CASE PRESENTATION
A 32-year-old Indian man presented to our clinic with 1 month of pulsatile swelling on the backs of his ears bilaterally. His history was remarkable for alcohol- and hepatitis C-related cirrhosis and decompensation in the form of ascites, upper gastrointestinal bleeding, and hepatic encephalopathy. On physical examination, he had signs of liver failure in the form of spider nevi on his chest and back, loss of axillary and pubic hair with scant facial hair, testicular atrophy, and gynecomastia possibly because of the adverse effects of the spironolactone therapy that he was on for the management of ascites. He had globular, pulsatile swelling over the backs of both ears that had a spider-like capillary network (Figure 1A and 1B), which on applying pressure blanched and on releasing pressure filled centripetally. A short video demonstrates the pulsatile nature, confirming the swelling as a giant spider nevus (available at: www.thepermanentejournal.org/files/2018/17-069.mp4).
Figure 1A and 1B.
Photographs showing the nodular lesions on the back of the ears.
Our patient had abnormal liver function test results, with a hepatitis C virus genotype 3 RNA load of 266,450 IU/mL. As of this writing, he has been started on combination therapy of sofosbuvir and velpatasvir.
DISCUSSION
Spider nevi are vascular lesions that have a large arteriole in the center and an outwardly radiating capillary network that give the lesions the appearance of spider legs. Chronic liver disease is one of the most common conditions associated with spider nevi. Other associations include hyperthyroidism, use of oral contraceptive pills or their withdrawal, hyperviscosity syndrome, and rheumatoid arthritis, among others.1 These can be seen in normal individuals with up to 30% prevalencein children of prepuberty age or during pregnancy.1 Various mechanisms lead to development of these lesions, including relative hyperestrogenic state, increased vascular endothelial growth factor/basic fibroblast growth factor, and substance P, all of which have a role in vasodilation and angiogenesis.2
Development of a giant spider nevus is a rare phenomenon, and the cause is unclear. It has been reported with hepatitis C-related cirrhosis,3,4 but any causal association needs further investigation. These lesions usually do not require any treatment, the only indication being cosmetic, and pulsed laser therapy or electrodessication can be used to ablate them. Spider nevi usually disappear with improvement in the underlying condition.3,4 v
Footnotes
Disclosure Statement
The author(s) have no conflicts of interest to disclose.
References
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