Intervention Program for Nursing Staff Regarding

Journal of the Egyptian Society of Parasitology, Vol.46, No.1, April 2016 J. Egypt. Soc. Parasitol. (JESP), 46(1), 2016: 167 - 178 INTERVENTION PROGRAM FOR NURSING STAFF REGARDING APPROACH TO A PATIENT WITH SPIDER PHOBIA AND/OR BITE By MAHFOUZ AHMAD AL-AGROUDI1, SALWA ABDALLA MOHAMMAD AHMED1 AND TOSSON A. MORSY2 Military Medical Academy1 and Department of Parasitology, Faculty of Medicine, Ain Shams University, Cairo 115662, Egypt Abstract Spider bites are uncommon medical events, since there are limited number of spiders worldwide with fangs strong enough to pierce human skin, and most spiders bite humans only as a fi- nal defense when being crushed between skin and another object. Thus, most lesions attributed to spider bites are caused by some other etiology. The spiders that can cause medically significant bites include widow and false widow spiders (worldwide), recluse spiders (mostly North and South America), Australian funnel web spiders (eastern coastal Australia) and Phoneutria spiders (Brazil). Acute spider bites most commonly result in a solitary papule, pustule, or wheal. Systemic symptoms can accompany envenomation of widow; funnel web, and Phoneu- tria spiders, and less often, those of recluse spiders. Key words: Spiders, Medical importance, Nursing, Control, General review. Introduction Most spiders pose no threat to humans. Spider bites are rare medical events. Of The venom of most spiders has little or no the thousands of spider species that exist effect on mammalian tissues (Swanson and around the world, only a handful causes Vetter, 2005). In addition, only a few spe- problems in humans. There are a variety of cies have cheliceral muscles powerful more common disorders that can mimic a enough to penetrate human skin, and most of spider bite, some of which represent a far these spiders bite humans only in rare and greater threat to the patient if not recognized extreme circumstances (e.g., as they are be- and treated appropriately (Vetter and Isbis- ing fatally crushed between skin and some ter, 2008). object). Thus, accurate diagnosis is the initial goal The spiders most likely to inflict medically of the clinician evaluating a patient with a significant bites in humans include widow lesion that might represent a spider bite. and false black widow spiders, recluse spi- Discerning among the various conditions in ders, Australian funnel web spiders, and the differential diagnosis of a spider bite re- Phoneutria spiders. Each of these spiders is quires familiarity with these disorders, as described briefly below, and their appear- well as a rudimentary understanding of the ance and geographical distribution are sum- distribution and behavior of medically im- marized (Tab. 1). portant spiders. Spider phobia (fear): Acarophobia, en- Review, Discussion & Recommendation tomophobia or delusional parasitosis is a Medical importance: Spiders are arachnids disorder that affected individuals has the (a group of arthropods), which are symmet- mistaken but unshakable belief (delusion) rical having four pairs of legs, similar to that they are infected by insects, spiders, scorpions, mites, and ticks (Fig. 1). They use scorpion, ticks, mites, parasitic worms, bac- sharp fangs at the end of their chelicerae to teria, or other living organisms (Sabry et al, bite prey (typically insects, other arthropods, 2012). Michalowski et al. (2014) investigat- or small vertebrates) and inject paralyzing ed long-term memory for unpleasant, neutral venom. and spider pictures in 15 spider-fearful and 167 15 non-fearful control individuals using be- whereas in the low-fear group only valence havioral and electrophysiological measures. affected perceived size. They concluded that spider-fearful but not Widow spiders: Latrodectus, or widow control participants responded with larger spiders (found worldwide), include the East- ERP positivity for correctly recognized old ern black widow (show picture 1) and West- when compared to correctly reject new spi- ern black widow in the United States, and der pictures, thus showing the same effects the Australian redback spider. Widow bites in the neural signature of emotional memory cause unremarkable local lesions that are for feared objects that were already discov- sometimes accompanied by a characteristic ered for other emotional materials. The in- systemic reaction with prominent, proximal- creased fear memory for phobic materials ly-spreading pain and localized diaphoresis observed in the present study in spider- surrounding the site of the bite. Antivenoms fearful individuals might result in an en- are available for several species. hanced fear response and reinforce negative Clinical history: Patients presenting with beliefs aggravating anxiety symptomatology widow bites typically have a recent (<8 and the hindering recovery. Effting et al. hours) history of an at risk activity such as (2016) suggest that implicit processes might gardening, chopping wood, or cleaning out a become more pertinent for fear behavior as garage. Three quarters of bites are on the the ability to control such processes wanes, extremities, particularly the lower extremi- which may be particularly relevant for anxi- ties (Maretic and Lebez, 1979). ety disorders given their association with Lesion and local symptoms: The typical lowered executive control functioning. As black widow bite is a mild lesion consisting such, training procedures that specifically of a blanched circular patch with a surround- target implicit processes or control abilities ing red perimeter and a central punctum might improve treatment outcomes for anxi- (show picture 8). Some bites resemble a ety disorders. They suggested that t implicit wheal and flare reaction. Most bites are ei- processes might become more pertinent for ther asymptomatic or cause local pain at the fear behavior as the ability to control such site of the bite. The time of onset of more processes wanes, which may be particularly generalized symptoms is typically 40 relevant for anxiety disorders given their minutes (20 to 120 minutes range) from the association with lowered executive control time of the bite, but may be longer on occa- functioning. As such, training procedures sion (Clark et al, 1992). Significant enven- that specifically target implicit processes or omation causes acute muscle pain and often control abilities might improve treatment localized diaphoresis in the affected limb, outcomes for anxiety disorders. and this presentation is highly suggestive of Leibovich et al. (2016) explored the role a widow bite. If the bite is on the lower ex- of valence and self-relevance in size estima- tremities, the muscular pain may extend to tion of neutral and aversive animals. The the abdomen; upper extremity pain may ex- participants were highly fearful of spiders tend to the chest. The pain may be accom- and participants with low fear of spiders rat- panied by tremor, weakness, myoclonus, and ed the size and unpleasantness of spiders local paresthesias. Diaphoresis may extend and other neutral animals (birds and butter- to involve the whole extremity, the body, or flies) and others included additional pictures may be limited to areas distant from the bite. of wasps (not self-relevant, but unpleasant) There may also be local lymphadenopathy and beetles. By the mediation analysis they (Diez Garcia et al, 1996). Black widow bites found that in the high-fear group both rele- do not become necrotic. vance and valence influenced perceived size, Systemic symptoms: Vital signs are usually normal with moderate envenomation, alt- 168 hough patients may be anxious and tachyp- including a vertebrate-specific toxin called neic. With more extensive envenomation, alpha-latrotoxin, a large protein toxin (120 patients may experience some or all of the kDa) that triggers massive exocytosis from following systemic symptoms (Saibil, presynaptic nerve terminals and in a variety 2000): The generalized musculoskeletal, ab- of neurosecretory cells (Sudhof, 2001). Ace- dominal, or back pain, hypertension and tylcholine, norepinephrine, dopamine, glu- tachycardia, nausea and/or vomiting. Gener- tamate, and enkephalin systems are all sus- alized or regional diaphoresis headache faci- ceptible to the toxin (Nicholson and al swelling, which can be mistaken for an Graudins, 2002). It appears this toxin is pre- allergic reaction sent in the venom of all medically important Pain is usually the most prominent feature widow spiders and this has clear implica- in systemic reactions. Severe abdominal tions for cross reactivity of anti-Latrodectus pain with abdominal wall rigidity but normal antivenoms. bowel sounds is characteristic. Abdominal Laboratory abnormalities: Abnormal la- pain from a widow bite has been mistaken boratory studies are present in up to half of for a variety of abdominal emergencies, in- cases upon presentation and most frequently cluding acute cholecystitis (Bush, 1999). include elevations in white blood cell counts Other case reports have described cardio- and serum concentrations of creatine phos- vascular collapse, pulmonary edema, and phokinase, glucose, and/or liver enzymes ileus (leiner-Baumgarten, 1991). Additional (Clark et al, 1992). However, laboratory reported complications include hematuria, tests are not necessary to make the diagnosis Horner's syndrome, compartment syndrome, of latrodectism. rhabdomyolysis, and the toxic epidermal False black widow spiders: Steatoda, or necrolysis (Cohen and Bush, 2005). Death is false black widow spiders (found world- unusual,

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