, but priapism and hypertension took twelve hours to resolve. One postulated mechanism for priapism in BWSE is through release of neurotransmitters such as acetylcholine and epinephrine, leading to diffuse neuromuscular, autonomic, and central nervous system effects.⁷

BWSE may cause overstimulation of the parasympathetic system, resulting in smooth muscle relaxation and increased blood flow into the sinusoids. Priapism also could be caused by the release of acetylcholine at the neuromuscular junction, with resulting obstruction to penile venous outflow by spasm of the ischio-cavernous and bulbo-cavernous muscles, in our patient, priapism resolved with benzodiazepines rather than surgical urologic intervention.

Conclusions

Priapism is a complication to be considered after spider bite (BWSE). Opiates and benzodiazepines are used for the management of pain and muscle spasms. Antivenin should be administered only in a location where anaphylaxis can be treated, such as an emergency department or intensive care unit.

Bibliographic references

1. Richard F, Susan Wethern, Michael Vance, Richard Gerkiang. Clinical presentation and treatment of black widow spider’s envenomation. A review of 163 cases. Annals of Emergency Medicine. July 1992. 21:7.
2. Ellenhorn MJ, Barceloux DG. Medical Toxicology. New York. Elsiever, 1988 p1150-1152.
3. Kobernic KM: Black widow spider bite. Am Fam Physician 1984; 29:241-245.
4. Nancy G. Hoover, MD, James D Forten berry. Pediatrics. Vol.114. No.1. July 2014. Available on: http://www.pediatrics.org/cgi/content/full/114/1/e128
5. Winter CC, Mc Dowell G. Experience with 105 patients with priapism: update review of all aspects. J Urol. 1988; 140:980–983.
6. Harmon WJ, Nehra A. Priapism: diagnosis and management. Mayo Clin Proc. 1997; 72:350–355.
7. Stiles AD. Priapism following a black widow spider bite. Clin Pediatr (Phila). 1982; 21:174-175.

Authors refer do not have ethic problems or conflicts of interest as well as there has been no significant financial support for this work that could have influenced its outcome. We have contributed in similar form to prepare and write the final manuscript.

¹ Letsholathebe II Memorial Hospital. Maun. Botswana.

² University of Botswana.

³ Centro Provincial de Epidemiología. Ciego de Ávila. Cuba.

⁴ Hospital Provincial de Santa Clara. Villa Clara. Cuba.

• Received: December, 22^th 2016
• Approved: January, 26^th 2017

Correspondence: Aurelio Rodriguez Fernandez. Letsholathebe II Memorial Hospital. Maun. Botswana. E-mail: rodriguezaurelio555@gmail.com