Summary Of Exposure |
A) ORGANISM: Loxosceles spiders are distributed in discreet populations across the US, primarily in the Midwest and Southwest. Loxosceles species include: L. reclusa, L. refescens, L. lacta, L. unicolor, L. deserta, L. arizonica, and others. These spiders are often found in ground cover or in plants as well as in human dwellings. They may have a distinct violin-shaped mark on the dorsum of the cephalothorax and can be differentiated from other spiders by their set of 6 eyes (in 3 pairs) rather than the 8 eyes seen in most other spider species. It is likely that some, if not many dermonecrotic lesions attributed to spider bites are from other causes.
B) TOXICOLOGY: The venom of Loxosceles species is composed of a number of proteins, enzymes, and nonenzymatic polypeptides. Brown recluse venom contains sphingomyelinase among other toxins and component synergism may play a part in the overall tissue response. Perhaps more important is the response of host cells to the presence of a complement-mediating foreign substance. Loxosceles venom has been shown to be a potent inducer of multiple inflammatory mediating chemokines. Venom toxins may act as proteases upon molecular constituents of plasma extracellular matrix and basement membrane constituents producing hemorrhage, delayed wound healing and renal failure, as well as the spreading of other noxious toxins.
C) EPIDEMIOLOGY: Painful bites may be noticed immediately and the offending spider seen, but many are not appreciated at the time and a diagnosis is made in retrospect from a characteristic history and physical examination. The incidence of necrotic arachnidism is unknown; there are no definitive diagnostic tests, and it is likely that some dermonecrotic lesions are falsely attributed to spider bites. In 2008, there were over 4,000 cases of spider or unknown insect bite reported to US poison centers, of which over 1700 were coded as "Brown Recluse" or "Necrotizing, other". Eleven major outcomes were reported, but no deaths.
D) WITH POISONING/EXPOSURE
1) MILD TO MODERATE TOXICITY: Bites by most of the species of spiders listed above are usually benign, although minor necrotic lesions have occasionally been reported. Bites by the Northwestern brown spider or hobo spider (Tegenaria agrestis) have been associated with minor necrotic lesions somewhat more frequently. Bites by L. reclusa are sometimes associated with large area of necrosis and systemic toxicity (loxoscelism). The initial reaction often consists of erythema and pain or pruritus. A small vesicle may form at the bite area, and the lesion may take on a "bull's eye" or "halo" appearance, having a central vesicle surrounded by an erythematous and ecchymotic area. A blanched ring may surround the discolored area. The vesicle may rupture, exposing an ulcer.
2) SEVERE TOXICITY: In severe cases cutaneous necrosis may occur and may extend to involve subcutaneous fat and muscle. The extent of local tissue injury is dependent on the amount of venom diffused following a L. reclusa envenomations. Systemic effects may develop, usually 24 to 72 hours after envenomation. Mild systemic effects include fever, chills, myalgias, arthralgias and generalized rash. Rarely, severe systemic effects may include hemolysis, jaundice, renal failure and shock. Systemic reactions are related to the degree of envenomation and not necessarily to the severity of skin lesions.
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Vital Signs |
3.3.1) SUMMARY
A) Fever and tachycardia are common in patients with systemic effects.
3.3.3) TEMPERATURE
A) Fever is common in patients with systemic effects and may develop more often in children (Way et al, 2005; Donepudi et al, 2005; Wright et al, 1997) (Schenone & Parts, 1961)(Rauber, 1983; Madrigal et al, 1972; Chu et al, 1978; Eichner, 1984; Baldwin et al, 1988; Cacy & Mold, 1999). Fever with chills and night sweats has also been reported (Sams et al, 2001).
B) It may develop within 8 hours of the bite (Rees et al, 1985) and may persist for days in the absence of documented infection (Bernstein & Ehrlich, 1986).
3.3.5) PULSE
A) Tachycardia may develop in patients with fever or hemolysis (Madrigal et al, 1972; Minton & Olson, 1964; Majeski & Durst, 1976).
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Heent |
3.4.6) THROAT
A) CASE REPORTS: Pharyngeal irritation was reported in several individuals after consuming deep-fried Chilean rose-haired tarantula (Grammostola spatulata) as part of a group undertaking novel experiences. Although the spiders were "blow torched", the remaining spiders were examined by an entomologist that confirmed the presence of urticating hairs on the spider's abdomen (Traub et al, 2001).
B) LOXOSCELISM: An 11-year-old boy presented with fever (up to 104 degrees F), pharyngitis, erythematous rash (over his ears, scalp, neck, trunk, buttocks, and proximal extremities), and a necrotic lesion on the lobule of the left ear after a brown recluse spider bite (Donepudi et al, 2005).
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Cardiovascular |
3.5.2) CLINICAL EFFECTS
A) TACHYARRHYTHMIA 1) WITH POISONING/EXPOSURE a) Tachycardia may develop in patients with fever or significant hemolysis (Madrigal et al, 1972; Minton & Olson, 1964; Majeski & Durst, 1976).
B) HYPOTENSIVE EPISODE 1) WITH POISONING/EXPOSURE a) Cardiovascular collapse has been described in several cases of presumed L. reclusa envenomation with severe hemolysis (Lessenden & Zimmer, 1960; Nicholson & Nicholson, 1962; Riley et al, 1964; Taylor & Denny, 1966; Vorse et al, 1972).
b) CASE REPORT: A 6-year-old boy developed massive hemolysis, disseminated intravascular coagulopathy, shock (BP 77/47 mm Hg) and acute renal failure after a suspected loxoscelism envenomation. The patient was initially admitted with a one day history of abdominal pain, nausea, vomiting and intermittent fever following a presumed spider bite; a dead spider was found by the mother in the child's bed (Note: there is no report that the spider was identified at home or brought to the hospital for identification). He had erythroderma and 2 large, bullous lesions with ecchymotic and erythematous bases on his lower abdomen. His initial laboratory studies were significant for an elevated WBC and coagulation abnormalities (ie, prothrombin time 30.1; partial thromboplastin time 65.6; and INR 2.96) and dark urine that was positive for hemoglobin and myoglobin. The patient required immediate intubation with fluid resuscitation and red blood cell transfusion. The patient required dopamine and epinephrine for ongoing hypotension. Further laboratory analysis was not possible due to massive hemolysis. Due to the presence of anuria, metabolic acidosis, hyperkalemia, and ongoing need for blood products, the patient was started on plasma exchange therapy (PEX) for hemolyzed plasma and continuous venovenous hemodiafiltration (CVVH). Over the next few weeks, the child gradually improved. By day 8, he was weaned off all inotropes and his neurologic function was normal. Hemolysis slowly resolved and PEX was discontinued on day 9 and CVVH was gradually weaned as his urine output increased. CVVH was discontinued on day 11 and the following day he was successfully extubated. He was discharged to home on day 28 with maintenance amlodipine therapy and no permanent sequelae (Said et al, 2014).
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Respiratory |
3.6.2) CLINICAL EFFECTS
A) DYSPNEA 1) WITH POISONING/EXPOSURE a) Respiratory difficulty developed in three of 22 subjects who sustained bites presumed to be from Tegenaria arestis (Vest, 1987).
B) EDEMA 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 7-year-old boy developed rapidly progressing neck swelling secondary to a brown recluse spider bite. Initially, the patient did not have any respiratory distress, but the edema progressed to include the clavicles and the upper chest. He complained of shortness of breath approximately 40 hours after exposure. Oxygen saturation on room air and a chest x-ray were both normal. Fiberoptic laryngoscopy showed mild edema of the glottis and supraglottis with normal vocal cord function and an adequate airway. Treatment included intravenous steroids, subcutaneous susphrine, and oral diphenhydramine. On hospital day 2, swelling had decreased and the patient did not complain of any further respiratory difficulty. He was discharged to home on day 5 (Goto et al, 1996).
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Neurologic |
3.7.2) CLINICAL EFFECTS
A) HEADACHE 1) WITH POISONING/EXPOSURE a) Persistent headache is common in patients with systemic effects (Eichner, 1984; Minton & Olson, 1964; Vorse et al, 1972; Vest, 1987; Sams et al, 2001).
B) ALTERED MENTAL STATUS 1) WITH POISONING/EXPOSURE a) Mental status changes ranging from confusion to lethargy to coma have been reported in severe suspected Loxosceles envenomations (Vorse et al, 1972; Schenone & Prats, 1961; Majeski & Durst, 1976).
b) Visual disturbances, hallucinations, disorientation and confusion have been reported after bites presumed to be from Tegenaria agrestis (Vest, 1987).
C) PARESTHESIA 1) WITH POISONING/EXPOSURE a) Persistent anesthesia and dysesthesia over the area of the bite has been reported (Longfield, 1981; Gross et al, 1990).
D) MYELITIS 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 19-year-old man developed transverse myelitis with partial permanent paralysis from occlusion of the anterior vertebral artery after a presumed L. reclusa bite (Wasserman & Anderson, 1984).
E) INTRACRANIAL HEMORRHAGE 1) WITH POISONING/EXPOSURE a) CASE REPORT: Subdural hematoma was discovered on autopsy of a 6 year old boy who developed severe hemolysis and DIC after a presumed L. reclusa bite (Vorse et al, 1972).
F) SEIZURE 1) WITH POISONING/EXPOSURE a) Seizures have been reported with severe presumed L. reclusa envenomations, but are rare (Majeski & Durst, 1976; Edwards et al, 1980).
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Gastrointestinal |
3.8.2) CLINICAL EFFECTS
A) VOMITING 1) WITH POISONING/EXPOSURE a) Nausea and vomiting may develop in patients with systemic effects (Russell et al, 1969; Madrigal et al, 1972; Eichner, 1984; Rees et al, 1985; Bradley & Starkey, 1988; Sams et al, 2001).
B) DIARRHEA 1) WITH POISONING/EXPOSURE a) Diarrhea was reported in a 72-year-old man one week after receiving a suspected envenomation by a brown recluse spider (Andersen et al, 2010).
C) LOSS OF APPETITE 1) WITH POISONING/EXPOSURE a) Anorexia was described in five of 22 subjects who sustained bites presumed to be from Tegenaris arestis (Vest, 1987).
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Genitourinary |
3.10.2) CLINICAL EFFECTS
A) HEMOGLOBINURIA 1) WITH POISONING/EXPOSURE a) Hemoglobinuria is reported in patients with hemolysis (Donepudi et al, 2005; Rauber, 1983; Chu et al, 1978; Madrigal et al, 1972) (Anderson, 1991)(Vorse et al, 1972) (Schenone & Parts, 1961) (Eichner, 1984).
b) Proteinuria and mild glycosuria have also been reported (Donepudi et al, 2005; Madrigal et al, 1972; Minton & Olson, 1964) (Anderson, 1991).
B) ACUTE RENAL FAILURE SYNDROME 1) WITH POISONING/EXPOSURE a) Acute tubular necrosis with resulting oliguria or anuria may develop in patients with severe hemolysis (Vorse et al, 1972; Schenone & Prats, 1961; Yarbrough, 1987).
b) CASE REPORT: A 71-year-old man presented to the hospital 5 days after a spider bite with a severe kidney failure, hemolysis, metabolic acidosis, and clotting disorder. He was diagnosed with viscerocutaneous loxoscelism. He died 5 weeks after admission despite supportive care (Zambrano et al, 2005).
c) CASE REPORT: A 6-year-old boy developed massive hemolysis, disseminated intravascular coagulopathy, shock (BP 77/47 mm Hg) and acute renal failure after a suspected loxoscelism envenomation. The patient was initially admitted with a one day history of abdominal pain, nausea, vomiting and intermittent fever following a presumed spider bite; a dead spider was found by the mother in the child's bed (Note: there is no report that the spider was identified at home or brought to the hospital for identification). He had erythroderma and 2 large, bullous lesions with ecchymotic and erythematous bases on his lower abdomen. His initial laboratory studies were significant for an elevated WBC and coagulation abnormalities (ie, prothrombin time 30.1; partial thromboplastin time 65.6; and INR 2.96) and dark urine that was positive for hemoglobin and myoglobin. The patient required immediate intubation with fluid resuscitation and red blood cell transfusion. The patient required dopamine and epinephrine for ongoing hypotension. Further laboratory analysis was not possible due to massive hemolysis. Due to the presence of anuria, metabolic acidosis, hyperkalemia, and ongoing need for blood products, the patient was started on plasma exchange therapy (PEX) for hemolyzed plasma and continuous venovenous hemodiafiltration (CVVH). Over the next few weeks, the child gradually improved. By day 8, he was weaned off all inotropes and his neurologic function was normal. Hemolysis slowly resolved and PEX was discontinued on day 9 and CVVH was gradually weaned as his urine output increased. CVVH was discontinued on day 11 and the following day he was successfully extubated. He was discharged to home on day 28 with maintenance amlodipine therapy and no permanent sequelae (Said et al, 2014).
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Acid-Base |
3.11.2) CLINICAL EFFECTS
A) ACIDOSIS 1) WITH POISONING/EXPOSURE a) CASE REPORT: Metabolic acidosis has been reported in a 6-year-old boy with severe hemolysis and DIC secondary to presumed L. reclusa envenomation (Vorse et al, 1972).
b) CASE REPORT: A 71-year-old man presented to the hospital 5 days after a spider bite with a severe kidney failure, hemolysis, metabolic acidosis, and clotting disorder. He was diagnosed with viscerocutaneous loxoscelism. He died 5 weeks after admission despite supportive care (Zambrano et al, 2005).
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Hematologic |
3.13.2) CLINICAL EFFECTS
A) HEMOLYSIS 1) WITH POISONING/EXPOSURE a) Acute intravascular hemolysis is not uncommon in severe envenomations (Rauber, 1983; Chu et al, 1978; Madrigal et al, 1972; Eichner, 1984; Yarbrough, 1987; Wasserman, 1988). In a retrospective review of 111 patients with suspected brown recluse spider bites treated during a 30-month period, mild hemolysis was reported in only one patient (Wright et al, 1997).
b) LABORATORY FINDINGS: Low hematocrit, hemoglobinuria, elevated plasma hemoglobin and direct bilirubin, and elevations of serum potassium, LDH and SGOT may develop with hemolysis.
c) PERIPHERAL SMEAR: The peripheral smear may show increased numbers of spherocytes, polychromasia, nucleated red blood cells, Heinz bodies, immature myeloid cells, and evidence of erythrophagocytosis (Way et al, 2005; Eichner, 1984; Chu et al, 1978).
d) COOMBS' TEST: May be positive (Eichner, 1984).
e) PEDIATRIC: Red blood cells from a child with hemolysis from presumed L. reclusa envenomation were found to be reactive by indirect antiglobulin test with most ABO-compatible serum samples (Hardman et al, 1983).
B) LEUKOCYTOSIS 1) WITH POISONING/EXPOSURE a) Leukocytosis and a left shift are common findings (Way et al, 2005; Eichner, 1984; Bernstein & Ehrlich, 1986).
b) CASE REPORT: An 11-year-old boy presented with fever (up to 104 degrees F), pharyngitis, erythematous rash (over his ears, scalp, neck, trunk, buttocks, and proximal extremities), and a necrotic lesion on the lobule of the left ear after a brown recluse spider bite. The lesion on the lobule developed a significant eschar on its anterior and posterior surface over 4 days. The eschar auto-amputated with a significant soft tissue defect. He also developed leukocytosis (WBC 22,400 cells/mm(3); previously 14,500 cells/mm(3)), hemolytic anemia, and proteinuria. He was diagnosed with systemic loxoscelism. Following 4 days of supportive care, he recovered and was discharged (Donepudi et al, 2005).
C) THROMBOCYTOPENIC DISORDER 1) WITH POISONING/EXPOSURE a) Thrombocytopenia may occur (Chu et al, 1978; Vorse et al, 1972).
D) HEMOLYTIC ANEMIA 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 9-year-old boy presented with fever (102 degrees F), myalgias and a pruritic rash with a draining flank wound following a brown recluse bite one day prior to admission. Laboratory evidence of hemolytic anemia was present and included: hemoglobin 10.4 g/dL, hematocrit 25.8%, mean corpuscular volume 89.0 cm mcgm, total bilirubin 1.3 mg/dL with an indirect component of 1.1 mg/dL, and normal liver transaminases. Urinalysis was normal. A peripheral smear collected after admission was positive for shistocytes and Heinz bodies further supporting the diagnosis of intravascular hemolysis. The patient required 2 units of packed red blood cells by day 3 for a persistent decline in hematocrit (lowest 13.4%), which stabilized by day 6 (Way et al, 2005).
b) CASE REPORT: An 11-year-old boy presented with fever (up to 104 degrees F), pharyngitis, erythematous rash (over his ears, scalp, neck, trunk, buttocks, and proximal extremities), and a necrotic lesion on the lobule of the left ear after a brown recluse spider bite. The lesion on the lobule developed a significant eschar on its anterior and posterior surface over 4 days. The eschar auto-amputated with a significant soft tissue defect. He also developed leukocytosis, hemolytic anemia (hematocrit 26.5%; previously 31.6%), and proteinuria. He was diagnosed with systemic loxoscelism. Following 4 days of supportive care, he recovered and was discharged (Donepudi et al, 2005).
E) DISSEMINATED INTRAVASCULAR COAGULATION 1) WITH POISONING/EXPOSURE a) CASE REPORT: Hemolysis, thrombocytopenia, prolonged PT and PTT, decreased fibrinogen and increased fibrin split products developed in a 6-year-old boy with severe envenomation presumed to be secondary to L. reclusa bite (Vorse et al, 1972).
b) CASE REPORT: A 71-year-old man presented to the hospital 5 days after a spider bite with a severe kidney failure, hemolysis, metabolic acidosis, and clotting disorder. He was diagnosed with viscerocutaneous loxoscelism. He died 5 weeks after admission despite supportive care (Zambrano et al, 2005).
c) CASE REPORT: A 6-year-old boy developed massive hemolysis, disseminated intravascular coagulopathy, shock (BP 77/47 mm Hg) and acute renal failure after a suspected loxoscelism envenomation. The patient was initially admitted with a one day history of abdominal pain, nausea, vomiting and intermittent fever following a presumed spider bite; a dead spider was found by the mother in the child's bed (Note: there is no report that the spider was identified at home or brought to the hospital for identification). He had erythroderma and 2 large, bullous lesions with ecchymotic and erythematous bases on his lower abdomen. His initial laboratory studies were significant for an elevated WBC and coagulation abnormalities (ie, prothrombin time 30.1; partial thromboplastin time 65.6; and INR 2.96) and dark urine that was positive for hemoglobin and myoglobin. The patient required immediate intubation with fluid resuscitation and red blood cell transfusion. The patient required dopamine and epinephrine for ongoing hypotension. Further laboratory analysis was not possible due to massive hemolysis. Due to the presence of anuria, metabolic acidosis, hyperkalemia, and ongoing need for blood products, the patient was started on plasma exchange therapy (PEX) for hemolyzed plasma and continuous venovenous hemodiafiltration (CVVH). Over the next few weeks, the child gradually improved. By day 8, he was weaned off all inotropes and his neurologic function was normal. Hemolysis slowly resolved and PEX was discontinued on day 9 and CVVH was gradually weaned as his urine output increased. CVVH was discontinued on day 11 and the following day he was successfully extubated. He was discharged to home on day 28 with maintenance amlodipine therapy and no permanent sequelae (Said et al, 2014).
3.13.3) ANIMAL EFFECTS
A) ANIMAL STUDIES 1) THROMBOCYTOPENIA a) DOGS: Marked thrombocytopenia and moderate hemolysis developed in each of 15 dogs injected with either crude extract of macerated L. reclusa, venom from milked spiders, or lyophilized pooled venom. Direct hemolytic activity of lyophilized venom was noted on human red blood cells in vitro (Denny et al, 1964).
b) RABBITS: Thrombocytopenia, decreased fibrinogen, and prolonged Lee White clotting time with normal PT and PTT developed in rabbits injected with L. reclusa venom (Berger, 1973).
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Dermatologic |
3.14.1) SUMMARY
A) In most cases local pain or a burning sensation develops within the first 10 minutes. A small vesicle may form at the bite area. The lesion may take on a "bull's eye" or "halo" appearance, having a central vesicle surrounded by an erythematous and ecchymotic area. A blanched ring may surround the discolored area. The vesicle may rupture, exposing an ulcer. Occasionally, the ulcer may enlarge and involve underlying tissues, including muscle.
B) A generalized pruritic morbilliform rash may develop over the trunk and extremities, usually during the first 24 to 72 hours.
3.14.2) CLINICAL EFFECTS
A) PAIN 1) WITH POISONING/EXPOSURE a) Pain or stinging may occur with the initial bite (Madrigal et al, 1972; Bradley & Starkey, 1988). Worsening pain, a burning sensation and pruritus may develop as the lesion progresses (Wand, 1972; Baldwin et al, 1988; Russell et al, 1969) Anderson, 1991; (Berger, 1973).
b) CASE SERIES: In a retrospective review of 19 documented cases of L. reclusa envenomation, the most common presenting symptom was pain at the site (most bites occurred on the extremities). In one patient, persistent pain required two lumbar sympathetic blocks (Sams et al, 2001).
B) BITE - WOUND 1) WITH POISONING/EXPOSURE a) Initial erythema surrounding the bite site is very common. The extremities are common areas for exposure (67% of exposures), but may also occur on the trunk or head and neck region (Cacy & Mold, 1999). This may progress to a "target lesion" with an erythematous central vesicle or puncta surrounded by a blanched ring which may in turn be surrounded by an erythematous ring (Berger, 1973; Russell et al, 1969; Anderson, 1987). A characteristic presentation of the site following a bite has been described as the "red, white, and blue" sign (erythema, ischemia, and necrosis) (Masters, 1998).
b) CASE REPORT: A 13-year-old girl developed dermonecrotic ulcer on her eyelid after a bite by a presumed L. spider. She developed no evidence of systemic reaction. She was treated with supportive care and erythema and edema resolved in one week (Bilgili et al, 2013).
c) CASE SERIES: In a retrospective review of 19 documented cases of L. reclusa envenomation, all patients presented with localized erythema (Sams et al, 2001).
C) SKIN NECROSIS 1) WITH POISONING/EXPOSURE a) The central vesicle may become sunken and dark purple or black and rupture, exposing an ulcer (Bradley & Starkey, 1988; Anderson, 1982a).
b) In severe cases, necrosis may involve large areas and extend into fat and muscle (Lewis & Regan, 1966; Russell et al, 1969; Edwards et al, 1980; Alario et al, 1987; Baldwin et al, 1988; Hoover et al, 1990).
c) In lesions destined to develop significant necrosis, bullae and hemorrhage have usually developed by 24 hours (Berger, 1973a).
d) CASE REPORT: A 22-year-old woman was bitten on the ear by a presumed Mediterranean recluse and she developed immediate pain which was followed by swelling of the face and a rash covering her entire body 48 hours after envenomation. Initial treatment included antihistamines but did not improve ear pain and by day 12 necrosis of the middle third of the ear was observed. Approximately 5 months later, partial reconstruction of the ear was required which was followed by a full thickness skin graft to close the posterior side of the ear (Holtslag et al, 2014).
e) CASE SERIES: In a retrospective review of 19 documented cases of L. reclusa envenomation, 11 patients (58%) had skin necrosis; 32% of those individuals had areas of necrosis larger than 1 cm(2). Time to healing was variable, and ranged from 5 days to more than 17 weeks (mean, 5.6 weeks). With severe lesions (grade 3; a total of 6 patients) average time to healing was 74 days; 22 days for moderate lesions (grade 2; a total of 5 patients), and 8 days for mild lesions (grade 1; a total of 8 patients). Tissue response was variable and ranged from mild erythema to severe cutaneous necrosis. Violaceous discoloration at presentation was indicative of incipient necrosis, and was present in 8 patients. Scarring was reported in 3 patients; chronic ulceration did not occur (Sams et al, 2001).
f) CASE SERIES/INCIDENCE: In a retrospective review of 149 possible brown recluse spider bites, skin necrosis was present in 41% of bites (Cacy & Mold, 1999).
g) SKIN GRAFTING: In a retrospective review of 111 patients with suspected brown recluse spider bites treated during a 30-month period, most bites required only supportive care and delayed skin grafting was only required in 3 cases (two of the three patients had been prescribed dapsone during the early phase of illness) (Wright et al, 1997).
h) LAMPONA SPECIES: Blistering, ulceration, pain and skin necrosis were found in 14 cases of spider bites thought to be from the white-tailed spider (note: only 3 cases were confirmed). One patient required amputation of the hand and distal forearm. In nine of the patients, the necrosis reoccurred (Pincus et al, 1999). Another patient had 2 reoccurrences of necrotic arachnidism in the 12 months following a bite by a white-tailed spider (Chan, 1998).
D) ACRAL ERYTHEMA 1) WITH POISONING/EXPOSURE a) HAND-FOOT SYNDROME 1) Hand-foot syndrome, a rare disorder characterized by painful erythema on the palms and soles of the feet, was described in a healthy adult 3 days after being bitten by a brown spider. Biopsies of the hand lesions showed subacute angiocentric dermatitis. Serology studies were negative. Treatment included topical steroids, cold compresses, and antihistamines (Farah et al, 2006).
E) GANGRENE 1) WITH POISONING/EXPOSURE a) Recurrent, chronic, indolent areas of ulceration, inflammation and infections similar to pyoderma gangrenosum have been reported in 5 patients with presumed L. reclusa envenomation (Hoover et al, 1990; Rees et al, 1985).
F) MACULOPAPULAR ERUPTION 1) WITH POISONING/EXPOSURE a) A generalized morbilliform rash may develop in patients with systemic effects (Russell et al, 1969; Bradley & Starkey, 1988) (Anderson, 1991) (Berger, 1973; Ingber et al, 1991).
b) INCIDENCE: In a retrospective review of 111 patients with suspected brown recluse spider bites treated during a 30-month period, 24 patients (22%) developed a secondary rash, usually described as maculopapular or consisting of "island lesions" (Wright et al, 1997).
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Musculoskeletal |
3.15.2) CLINICAL EFFECTS
A) MUSCLE PAIN 1) WITH POISONING/EXPOSURE a) Myalgias, arthralgias and general weakness are common symptoms in patients with systemic effects (Russell et al, 1969; Wasserman & Anderson, 1984; Sams et al, 2001).
B) RHABDOMYOLYSIS 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 20-year-old man was bitten on the neck by a Loxosceles arizonica (entomologist-identified) and initially developed pain, muscle cramping, tremulousness, and fever (103.4 degrees F). Two days later, the patient had a macular rash and a CPK of 17,000 U/L; total bilirubin of 3.5 mg/dL; platelets 120,000/mm(3); creatinine 1.4 mg/dL; SGOT 175 U/L; and an elevated urine myoglobin. Treatment included intravenous hydration, antibiotics, and urinary alkalinization. CPK peaked at 24,503 U/L and SGOT at 182 U/L. Labs were improving by day five. At 2 weeks the patient was clinically improved with a resolving dermatonecrosis (Seifert et al, 2000).
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Reproductive |
3.20.1) SUMMARY
A) Two cases of L. reclusa envenomation during the third trimester of pregnancy have been documented. Maternal symptoms were mild and both delivered healthy infants.
3.20.3) EFFECTS IN PREGNANCY
A) CASE SERIES 1) Two cases of documented L. reclusa envenomation and three of suspected L. reclusa envenomations have been described in women during the third trimester of pregnancy. All envenomation syndromes were mild and resolved rapidly, and all five women subsequently delivered healthy infants (Anderson, 1982).
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