Brown Recluse Spider Bite: A Rare Cause of Necrotic Wounds

Author(s): 
Pamela S. Norden, MD, MBA, and Tania J. Phillips, MD, FRCPC

A 55-year-old white woman presents with a 9-month history of nonhealing ulceration inferior to the right axilla. The patient does not recall any trauma or antecedent event but remembers cleaning a garage in northern California 3 days prior to ulcer appearance. The wound was initially small but subsequently enlarged and developed satellite ulcers. Multiple courses of both topical and oral antibiotics and topical steroids did not improve the condition. The patient reports that nonadherent granulation occurs and that the ulcer often produces clear drainage, bleeds easily, and is extremely painful. She denies that the affected site was ever blue, gray, or black in color. After months of evaluation by numerous physicians, the patient is diagnosed with a brown recluse spider bite.
Physical examination is notable for a 5 cm x 4 cm well-demarcated circular ulcer of the right lateral chest, inferior to the axilla (Figure 1). The left lateral border shows overgranulation. The right lateral aspect reveals increased depth with fibrinous exudate. Three adjacent superficial ulcers, each approximately 1 cm in diameter, are also present. The surrounding skin is notable for macular erythema. There is no cervical or axillary lymphadenopathy. The remainder of the patient’s full skin examination is within normal limits. Scars are noted on bilateral breasts from prior mastectomy and reconstruction surgery.
Has the patient been correctly diagnosed?

Background

The brown recluse spider (Loxosceles reclusa) is the most common of the Loxosceles species in the United States.1 Human Loxosceles bites were first described in the literature1 in 1879 and were first associated with necrosis2 in 1958. While the majority of wounds caused by this spider do not require medical attention, bites may result in necrotic skin lesions, hemolysis, and renal failure. Each year, approximately 10,000 spider bites are reported to poison control centers in the US. In 1994, 1,835 of these were attributed to L. reclusa.3
The brown recluse spider is found in the southern central states of the midwestern region of the US (Figure 2).4 The heavy concentration of these spiders in this region is primarily attributable to its warm climate and moderate winters.5 Similar species found in southern California, Arizona, and Texas are known by common names, such as the desert recluse and the Arizona recluse. Many physicians incorrectly refer to all of these species as brown recluse spiders.4
Verified reports of spider travel outside of the native area are rare and almost always involve single spiders.4 Bites are uncommon in locations where spider populations are abundant and are distinctly rare in nonendemic regions. A collaborator in a 2001 study in Kansas collected more than 2,000 brown recluse spiders in her home, but no one in the home ever showed evidence of a bite.6
In contrast to the majority of spider species, which have 8 eyes, recluse spiders possess 3 pairs of eyes (dyads) on the anterior portion of the cephalothorax. The dorsum of the recluse cephalothorax is notable for a dark-brown violin-shaped marking (Figure 3). Though spiders may darken as they age and obscure the marking, these 2 findings often assist the layperson in identifying the recluse.7 Other distinguishing characteristics include an abdomen that lacks a coloration pattern and legs covered with fine hairs, in contrast to the thickened spines of other species.4 Brown recluse spiders often seek shelter in places away from plain view, such as abandoned buildings, basements, dresser drawers, stairwells, and clothing. The spider bites only when forced into contact with human skin.5

Clinical Presentation

Numerous attempts have been made to classify the clinical spectrum of loxoscelism, the condition of human envenomation by a Loxosceles spider.

References: 

References

1. Caveness W. Insect bite complicated by fever. Nashville Journal of Medicine and Surgery. 1872;10:333.
2. Atkins JA, Wingo CW, Sodeman WA, Flynn JE. Necrotic arachnidism. Am J Trop Med Hyg. 1958;7(2):165–184.
3. Centers for Disease Control and Prevention (CDC). Necrotic arachnidism—Pacific Northwest, 1988–1996. MMWR Morb Mortal Wkly Rep. 1996;45(21):433–436.
4. Vetter R. Identifying and misidentifying the brown recluse spider. Dermatol Online J. 1999;5(2):7.
5. Wong RC, Hughes SE, Voorhees JJ. Spider bites. Arch Dermatol. 1987;123(1):98–104.
6. Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in nonendemic areas. J Med Entomol. 2002;39(6):948–951.
7. Forks TP. Brown recluse spider bites. J Am Board Fam Pract. 2000;13(6):415–423.
8. Gendron BP. Loxosceles reclusa envenomation. Am J Emerg Med. 1990;8(1):51–54.
9. Sams HH, Hearth SB, Long LL, Wilson DC, Sanders DH, King LE Jr. Nineteen documented cases of Loxosceles recluse envenomation. J Am Acad Dermatol. 2001;44(4):603–608.
10. Cacy J, Mold JW. The clinical characteristics of brown recluse spider bites treated by family physicians: an OKPRN Study. Oklahoma Physicians Research Network. J Fam Pract. 1999;48(7):536–542.
11. Wright SW, Wrenn KD, Murray L, Seger D. Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med. 1997;30(1):28–32.
12. Sams HH, Dunnick CA, Smith ML, King LE Jr. Necrotic arachnidism. J Am Acad Dermatol. 2001;44(4):561–573.
13. Anderson PC. Spider bites in the United States. Dermatol Clin. 1997;15(2):307–311.
14. Majeski JA, Durst GG. Necrotic arachnidism. South Med J. 1976;69(7):887–891.
15. James JA, Sellars WA, Austin OM, Terrill BS. Reactions following suspected spider bite. A form of loxoscelism? Am J Dis Child. 1961;102:395–398.
16. Nance WE. Hemolytic anemia of necrotic arachnidism. Am J Med. 1961;31:801–807.
17. King LE Jr, Rees RS. Treatment of brown recluse spider bites. J Am Acad Dermatol. 1986;14(4):691–692.
18. Rekow MA, Civello DJ, Geren CR. Enzymatic and hemolytic properties of brown recluse spider (Loxosceles reclusa) toxin and extracts of venom apparatus, cephalothorax and abdomen. Toxicon. 1983;21(3):441–444.
19. Berger RS. Management of brown recluse spider bite [letter]. JAMA. 1984;251(7):889–890.
20. Anderson PC. What’s new in loxoscelism—1978: case report. Mo Med. 1977;74(9):549–552, 556.
21. Gates CA, Rees RS. Serum amyloid P component: its role in platelet activation stimulated by sphingomyelinase D purified from the venom of the brown recluse spider (Loxosceles reclusa). Toxicon. 1990;28(11):1303–1315.
22. Vetter RS, Bush SP. The diagnosis of brown recluse spider bite is overused for dermonecrotic wounds of uncertain etiology. Ann Emerg Med. 2002;39(5):544–546.
23. Osterhoudt KC, Zaoutis T, Zorc JJ. Lyme disease masquerading as brown recluse spider bite. Ann Emerg Med. 2002;39(5):558–561.
24. Vetter RS, Bush SP. Chemical burn misdiagnosed as brown recluse spider bite. Am J Emerg Med. 2002;20(1):68–69.
25. Roche KJ, Chang MW, Lazarus H. Images in clinical medicine. Cutaneous anthrax infection. N Engl J Med. 2001;345(22):1611.
26. Vetter RS, Bush SP. Reports of presumptive brown recluse spider bites reinforce improbable diagnosis in regions of North America where the spider is not endemic. Clin Infect Dis. 2002;35(4):442–445.
27. Edwards GB. The present status and a review of the brown recluse and related spiders, Loxosceles spp. (Araneae: Sicariidae), in Florida. Entomology Circular. 2001;406:1–6.
28. Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown recluse spider bites (loxoscelism) greatly outnumber actual verifications of the spider in four western American states. Toxicon. 2003;42(4):413–418.
29. Barrett SM, Romine-Jenkins M, Blick KE. Passive hemagglutination inhibition test for diagnosis of brown recluse spider bite envenomation. Clin Chem. 1993;39(10):2104–2107.
30. Miller MJ, Gomez HF, Snider RJ, Stephens EL, Czop RM, Warrem JS. Detection of Loxosceles venom in lesional hair shafts and skin: application of a specific immunoassay to identify dermonecrotic arachnidism. Am J Emerg Med. 2000;18(5):626–628.
31. Gomez HF, Krywko DM, Stoecker WV. A new assay for the detection of Loxosceles species (brown recluse) spider venom. Ann Emerg Med. 2002;39(5):469–474.
32. King LE Jr. Brown recluse spider bites: stay cool [letter]. JAMA. 1985;254(20):2895–2896.
33. Dillaha CJ, Jansen GT, Honeycutt WM, Hayden CR. North American loxoscelism. Necrotic bite of the brown recluse spider. JAMA. 1964;188:33–36.
34. Rees R, Shack RB, Withers E, Madden J, Franklin J, Lynch JB. Management of the brown recluse spider bite. Plast Reconstr Surg. 1981;68(5):768–773.
35. Berger RS, Adelstein EH, Anderson PC. Intravascular coagulation: the cause of necrotic arachnidism. J Invest Dermatol. 1973;61(3):142–150.
36. Wendell RP. Brown recluse spiders: a review to help guide physicians in nonendemic areas. South Med J. 2003;96(5):486–491.
37. King LE Jr, Rees RS. Dapsone treatment of a brown recluse bite. JAMA. 1983;250(5):648.
38. Phillips S, Kohn M, Baker D, et al. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptidine. Ann Emerg Med. 1995;25(3):363–368.
39. Rees RS, Altenbern DP, Lynch JB, King LE Jr. Brown recluse spider bites. Ann Surg. 1985;202(5):659–663.
40. Gutowicz M, Fritz RA, Sonoga AL. Brown recluse spider bite. A literature review and case report. J Am Podiatr Med Assoc. 1989;79(3):142–146.
41. 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. Ann Emerg Med. 2001;37(2):161–165.
42. Barrett SM, Romine-Jenkins M, Fisher DE. Dapsone or electric shock therapy of brown recluse spider envenomation? Ann Emerg Med. 1994;24(1):21–25.



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