A giant spider nevus in a patient of hepatitis C-related liver cirrhosis: A rare presentation.

Spider nevi are benign vascular lesions mostly seen in patients with decompensated liver cirrhosis. Mostly, these are seen in the superior vena cava distribution and are small with pinhead size central vessel. Giant spider nevus is rarely seen and hence this report.

INTRODUCTION

Spider nevus (also known as spider angioma or vascular spider) is a common benign vascular anomaly that may appear as solitary or multiple lesions. Spider nevi are represented by telangiectases that consist of a large arteriole from which radiate numerous small vessels that resemble spider's legs. They are found in the distribution of the superior vena cava, that is, on the face, neck, arms, and upper trunk. Spider nevi are usually <2 cm in diameter and rarely grow to assume large size more than 2 cm.[12] We hereby report a case of very large spider nevus in a patient with hepatitis C virus (HCV) related liver cirrhosis.

CASE REPORT

A 48-year-old-female presented with a history of abdominal distension and jaundice of 3-month duration. Physical examination revealed pallor, icterus, pedal edema, hepatospleenomegaly and tense ascites. She had multiple classical spider nevi over the chest. Also, she had a large spider nevi situated on the forehead, measuring 8 cm in largest dimension with palpable dilated vessels and venous hum [Figure 1]. Deep compression on the central area of the lesion produced complete disappearance with blanching and when released refilling of vessels occurred. Laboratory tests revealed a hemoglobin level of 9.8 g/dl, a white-cell count of 4240/mm3, and a platelet count of 77,000/mm3. Renal function tests were normal. Anti-HCV antibody for HCV was positive with HCV RNA of 1.6 × 106 IU/ml. An ultrasound abdomen was suggestive of liver cirrhosis with portal hypertension (portal vein diameter of 14 mm), ascites and splenomegaly. Thus, a diagnosis of cirrhosis liver with portal hypertension was made (CTP-9, Class B, and MELD – 11). She was not fit for antiviral therapy because of the already decompensated state. She was put on diuretics for the control of ascites but developed hepatic encephalopathy and renal dysfunction. Diuretics were stopped and in view of refractory tense ascites, she was taken up for a transjugular intrahepatic portosystemic shunt. However, during the procedure she had massive intrahepatic bleed and in spite of intensive resuscitative measures she died 48 hours later.

Figure 1

Photograph showing giant spider nevi over forehead of patient

DISCUSSION

Spider nevi can be seen in pregnancy, in patients with thyrotoxicosis, rheumatoid arthritis, oral contraceptive use and most commonly, liver cirrhosis.[3] These frequently appear in alcoholic cirrhotic or when liver function deteriorates in patients of the chronic liver disease.[4] The pathogenesis of spider nevi is still unclear. Increased plasma levels of estrogen, vascular dilation, and neovascularisation are possible etiologies. Li et al.[5] found elevated levels of vascular endothelial growth factor and basic fibroblast growth factor in patients with liver cirrhosis, especially in those with spider nevi. In patients with nonalcoholic cirrhosis, the levels of substance P are elevated which may play an important role in the pathogenesis of spider nevi by causing vasodilatation.[6] Most remain small in size and rarely do they assume the size as seen in our patient. The exact cause as of why these assume such large size remains elusive. There are only few case reports of large spider nevi reported in the literature.[127] The present case is unique because of its very large size, rare presentation over the forehead and palpable mass like vascular lesion in a patient with nonalcoholic cirrhosis.

Electrodesiccation and laser treatments under local anesthesia are effective therapeutic procedures for facial spider nevi. Spider nevi, however, usually do not require any treatment in cirrhotic patients due to a high risk of bleeding from these vascular lesions. These lesions may disappear with improvement in underlying hepatic disease[8] and after liver transplantation.[9]