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Spider Bites that aren't MRSA

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Real spider bites, not cutaneous abscesses

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Spider Bites that aren't MRSA

  1. 1. Spider Bites that aren’t MRSA Widows and Recluses Justin Hensley, MD Assistant Professor of Emergency Medicine Texas A&M Health Science Center/Christus Spohn
  2. 2. Disclosures • None
  3. 3. Recluse Spiders  100 species found nearly worldwide  80% Western Hemisphere  Mostly temperate and tropical areas  Synanthropic Swanson, DL., Vetter, RS. Loxoscelism. Clinics in Dermatology. 2006 May-Jun;24(3):213-21. Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29. • Attics • Stored clothing • Boxes
  4. 4. Recluse Web http://brown-recluse-spiders.net/spider_web.htm
  5. 5. Loxosceles spp • Brown Recluse-Loxosceles reclusa • Texas Recluse-Loxosceles devia • Big Bend Recluse-Loxosceles blanda • Apache Recluse-Loxosceles apachea • Desert Recluse-Loxosceles deserta • Arizona Recluse-Loxosceles arizonica
  6. 6. Loxosceles Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29.
  7. 7. Eyes http://www.alexanderwild.com/Insects/Amazing-Arachnids/10458708_pkHZ7z#!i=1468329946&k=V5DVrbX
  8. 8. Fiddleback http://www.tpwd.state.tx.us/outdoor-learning/hunter-education/online-course/preparation-and-survival/bites-and-stings
  9. 9. Arizona http://bugguide.net/node/view/380945/bgimage
  10. 10. Brown http://www.arachnologyatjunction.com/14.html
  11. 11. Big Bend http://www.arachnologyatjunction.com/14.html
  12. 12. Apache http://bugguide.net/node/view/717100/bgimage
  13. 13. Desert http://bugguide.net/node/view/424379/bgimage
  14. 14. Texas http://bugguide.net/node/view/594647/bgimage
  15. 15. Loxoscelism  Bites accidental  First reported case of loxoscelism was in 1872  Venom has multiple components  Sphingomyelinase D Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29. • Minor • Cutaneous • Systemic
  16. 16. Caveness W. Insect bite complicated by fever. Nashville Journal of Medicine and Surgery. 1872;10:333.
  17. 17. Minor Loxoscelism • Edema • Erythema Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29.
  18. 18. Cutaneous Loxoscelism Vetter, RS. Spiders of the genus Loxosceles (Araneae, Sicariidae): a review of biological, medical and psychological aspects regarding envenomations . The Journal of Arachnology. 2008 36:150–163. Anderson, RJ, Campoli, J, Johar, SK, Schumacher, KA, Allison, EJ. Suspected brown recluse envenomation: A case report and review of different treatment modalities. Journal of Emergency Medicine. 2011;41(2):31-37. Isbister GK, Fan HW. Spider bite. Lancet. 2011 Dec 10;378(9808):2039-47 Swanson, DL., Vetter, RS. Loxoscelism. Clinics in Dermatology. 2006 May-Jun;24(3):213-21. • Dermal Edema • Endothelial thickening • Vasodilation • Leukocyte infiltration • Coagulation • Hemorrhage
  19. 19. Systemic Loxoscelism • Rash – Petechial or morbilliform • Fever • Malaise • Nausea • Vomiting • Hemolysis • Myonecrosis – Acute renal failure • Disseminated intravascular coagulation • Complement mediated • Direct toxin effect Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29.
  20. 20. Treatments Effective • Cold compresses (RICE) • Tetanus • Symptomatic treatment – Antihistamines – Analgesics • Wound Care • Blood products – Systemic Less Effective • Heat Packs • Hyperbaric Oxygen • Nitroglycerin • Steroids • Electric Shock • Early surgical excision • Dapsone Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency department death from systemic loxoscelism. Annals of Emergency Medicine. 2012 Oct;60(4):439-41. Isbister GK, Fan HW. Spider bite. Lancet. 2011 Dec 10;378(9808):2039-47. Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29. Anderson, RJ, Campoli, J, Johar, SK, Schumacher, KA, Allison, EJ. Suspected brown recluse envenomation: A case report and review of different treatment modalities. Journal of Emergency Medicine. 2011;41(2):31-37.
  21. 21. Probably Shouldn’t Do • Hyperbaric Oxygen – May help lesions that are not healing (and are unclassified) Maynor ML, Abt L, Osborne PD. Brown recluse spider bites: beneficial effects of hyperbaric oxygen. J Hyperb Med 1992;7:89–102. – Not beneficial to pigs or rabbits Svendsen FJ. Treatment of clinically diagnosed brown recluse spider bites with hyperbaric oxygen: a clinical observation. J Ark Med Soc 1986;83:199 - 204. Phillips S, Kohn M, Baker D, et al. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptadine. Ann Emerg Med 1995;25:363- 8. Hobbs GD, Anderson AR, Greene TJ, Yealy DM. Comparison of hyperbaric oxygen and dapsone therapy for Loxosceles envenomation. Acad Emerg Med 1996;3:758 - 61. • Steroids – May help systemic symptoms Anderson PC. Loxoscelism threatening pregnancy: five cases. Am J Obstet Gynecol 1991;165:1454 - 6. – No help for ulcers Dillaha CJ, Jansen GT, Honeycutt WM, Hayden CR. The gangrenous bite of the brown spider in Arkansas. J Ark Med Soc 1963;60:91.
  22. 22. Don’t Do • Heat Packs – Worsen ulceration and necrosis King, LE. Brown recluse spider bites: keep cool. JAMA, 254 (1983), pp. 2895–2896 • Topical Nitroglycerin – Theoretically vasodilation may lessen necrosis – Does not help rabbits, may increase systemic effects Lowry BP, Bradfield JF, Carroll RG, Brewer K, Meggs WJ. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Annals of Emergency Medicine 2001;372:161–5.
  23. 23. Don’t Do • Electric Shock – Doesn’t help Barrett SM, Romine-Jenkins M, Fisher DE. Dapsone or electric shock therapy of brown recluse spider envenomation? Ann Emerg Med 1994;24:21- 5. – Unless done late? Osborn CD. Treatment of spider bites by high voltage direct current.J Okla State Med Assoc 1991;84:257 - 60. • Surgical Excision – Early surgery increases inflammation and may worsen venom effects Rees RS, Altenbern DP, Lynch JB, King LE. Brown recluse spider bites. A comparison of early surgical excision versus dapsone and delayed surgical excision. Ann Surg 1985;202:659–63. – Late surgery may be beneficial after necrosis margins declared Forks TP. Brown recluse spider bites. J Am Board Fam Pract 2000;13:415–23.
  24. 24. Dapsone • Theoretically inhibits leukocyte aggregation Bryant SM, Pittman LM. Dapsone use in Loxosceles reclusa envenomation: is there an indication? American Journal of Emergency Medicine 2003;21:89 - 90. King LE, Rees RS. Dapsone treatment of a brown recluse bite. JAMA 1983;250:648. • Reduces lesion size in guinea pigs Barrett SM, Romine-Jenkins M, Fisher DE. Dapsone or electric shock therapy of brown recluse spider envenomation? Ann Emerg Med 1994;24:21- 5. • No benefit in rabbits Elston DM, Miller SD, Young III RJ, et al. Comparison of colchicine, dapsone, triamcinolone, and diphenhydramine therapy for the treatment of brown recluse spider envenomation: a double-blind, controlled study in a rabbit model. Arch Dermatol 2005;141:595-7. Phillips S, Kohn M, Baker D, et al. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptadine. Ann Emerg Med 1995;25:363-8. • No prospective trials with benefits to humans Swanson, DL., Vetter, RS. Loxoscelism. Clinics in Dermatology. 2006 May- Jun;24(3):213-21. • Side Effects – Hemolysis in all patients – Methemoglobinemia – Headache – GI upset – Hepatitis – Exfoliative dermatitis – Agranulocytosis – Motor neuropathy
  25. 25. Witnessed Recluse Bite? Well Appearing  UA Ill Appearing • Resuscitation • CBC • INR • Fibrinogen • BMP • CK Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency department death from systemic loxoscelism. Annals of Emergency Medicine. 2012 Oct;60(4):439-41.
  26. 26. Loxoscelism vs MRSA Rogers, KM, Klotz, CR, Jack, M, Seger, D. Systemic Loxoscelism in the Age of Community Acquired Methicillin Resistant Staphylococcus aureus. Annals of Emergency Medicine. 2011 Feb;57(2):138-40.
  27. 27. Systemic Loxoscelism Case  3 yr old previously healthy girl bitten by “fiddleback” while removing old blankets  2-3 hours- presented to rural ED, discharged home after evaluation  6 hours- fever to 39.3ºC  12 hours- N/V, malaise, increased pain at bite, tea colored urine • 15 hours-presented to urban children's ED – WBC 20.7, Hbg 9.5, Plt 54 – INR 1.8 • 18 hours-transfused • 19 hours- apneic, pulseless – Massive transfusion (6u PRBCs, 1 FFP, 1 platelet) – Undetectable hemoglobin Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency department death from systemic loxoscelism. Annals of Emergency Medicine. 2012 Oct;60(4):439-41.
  28. 28. Chilean Recluse • Loxosceles laeta • Common to all of South America • Los Angeles • Winter Park, Florida • Cambridge, Massachusetts • Vancouver • Treatment is same • No more toxic than other native recluses
  29. 29. http://ihdwallpapers.com/the_avengers_black_widow-wallpapers.html
  30. 30. Widow Spiders • 30 species worldwide • Females do not often eat males Vetter, RS, Isbister GK. Medical aspects of spider bites. Annual Review of Entomology. 2008;53:409-29. • Dark or dry places – Outdoor furniture – Potted plants – Storage boxes – Outhouses
  31. 31. Widow Web http://www.venombyte.com/venom/spiders/northern_black_widow.asp
  32. 32. Latrodectus spp • Southern Black Widow- Latrodectus mactans • Northern Black Widow- Latrodectus variolus • Western Black Widow- Latrodectus hesperus • Red Widow- Ladrodectus bishopi • Brown Widow- Latrodectus geometricus
  33. 33. http://bugguide.net/node/view/1999/data Widows
  34. 34. Southern Black http://www.whatsthatbug.com/2010/07/17/black-widows/
  35. 35. http://bugguide.net/node/view/26336/data Southern Black
  36. 36. http://www.pestid.msu.edu/InsectsArthropods/NorthernBlackWidowSpiderLatrodectusvariolus/tabid/263/Default.aspx http://commons.wikimedia.org/wiki/File:Latrodectus_variolus_(Northern_Black_Widow),_F_Theridiidae.jpg Northern Black
  37. 37. Northern Black http://bugguide.net/node/view/26421/data
  38. 38. Western Black http://nathistoc.bio.uci.edu/spiders/Latrodectus%20hesperus.htm
  39. 39. http://bugguide.net/node/view/26346/data Western Black
  40. 40. Red http://www.freshfromflorida.com/pi/enpp/ento/venomousspiders.html
  41. 41. Red http://bugguide.net/node/view/26290/data
  42. 42. Brown http://nathistoc.bio.uci.edu/spiders/Latrodectus%20geometricus.htm http://cisr.ucr.edu/images/brown_widow_spider_large.jpg
  43. 43. http://bugguide.net/node/view/23403/data Brown
  44. 44. Latrodectism • Venom is α-Latrotoxin (α-LTX) • Acetylcholine release at NMJ • Pain – Local, radiating, or regional • Diaphoresis – Local, radiating, or regional • Hypertension • Agitation • Fever • Muscle contraction • Rhabdomyolysis Monte AA, Bucher-Bartelson B, Heard KJ. A US perspective of symptomatic Latrodectus spp. envenomation and treatment: a National Poison Data System review. Ann Pharmacother. 2011 Dec;45(12):1491-8. Isbister GK, Fan HW. Spider bite. Lancet. 2011 Dec 10;378(9808):2039-47.
  45. 45. Treatments Effective • Analgesics • Benzodiazepines • Tetanus • Antivenom Less Effective • Calcium • Antibiotics • Magnesium Monte AA. Black widow spider (Latrodectus mactans) antivenom in clinical practice. Current Pharmaceutical Biotechnology. 2012 Aug;13(10):1935-9. Clark R, Wethern-Kestner S, Vance M, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Annals of Emergency Medicine 1992;21:782-7.
  46. 46. Antivenom • Antivenin (Latrodectus Mactans) • Analatro ® Monte AA. Black widow spider (Latrodectus mactans) antivenom in clinical practice. Curr Pharm Biotechnol. 2012 Aug;13(10):1935-9. Dart RC, Bogdan G, Heard K, Bartelson BB, Garcia-Ubbelohde W, Bush S, Arnold T, Clark RC, Hendey GW, Holstege C, Spradley EA. A Randomized, Double-Blind, Placebo- Controlled Trial of a Highly Purified Equine F(ab)2 Antibody Black Widow Spider Antivenom. Ann Emerg Med. 2013 Feb 1. Clark R, Wethern-Kestner S, Vance M, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med 1992;21:782-7.
  47. 47. Don’t Do • Calcium – Old study Key GF. 1981. A comparison of calcium gluconate and methocarbamol (Robaxin) in the treatment of latrodectism (black widow spider envenomation). Am. J. Trop. Med. Hyg.30:273–77 – 96% with no relief Clark R, Wethern-Kestner S, Vance M, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med 1992;21:782-7. • Magnesium – Old study Cesareo DA. 1934. “Red back” spider bite and magnesium sulphate treatment. Am. J. Trop. Med. Hyg. 14:33–44 • Antibiotics – No benefit, harmful side effects
  48. 48. Conclusions • Consider envenomation in endemic areas • Treat supportively
  49. 49. Questions?

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