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Spider nevi: A presenting feature of chronic liver disease
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Vedamurthy M, Vedamurthy A. Spider nevi: A presenting feature of chronic liver disease. Indian J Dermatol Venereol Leprol 2008;74:397-398
The vascular spider, arterial spider or spider angioma is the most classical vascular lesion that is sometimes a presenting sign of chronic liver disease. Spider telangietasia occur in up to 15% of normal individuals and may also be seen in pregnant women. The main vessel of the spider is an arteriole represented by a red point from which numerous, small, twisted vessels radiate. Application of pressure on the central arteriole with the head of a pin or a match stick causes blanching of the whole lesion. We report here a case with profusion of spider nevi predating the onset of liver disease.
A 36 year-old, non-alcoholic man presented to the Dermatology OPD for evaluation of multiple, eight months old, erythematous, asymptomatic macules distributed mainly over the front of the chest, with a few on the upper arm and back [Figure - 1]. The rash was earlier diagnosed as an allergic reaction and was treated with antihistamines by a general physician. Six months after the patient presented to us, he developed jaundice and was investigated and found to have chronic liver disease.
Dermatological examination showed hundreds of erythematous macules 2-5 mm in size, mainly over the front of the chest, upper abdomen and a few on the upper arm and back [Figure - 1]. The central body and the vessels radiating from it, could be seen clearly in a few lesions; mucous membranes were spared. There was no other dermatological evidence of chronic liver disease.
Hematological investigations revealed thrombocytopenia: 1,25,000 (Normal = 1,50,000-4,50,000); prothrombin time = 17 s (control: 13 s ) and activated partial thromboplastin time = 36 s (control: 26 s) were prolonged. Viral markers for hepatitis were all absent. Total estrogen level was 85.7 pg/mL (normal < 56 pg/mL) and the total testosterone level was 218 mg/dL (normal: 245-1836 mg/dL). Tests for antinuclear antibody and alpha fetoprotein were also negative. Liver function tests showed elevated bilirubin (total 4.3 mg/dL) and elevated enzyme levels (ALT: 93 IU/L, ALP: 328 IU/L) (expand abbreviations). Blood sugar and renal parameters were normal. An ultrasound of the whole abdomen showed a shrunken liver with a coarse and nodular echo texture, suggestive of chronic liver disease, splenomegaly and ascites. A liver biopsy was not done as the patient was unwilling to have it done. Based on the above findings, a diagnosis of cryptogenic cirrhosis was made.
Spider nevi are commonly distributed over the face, necklace area, forearms, hands and the upper part of chest, i.e., mainly over the region drained by the superior vena cava.  Vascular spiders have been attributed to excessive levels of estrogen because estrogens cause blood vessels to enlarge and dilate.  Serum estradiol and total testosterone levels are altered particularly in male patients with cirrhosis and spiders. Serum estradiol levels are increased and the total free testosterone level is reduced, thus leading to high estradiol/free testosterone ratios in male patients with spiders. Regression of spiders in patients with liver disease is possible with an improvement in the underlying condition although persistence of these spiders is more likely. 
Morphological studies and reconstruction methods demonstrated that spiders represent an arteriole and an organ with five separate parts:
- A cutaneous arterial net,
- A central spider arteriole,
- A subepidermal ampulla
- A star-shaped arrangement of afferent spider vessels, and
- Capillaries 
Awareness of the association of spider nevi with systemic illnesses is essential to determine the underlying pathology. This case is presented for two reasons: 1. As spider nevi can precede liver diseases, it would be advisable to screen the patients with spider nevi for liver disease as early detection could prove to be beneficial to the patient, 2. The presence of spider nevi is also considered to be one of the physical findings predicting the presence of esophageal or gastric varices in patients with advanced liver disease.  It could therefore be cost-effective to screen and identify a group of patients who would most benefit from endoscopic screening for varices.
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