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Home , Blister, Brown recluse spider, Envenomation, Loxosceles arizonica, Loxoscelism, Recluse spider

J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from

CUNICAL REVIEW Brown Recluse Bites

Thomas P. Forks, DO, PhD

Background: Brown bites are a serious medical problem in the southeastern United States. Although most bites are asymptomatic, can result in a constellation of systemic symptoms referred to as . Patients can also develop necrotic ulcers (necrotic ­ ism). These ulcers are often difficult to heal and can require skin grafting or of the bitten appendage. Metbods: A search of the literature was performed using the search words "spider envenomation," " bites," and "arachnid envenomation." Results and Conclusions: Most brown recluse spider bites are asymptomatic. All bites should be thoroughly cleansed and status updated as needed. Patients who develop systemic symptoms require hospitalization. Surgical excision of skin lesions is indicated only for lesions that have stabi­ lized and are no longer enlarging. Steroids are indicated in bites that are associated with severe skin lesions, loxoscelism, and in small children. should be used only in adult patients who experi­ ence necrotic arachnidism and who have been screened for glucose-6-phosphate dehydrogenase defi­ ciency. Topical nitroglycerin can be of value in decreasing the enlargement of necrotic skin ulcers. (J Am Board Fam Pract 2000;13:415-23.)

Brown recluse spider bites are a relatively common of the venomous South American brown spider problem in the United States and occur most fre­ (Loxosceles Ioeta) was initially described by Macchia­ quently in the midwest, south-central and south­ vello in 1937.2 It was not until 1957 that investiga­ eastern areas of the country. According to the Cen­ tion by Atkins et al 3 implicated of the brown ters for Disease Control, these bites are not a recluse spider (Loxosceles reclusa) as the agent of reportable illness; consequently, the numbers of necrotic arachnidism in the United States. patients developing systemic or cutaneous manifes­ tations caused by the venom of these can Methods

1 http://www.jabfm.org/ only be guessed. These bites can result in consid­ A search of the literature was performed using the erable morbidity and occasionally require the am­ search words "spider envenomation," "brown re­ putation of an involved extremity. Deaths from cluse spider bites," and "arachnid envenomation." , although rare, are usually caused by the induction of renal failure as a consequence of red cell . Treatment of these bites is Brown Recluse Spider All spiders are poisonous; however, most have fangs controversial and is generally directed at managing on 30 September 2021 by guest. Protected copyright. the cosmetic to the integument. A secondary that are too small to penetrate the skin of human focus of treatment is the management of the less beings. There are 23 or 24 genera, including 60 frequent but potentially more serious systemic ef­ odd species of spiders indigenous to the United States, that have been implicated in causing human fects of the neurotoxic venom, often referred to as injury. Members of at least six of these genera loxoscelism. Gangrenous spot, or necrotic spot of produce bites that can be confused with those of the (dermonecrosis), as a consequence of the bite brown recluse spider. These genera (AtrtlX, Argiope, ChirtlCanthium, Lycosa, Phidippus, Tegenaria) include the wolf, jumping and yellow garden spiders. These Submitted, revised, 16 February 2000. From the Department of Family Medicine, The Univer­ spiders are common, well recognized inhabitants of sity of Mississippi Medical Center, Jackson. Address reprint neighborhood backyards and flower gardens. The requests to Thomas P. Forks, DO, PhD, Department of Family Medicine, The University of Mississippi Medical (Tegenaria agrestis) has recently been Center, 2500 North State Street, Jackson, MS 39216-4505. implicated in cases of necrotic arachnidism in the

Brown Recluse Spider Bites 415 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from

northwest United States. 1,4 Members of Atrar are borders of , , and to the not indigenous to the United States. Members of Atlantic coast. Isolated populations of this species this are normally found in eastern can also be found in the more northern states of and inflict human bites in the United States when , , and . The species is imported with Australian produce. Worldwide, most concentrated in the central plain states of there are at least 200 species of spiders that have , Kansas, Oklahoma, and . Speci­ been implicated in the cutaneous or systemic poi­ mens have also been identified from California and soning of human beings. 5 after presumably being transported to those Numerous other indigenous North American locations with the personal possessions of travelers. and , including kissing bugs, ticks, L IlrizoniclI is indigenous to Arizona, New Mex­ , bedbugs, flies, fleas, snakes, rats, ico, Nevada, Texas, , southern California, and and mice, produce bites that can be superficially northwestern ; serious complications sec­ confused with mild cases of loxoscelism.6 Other ondary to envenomation by this species have also disease states, including herpetic ulcers, , been documented. lo L desertll, also known as L trauma, diabetic ulcers, rhus , bed sores, unicolor, is relatively uniform in color and its violin , Stevens-Johnson syn­ is nearly indistinct. This species has been less well drome, , drug reactions, throm­ studied and is normally found in the deserts of the boangiitis obliterans, and vascular disease,'-9 also western states. In the United States, L rufescens is produce skin lesions that can be confused with cases most commonly found in Texas and is referred to of necrotic arachnidism. Consequently, unless the by Gertschll as a cosmopolitan species, ie, a species offending is presented for identification introduced into the United States from Central with the bitten patient, it is prudent to designate all America on commercial vehicles. suspected brown recluse spider bites as presump­ by L rufescens and L laeta are tive brown spider bites, or presumptive necrotic well documented from Central and South Ameri­ arachnidism until definitive proof is obtained. ca. 12 L rufipes and L gllucho are also medically Six-eyed spiders (family Loxoscelidae) are rep­ important species in Central and South America, resented in the United States by 13 species of respectively. Loxosceles species is represented in Af­ spiders. Five of these species (L IlrizoniclI, L reciuslI, rica by 17 species, and reports of bites on the L rufescens, L desertll, and L laeta) have been impli­ African continent (L rufescens, L parnl1m) have been cated in systemic of bitten patients. published in the literature.13 Envenomations from These species are all very similar and all five species Loxosceles species have also been reported from Eu­

are appropriately referred to as fiddleback or violin rope and the Mideast, including Israel, presumably http://www.jabfm.org/ spiders. Although there is some interspecies varia­ by L rufescens. 14 Southcott15 documented bites tion in potency, all Loxosceles species produce a from the Australian continent (L rufescens, L laeta). neurotoxic venom that can potentially induce der­ Envenomations have also been repqrted by un­ monecrosis, varied systemic symptoms, and ana­ known species (probably L rufoscens) from , phylaxis in bitten patients. Loxosceles species are Russia, and . found in all the states as a result of translocation on on 30 September 2021 by guest. Protected copyright. clothing, bagging, and camping gear. Intrastate and interstate relocation of home furnishings and be­ Natural History longings, along with the nests, spiders, and eggs Brown recluse spiders are generally shy and inof­ contained therein, is also involved in the movement fensive. These spiders invariably seek shelter in of these spiders into nonindigenous areas. abandoned or infrequently used buildings, in base­ The brown recluse spider (brown spider, recluse ments, under tables, in dresser drawers, or in stair­ spider) is the most widely distributed member of wells. They can also be found in stored clothing, the genus in the United States and is the species under wood or rock piles, and within the loosened most often implicated in necrotic arachnidism. L and flaking bark of trees and logs. They produce reciuslI is indigenous to the states roughly south of small, irregularly formed webs (sheets) that cover the Mason-Dixon line or approximately 42 degrees and line their burrows or hides. These nocturnal latitude and east of 100 degrees longitude. These spiders prey on various small invertebrates and in­ spiders can be found eastward from the western sects, including firebrats and related silverfish.16

416 JABFP November-December 2000 Vol. 13 No. 6 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from

Although they have been shown to live up to 3 VMOIII PlllbopbysIoloD years in reproduced, artificial environments, their Electron microscopic studies of rabbit blood vessels natural life span is probably about 1 year. have shown endothelial damage as soon as 3 hours Morphologically, female brown recluse spiders after the manual injection of brown recluse venom. are slightly larger than the males and average 9 mm This damage is accompanied by , in length. Older, mature spiders are capable of altered prothrombin and partial thromboplastin attaining lengths up to 3 or 4 cm, inclusive of their times, and decreased fibrinogen levels. Shortly legs. The body accounts for approximately one fifth thereafter, small capillaries become occluded with of the adult size and is light tannish brown or thrombi, resulting in further tissue anoxia and de­ gray-brown in color. Female brown recluse spiders struction.19 Anderson20 indicated that large quan­ are generally larger than the males; consequently, tities of platelets become trapped very early in ven­ they produce a larger amount of venom and their om-damaged capillaries. Tissue is grossly bite is potentially more serious. The distinctive, visible at 24 hours after envenomation. dark brown or black violin, from which the spider Studies investigating the hemolytic activity of receives its name, is situated on the dorsal aspect of brown recluse venom have produced conflicting the oval cephalothorax. Individual spiders com­ results. Material extracted from the cephalothorax monly darken as they age, and the violin can be­ of brown recluse spiders has been shown to induce come indistinguishable. The neck of the violin is the direct hemolysis of human red blood cells. 21 oriented toward the grayish, oblong, sensillum­ Cephalothorax extracts contain materials from covered abdomen of the spider. both the gut and venom glands of spiders. In their In contrast to most spider species, recluse spi­ 1966 case report, Taylor and Dennr2 described ders possess six eyes arranged in a semicircle of the clinical course and death of a man who was three diads rather the eight eyes of other species. presumed to have been bitten by a brown recluse Adult spiders can live approximately 6 months spider and who developed hemolysis and renal fail­ without eating and can withstand temperature ex­ ure. Smith and Micks23 were unable to elicit any tremes of 8° to 43° cY Their ability to tolerate hemolytic activity of the venom of L laeta, L rec/us(l, such variations in temperature contributes to their and L rufescens. Abdominal extracts, however survival when accidentally transported to extreme caused the in vitro hemolysis of human red cells. or unusual environments, eg, . Researchers Morgan et al24 reported the in vitro hemolysis of discovered that the entire first floor of a University human red blood cells in blood plasma when brown of Helsinki building was infested with imported L recluse venom was added. Chu et al25 described the 18 laeta. case of a 2-year-old boy who was bitten on the http://www.jabfm.org/ chest and who developed a severe case of . This patient did not develop a correspond­ Fiddleback Venom ing dermonecrosis. Futrell et al26 proved that a very The collection of adequate volumes of brown re­ active component of brown recluse venom attaches cluse venom for biochemical analysis has been dif­ to human red cell membranes. They speculated ficult and challenging. Researchers have attempted that the resulting lysis of the red blood cells was on 30 September 2021 by guest. Protected copyright. to collect and fractionate venom for study by using accomplished through an interaction between this electrical stimulation and microdissection of the component and complement factors contained in venom glands. These studies have indicated that human serum. Conclusive evidence of the lytic ac­ the hemolytic component of the venom is heat tivity of brown recluse venom on human red blood labile, calcium dependent, and optimally active at a cells was described by Forrester et al. 27 Wtlliams pH of 7.1. Collectively, research to date has shown and coworkers28 described two cases of severe he­ that purified brown recluse venom contains a min­ molytic anemia resulting from brown recluse en­ imum of eight or nine different enzymes and pro­ venomation. One adult female patient suffered a teins, including alkaline phosphatase, esterase, fatal myocardial infarction after debridement of the lipase, protease, hyaluronidase, hemolysins, le­ large necrotic on her right upper arm. varterenol bitartrate, and sphingomyelinase D. Morgan and Felton29 illustrated human epithe­ Sphingomyelinase D is the most important and lial cell breakdown secondary to brown recluse most active enzyme in brown recluse spider venom. venom. A generalized breakdown of body fats in

Brown Recluse Spider Bites 417 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from insects has been shown to occur by Eskafi and Table 1. Systemic and Cutaneous Symptoms of Nonneneo after injection of brown recluse venom. Loxoscelism.

Sphingomyelinase D is a major component of Chills brown recluse spider venom and has been shown to Fever up to 105°F be cytotoxic to both endothelial cells and red blood Myalgia and arthralgia cells.27 This enzyme has also been shown to induce Nausea and emesis tissue necrosis in rabbit tissue. 31 •32 Tissue necrosis Pain in the bite site is directly attributable to the induction of endothe­ and ulceration lial cell disruption, intravascular hemolysis, platelet Skin necrosis aggregation, and thrombi fonnation by sphingo­ Thrombocytopenia myelinase D. This enzyme is also implicated in the Hemolysis disruption of nerve impulse transmission and in Disseminated intravascular coagulation Death contributing to cutaneous anesthesia. 33 Tissue ne­ crosis is also partly due to polymorphonuclear­ leukocyte-induced . tain. Cacy and Mold35 have noted that most brown The hyaluronidase in the venom contributes to recluse bites are clinically insignificant. the fluidity of the tissue and resultant spread of Systemic symptoms (Table 1) of loxoscelism can venom through the subcutaneous tissue. Gravity include fever up to 105° F36 chills, nausea, arthritic might play some role in the spread of the venom complaints, and blood abnonnalities.37- 39 Young40 and degraded tissue into dependent tissues. Bites in reported the interesting case of a 38-year-old man fatty areas seem to fare worse. It has been postu­ who was bitten by a brown recluse spider and who lated20 that the lipase and other components of the developed marked thrombocytopenia (platelet venom act directly on the fatty tissue, releasing count of 13,OOO/f.l.L) but no associated hemolysis or small microemboli and nonphysiologic products disseminated intravascular coagulation. Although into the bloodstream. the patient had a few petechiae on his lower ex­ tremities, his thrombocytopenia subsequently re­ solved without sequelae. Several authors have also Clinical Presentation described a generalized erythema or scarlatinifonn When initially bitten by brown recluse spiders, rash.41- 43 This rash is generally much more severe many patients experience a mild burning sensation in more severely envenomated patients. that might resolve only to reoccur much amplified Patients with small faciallesions44 secondary to several hours later. Pruritus, pain, and erythema brown recluse spider bites have had massive facial http://www.jabfm.org/ can develop around the bite site during the first 6 edema. Gotto and coUeagues45 described a case of hours after the bite. Hobbs and Harre1l 34 described severe cervical soft-tissue edema and swelling in a the fonnation of an ischemic ring, followed by the 7-year-old boy as a complication of brown recluse development of an irregular erythematous ring sur­ spider bite to the neck. L arizonica envenomation rounding the bite site within the first 24 hours. has been implicated in the induction of shock in a Some patients, presumably those who have experi­ 13-year-old girl in Arizona. lO This patient also de­ on 30 September 2021 by guest. Protected copyright. enced minimal envenomation, are devoid of any veloped a dysesthetic, hyperesthetic, -like discomfort at the time of the bite and are mystified rash on her trunk and proximal extremities. Sauer46 at the subsequent emergence and evolution of skin reported the case of a patient who developed bowel lesions. Patients are usually bitten when they are and bladder incontinence, transverse myelitis, and dressing themselves by spiders that have previously paralysis after a brown recluse spider bite to the crawled into their clothing. When bites are imme­ right buttock. At discharge, nearly 7 112 weeks diately painful, the spiders are invariably crushed. later, the patient had recovered only partial use of All spiders should be brought in by the patient for his lower extremities. proper identification even if only partial remains Within 24 hours after the bite, the local area can be collected. Using a hand lens or other suit­ around the bite site generally turns a reddish blue able magnifying device, the physician might be able color. A or bleb then fonns, and as necrosis to identify the diagnostic six eyes of the spider, continues, the lesion can evolve into an eschar thereby making the diagnosis of loxoscelism cer- during the next 2 or 3 days. The eschar will even-

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Table 2. Treatment Regimens for Brown Recluse they develop systemic symptoms, at which point Spider Bites. immediate hospitalization is indicated.

Early and late sllrgical excision of Surgical correction of venom-induced skin ne­ Wound curettage crosis can add considerable cost to the treatment of Steroids violin spider bites. Additionally, it is difficult to Dapsone determine presumptively which skin lesions will Hyperbaric oxygen progress to the point where they will require a surgical correction. Hershey and Aulenbacher48 ad­ vocated treatment with a combination of steroids, tuaIly slough off leaving a crater of variable size but , and , where indicated. They ad­ generally 1 to 2 cm wide. Ulcers can become ex­ mitted that none of these three therapies could tensive and enlarge to 30 cm in diameter. Large prevent necrosis of the bite site but suggested that ulcers might require up to 6 months to heal com­ early surgery to remove the involved skin and un­ 49 pletely and could require skin grafting. Some pa­ derlying fat was the preferred therapy. Amold tients will develop persistent, granulating ulcers at promoted surgical excision of all lesions 1 cm or 20 or near the bite site.36 Recurrent ulcers resembling greater in diameter. Anderson described lesions pyoderma gangrenosum can develop years later, that enlarged rapidly. These lesions were reported even in cases that had originally required treatment to cease enlarging suddenly, at which point they with skin grafts. developed a well-defined margin. Grouping the various clinical symptoms of lox­ When surgery is performed, it should be done oscelism and necrotic arachnidism by severity of for lesions that have stabilized, ie, late lesions. The systemic symptoms can facilitate treatment.47 Such surgeon must be reasonably confident that no post­ grouping is similar to the grading commonly used surgical enlargement of the lesion will occur. De- L · I so· when determining the severity of poisonous snake OZler et a, III a retrospective study of 31 patients bites. Patients who experience local bite site pruri­ with hand or upper extremity spider bites, deter­ tus and who lack systemic symptoms are in group 1. mined that delayed excision of the necrotic lesion Group 2 comprises patients whose bites exhibit an was preferable. He found that as many as 20% of area of necrosis approximately 1 cm or less. The the patients who underwent early excision of their area of necrosis surrounds a central vesicle. Group necrotic lesions subsequendy developed either a 3 comprises patients who exhibit' definite systemic wound breakdown or a functional limitation in the symptoms and who possess ulcers larger than 1 cm. use of the bitten extremity. Hollabaugh and Fer­

Group 4 comprises patients who exhibit large ul­ nandes 44 recommended curettage of the necrotic http://www.jabfm.org/ cers, greater than 4 cm, and who also exhibit severe tissue with local anesthesia for treatment of brown systemic symptoms. The usefulness of such grading spider bites. All 18 of the patients in their study schemes in determining severity of envenomation who were treated with curettage had that by fiddleback spiders is questionable because there healed without requiring skin grafting. Gutowicz et 9 is little correlation between the severity of skin al advocated wide excision of the necrotic lesion after the area of necrosis became well demarcated, necrosis and the development of systemic symp­ on 30 September 2021 by guest. Protected copyright. toms. 6 to 8 weeks after the bite. Wright et al,51 in a study of 111 patients with suspected brown recluse spider bite, found that most did not need surgery; how­ Treatment ever, 16 of the 111 patients in their study developed The appropriate treatment of brown recluse spider systemic symptoms. Three patients required de­ bites remains controversial, and various treatment layed skin grafting. Two of the 3 patients requiring regimens (Table 2) have been advocated with vary­ skin grafting had initially received dapsone therapy ing success. The care of mild, nonprogressive cases for treatment of their spider bite. of brown spider bite, however, should include thor­ Jansen et al,52 working with white rabbits, did ough cleansing of the wound site, elevation of the not find any treatment value of either intramuscu­ bitten extremity, administration of , and lar or intralesional administration of methylpred­ administration of tetanus vaccine, when indicated. nisolone (Depo-Medrol) in the prevention of der­ Patients should be observed closely to see whether monecrosis. Berger et al 19 also concluded that large

Brown Recluse Spider Bites 419 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from

doses of steroids had little effect on the progression oxyhemoglobin shifts the oxyhemoglobin dissocia­ or development of necrotic arachnidism. Sauer,46 tion curve to the left. Methemoglobin levels of however, advocated both intramuscular and intrale­ 35% or more can produce shortness of breath, sional injection of in the treatment of headache, and fatigue. Levels as high as 70% can severe bites. result in death of the patient. Patients suffering Anderson2o advocated the use of steroids only in from methemoglobinemia usually have a bluish tint severe bites, bites that were associated with loxos­ to their mucus membranes and their nail beds. celism, and bites involving small children. For chil­ Peripheral neuropathies, although rare, can also dren he specifically recommended using 100 mg of occur as a consequence of dapsone administration. prednisone daily for a minimum of 3 days, pending Willie and Morrow57 described a patient who de­ the results of additional studies to rule out hemo­ veloped fever, chills, nausea, headache, myalgia, lysis and renal failure. In this same publication, anorexia, and mild hemoglobinuria after treatment Anderson described the development of hemolysis, of brown spider bite with dapsone. Dapsone hyper­ intravascular hemorrhage, coagulation, hyponatre­ sensitivity normally occurs within 6 weeks of start­ mia, myoglobinuria, hemoglobinuria, and coma in ing the drug and resolves within 2 weeks of discon­ a 5-year-old boy who was bitten on his thigh. Ste­ tinuing therapy. This syndrome does not appear to roid therapy was instituted; however, the patient's be dose related. decreasing kidney output required peritoneal dial­ Other commonly seen side effects of dapsone ysis. Complete resolution of the sequelae of the therapy include sore throat, pallor, purpura, chole­ spider bite required a full 12 months. static jaundice, and hyperbilirubinemia. Many of Dapsone has been a cornerstone of the therapy these symptoms can also be a result of brown spider of brown recluse spider bite but has severe side envenomation, thereby confusing the clinical pic­ effects. Dapsone has been used to treat brown spi­ ture. Because of these serious side effects, dapsone der bites because it can inhibit polymorphonuclear should be reserved for adult patients who have leukocyte diapedesis and infiltration into the bite rapidly progressing, necrotic lesions. It should not site. Animal studies using dapsone have also had be administered to children. Adults who are se­ conflicting results. Several authors using venom­ lected to receive dapsone must first be screened for injected animal models have shown a decrease in glucose-6-phosphate dehydrogenase deficiency. the average size of necrotic lesions in the animals Dapsone should be given at dosages of 50 to 100 treated with dapsone. B ,54 Rees et al 36 in a compar­ mg daily.53,58 ative study found that the combination of dapsone The effect of hyperbaric oxygen in decreasing

and delayed surgical excision was preferable to im­ the size of necrotic skin lesions resulting from http://www.jabfm.org/ mediate surgical resection for the treatment of spi­ brown recluse envenomation has also been studied. der bite. Beilman et al 55 indicated that dapsone, to One studl9 using white rabbits showed an earlier be effective, must be administered within 36 hours reepithelization of the necrotic ulcers when these of the bite. This study showed no benefit to pre­ rabbits were treated with hyperbaric oxygen twice treatment of spider bites with dapsone. This study daily. Treatments were initiated at 72 hours after also showed no discernible benefit in giving pa­ injection of venom. Maynor et al60 speculated that tients dapsone when they sought treatment more hyperbaric oxygen inactivated sphingomyelinase D on 30 September 2021 by guest. Protected copyright. than 36 hours after the bite. Phillips et al,56 how­ by the disruption of sulfhydryl groups. Hyperbaric ever, were unable to detect any clinical benefit oxygen has also been postulated to decrease wound when using dapsone for the treatment of spider damage secondary to brown recluse envenomation bite. in at least two additional ways.56 It has been spec­ There are serious side effects associated with the ulated that wound damage is decreased in part use of dapsone. Almost all patients given dapsone because of the pulmonary sequestration of neutro­ will develop dose-related hemolysis. Agranulocyto­ phils. Hyperbaric oxygen therapy also increases the sis, aplastic anemias, and methemoglobinemia oc­ production of collagen by fibroblasts, thereby facil­ casionally occur. Methemoglobin is unable to bind itating wound healing. Beilman et al 55 found that oxygen and is produced when more than 1% of the pig models which had hyperbaric oxygen hemoglobin is oxidized to the ferric (HbFe3+) therapy as pretreatment had significantly smaller state. The resulting increase in oxygen affinity of areas of necrosis when compared with control an-

420 JABFP November-December 2000 Vol. 13 No. 6 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from imals or animals given dapsone as pretreatment. wearing clothes that have been strewn on the floor Animals that had hyperbaric oxygen therapy after during the evening. the injection of recluse venom did not show a corresponding decrease in skin necrosis. Phillips et References al,56 however, using white rabbits, were unable to 1. Necrotic arachnidism-Pacific Northwest, 1988- show any decrease in lesion size when compared 1996. MMWR Morb Mortal WkIy Rep 1996;45: with controls. These animals were injected with 20 433-6. f.Lg of L laeta venom and underwent hyperbaric 2. Macchiavello A. Cutaneous arachnidism or gangre­ oxygen therapy 4 hours after the injection. In a nous spot of Chile. Public Health Trop Med 1947; similar manner, Phillips and colleagues were also 22:425-66. unable to show any benefit from treatment with 3. Atkins JA, Wingo CW, Sodeman WA. Probable cause of necrotic spider bite in the Midwest. Science or dapsone. 1957;126: 73. Electric shock therapy has also received atten­ 4. Blackman JR. Spider bites. J Am Board Fam Pract tion as a possible mechanism of inactivating the 1995;8:288-94. enzymes contained in brown recluse venom. 54 As 5. Russell FE. A confusion of spiders. Emerg Med with snake envenomation, using electric shock to 1988;15:6-10. treat spider envenomation is disappointing and 6. Russel FE, Gertsch "W]. For those who treat spider cannot be recommended. or suspected spider bites. Toxicon 1983;21:337-9. Burton61 described his 10 years of experience 7. Pucevich M, McChesney T. Histopathologic analy­ with applying nitroglycerin patches to the bite site sis of human bites by the brown recluse spider. Arch area. His experiences indicate that necrosis and Dermatol 1983;119:851. ulceration can be aborted if the nitroglycerin patch 8. Iserson KV. Methemoglobinemia from dapsone is applied within 48 hours of the time the patient therapy for a suspected brown spider bite. J Emerg Med 1985;3:285-8. was bitten. He promoted the use of a O.l-mgJh 9. Gutowicz M, Fritz RA, Sonoga AL. Brown recluse patch and speculated that the nitroglycerin patches spider bite. A literature review and case report. J Am prevented necrosis through reversal of blood vessel Podiatr Med Assoc 1989;79:142-6. spasm. 10. Bey TA, WaIter FG, Lober W, SchmidtJ, Spark R, Brown recluse specific antivenin has been shown Schlievert PM. bite associated by Rees et aj31 to be most effective for limiting with shock. Ann Emerg Med 1997;30:701-3. dermonecrosis secondary to brown recluse venom. 11. Gertsch "W]. The spider genus Loxosceles in South Similar to antivenin use in the treatment of ­ America. Bull Am Natl Hist 1967;136:121. 12. MacKinnon JE, Witkind J. Arachnidismo necrotico. ous , brown recluse spider antivenin must http://www.jabfm.org/ be administered within the first 24 hours. It is most Ann Fac Med Montevideo 1953;38:75-100. effective when administered as soon as possible 13. Newlands G, Atkinson P. Review of the southern after the bite, unfortunately at a time when the African spiders of medical importance, with notes on the signs and symptoms of envenomation. S Afr Med amount of venom injected by the spider is open to J 1988;73:235-9. speculation. Consequently, it can only be guessed 14. Efrati P. Bites by Loxosceles spiders in Israel. Toxicon whether the patient received a sufficient quantity of 1969;6:239-41. on 30 September 2021 by guest. Protected copyright. venom to require treatment with antivenin. 15. Southcott RV. Spiders of the genus Loxosceles in Australia. Med] Aust 1976;1:406-8. 16. Luke, Snetsinger. Fiddleback spider-natural pred­ Prevention ator of firebrats. Sci Agri 1971; 18: 7. (Au, please add flU Insecticides that are effective in reducing brown initials) recluse sp~der populations have been shown to be 17. Hite JM, Gladney "W], Lancaster JL, Whitcomb exceedingly toxic to human beings, and their use in WH. Biology of the brown recluse spider. Univ Ark Agr Exp Sta Bull 1966;711:1-26. human dwellings is ill advised. Reinfestation is a 18. Huhta V. Loxosceles laeto (Nicolet) (ARANEAE, continuous problem, and spiders can hide in areas LOXOSCELINAE), a venomous spider established where insecticides cannot be placed. 59 Good in a building in Helsinki, Finland, and notes on some housekeeping is essential in the prevention of in­ other sympathic spiders. Ann Ent Fennici 1972;38: festation, as the elimination of food sources will 152. decrease infestation. It is also prudent to avoid 19. Berger RS, Adelstein EH, Anderson Pc. Intravascu-

Brown Recluse Spider Bites 421 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-415 on 1 November 2000. Downloaded from

lar coagulation-the cause of necrotic arachnidism. Brown recluse spider bites. A comparison of early ] Invest DermatoI1973;61:142-50. surgical excision versus dapsone and delayed surgical 20. Anderson Pc. What's new in loxoscelism-1978: case excision. Ann Surg 1985;202:659-63. report. Mo Med 1977;74:549-52, 556. 37. Majeski ]A, Durst GG Sr. Necrotic arachnidism. 21. Denny WF, Dillaha Cl, Morgan PN. Hemotoxic South Med J 1976;69:887-91. effect of Loxosceles reclusus venom: in vivo and in vitro 38. Weiner RC, Stoffer RP, Chornock FW, et al. Mas­ studies.] Lab Clin Med 1964;64:291-8. sive intravascular hemolysis. J Kan Med Soc 1960; 22. Taylor EH, Denny WF. Hemolysis, renal failure 61:206-7. and death, presumed secondary to bite of brown 39. lames ]A, Sellars WA, Austin OA, et al. Reactions recluse spider. South Med] 1966;59:1209-11. following suspected spider bite. Am J Dis Child 23. Smith CW, Micks DW. 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56. Phillips S, Kohn M, Baker D, et a1. Therapy of 59. Strain GM, Snider TG, Tedford BL, Cohn GH. brown spider envenomation: a controlled trial of Hyperbaric oxygen effects on brown recluse spider hyperbaric oxygen, dapsone, and cyproheptadine. (Loxosceles reclusa) envenomation in rabbits. Toxicon Ann Emerg Med 1995;25:363-8. 1990;29:989-95. 57. WilIe RC, Morrow JD. Case report: dapsone hyper­ 60. Maynor ML, Abt JL, Osbome PD. Brown recluse sensitivity syndrome associated with treatment of the spider bites: beneficial effects of hyperbaric oxygen. bite of a brown recluse spider. Am J Med Sci 1988; J Hyperbaric Med 1992;7:89-102. 296:270-1. 61. Burton KG. Nitroglycerine patches for brown re­ 58. Gendron BP. Loxosceles reclusa envenomation. Am J cluse spider bites. Am Fam Physician 1995; Emerg Med 1990;8:51-4. 51:1401.

Correction

In the article "Treatment of AIDS and HIV­ Related Conditions: 2000" by Ronald H. Goldschmidt and Betty J. Dong a Am Board Fam Pract 2000;13:274-98), an incorrect Web site was listed for the article in the credit line (p. 274). The article can be found at http:// www.ucsf.edulwannlinelarticlesljabfpOO.pdf. The authors regret the error. http://www.jabfm.org/ In a reply to a letter to the editor (Prenatal Testing and Counseling for Down Syn­ drome. J Am Board Fam Pract 2000;13:227- 8), Dr. Cate's first name should have been spelled Sara. The publisher regrets the error. on 30 September 2021 by guest. Protected copyright.

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