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38.4°C), and general malaise.

The findings of a general


Centipede Bite: A Case Report physical examination were normal.
Laboratory findings showed leukocytosis (11 900 white
blood cells/µL) and an elevated erythrocyte sedimenta-

C entipedes are arthropods that live primarily in


tropical and subtropical regions and belong to
the class Chilopoda, which includes approxi-
mately 3000 species. The strong mandibles and venom-
ous fangs, called forcipules, are derived from the first pair
tion rate (56 mm/h). (To convert white blood cells to
⫻109/L, multiply by 0.001.) Bacteriologically, the pus-
tules tested positive for Staphylococcus aureus.
The patient was treated with paracetamol (2 g/d), oral
of legs. Skin reactions caused by Scolopendra subspinipes prednisone (starting dose, 75 mg/d), and intramuscular
bites are well known,1 but they have very rarely been re- ceftriaxone (2 g/d for 10 days). Complete remission was
ported in the dermatologic literature.2-5 seen 10 days after the start of therapy.

Report of a Case. A 33-year-old man was admitted be- Comment. Cases of centipede bites have been observed
cause of acute edema involving the right hand (Figure 1). in Israel, Japan, Taiwan, the Philippines, the United
The patient reported that he was in good general health States, and Australia, where the largest number of cases
and that he was not taking any medication. The reac- has been reported (n=48).1 Centipede bites, which usu-
tion appeared 2 days before admission, during a trip to ally occur on the hands or feet, can be caused by Scolo-
Malaysia. The patient reported that he had been bitten pendra angulata, Scolopendra gigantea, Scolopendra
by a centipede as he lay sleeping in the garden of a ho- heros, Scolopendra morsitans, S subspinipes, and Scolo-
tel. Despite acute burning of the hand, the patient, a pro- pendra viridicornis nigra.1 The venom of S morsitans, S
fessional biologist, was able to capture the 20-cm-long subspinipes, and S viridicornis contains 14 proteins, 13
centipede and bring it to Milan, where it was classified lipoproteins, and several lipids and enzymes: S subspin-
as a specimen of S subspinipes (Figure 2). ipes venom contains scolopendrine, a quinoline alka-
Dermatologic examination revealed a severe, slightly loid active against bacteria and fungi; S viridicornis
erythematous edema involving the entire right hand. venom contains 5-hydroxytryptamine; and S subspin-
Vesicles, blisters, and pustules were also present. The pa- ipes dehaani venom induces histamine release.
tient complained of severe pain, fever (temperature, Erythema,2,3 edema,2-4 hemorrhagic vesicles,4 blis-
ters,4 and necrosis may appear minutes, hours, or days
after the bite. Rare cases of local numbness, paresthesia
at the site of the bite,3,5 and bacterial superinfections with
lymphangitis and lymphadenitis2 have also been de-
scribed. Pain is the most frequent symptom.1,2,5 Some pa-
tients also complain of burning2 and itching.1,4 In addi-
tion, several systemic manifestations, some of them very
severe, have been reported in the literature: pericoroni-
tis, nausea, vomiting, headache,2 cold sweating, anxi-
ety,2 dizziness,2 blurry vision, loss of consciousness, mul-
tiple neuropathies, fever,4 dyspnea, irregular peripheral
pulses,2 myocardial infarction, rhabdomyolysis, protein-
uria, acute renal failure, and abnormalities of coagulation.
The treatment of centipede bites consists of intrale-
sional or systemic analgesics,1-3 topical and/or systemic
corticosteroids,3 antihistamines,2 and systemic anti-
biotics in patients with bacterial superinfections. Ice
pack application and immersion in hot water (to exploit
the sensitivity of centipede venoms to high and low

cm 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Figure 1. Severe, mildly erythematous edema involving the entire right hand. Figure 2. Scolopendra subspinipes. The scale bar indicates centimeters, and
Vesicles, blisters, and pustules are also present. the inset shows a closer view of the head, buccal apparatus, and fangs.

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temperatures)1 and arm elevation can also be helpful. 1. Balit CR, Harvey MS, Waldock JM, Isbister GK. Prospective study of centi-
pede bites in Australia. J Toxicol Clin Toxicol. 2004;42(1):41-48.
Tetanus prophylaxis has been suggested.2 To our 2. Burnett JW, Calton GJ, Morgan RJ. Centipedes. Cutis. 1986;37(4):241.
knowledge, no centipede antivenoms are available. 3. Mohri S, Sugiyama A, Saito K, Nakajima H. Centipede bites in Japan. Cutis.
1991;47(3):189-190.
Stefano Veraldi, MD 4. Friedman IS, Phelps RG, Baral J, Sapadin AN. Well’s syndrome triggered by
centipede bite. Int J Dermatol. 1998;37(8):602-605.
Anna Chiaratti, MD 5. Elston DM. What’s eating you? centipedes (Chilopoda). Cutis. 1999;64(2):83.
Lorenzo Sica, MD

Author Affiliations: Dipartimento di Anestesiologia, Te- An Intracranial Dural Arteriovenous Fistula


rapia Intensiva e Scienze Dermatologiche, Università de- Found During a Dermatologic Examination
gli Studi di Milano, Fondazione IRCCS, Ospedale Mag-
giore Policlinico, Mangiagalli e Regina Elena, Milan, Italy. Report of a Case. A 73-year-old healthy white man was
Correspondence: Dr Veraldi, Dipartimento di Aneste- seen with a 2.8⫻1.5-cm pearly plaque on the left post-
siologia, Terapia Intensiva e Scienze Dermatologiche, Uni- auricular region. A shave biopsy specimen revealed a
versità degli Studi di Milano, Fondazione IRCCS, Os- basal cell carcinoma, which was treated successfully
pedale Maggiore Policlinico, Mangiagalli e Regina Elena, with Mohs micrographic surgery. All other cutaneous
Via Pace 9, Milan, 20122, Italy (stefano.veraldi@unimi examination findings were unremarkable except for a
.it). soft, pulsating mass measuring approximately 4 cm on
Financial Disclosure: None reported. the scalp vertex (Figure 1A). A bruit could be heard

A B

C D

Figure 1. Clinical (A) and computed tomography angiography (CTA) images (B-D) of dilated scalp arteries. A, The prominent scalp artery outlined with the box
was easily palpable during examination (inset shows artery half surrounded by arrows). B, The CTA imaging reveals underlying dilated scalp arteries. C, The
arteries form an extraosseous medusalike confluence. D, Branches of the bilateral occipital and superficial temporal arteries centered near the sagittal sinus are
associated with a dilated large intracranial varix.

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©2010 American Medical Association. All rights reserved.