Clinical Review

Bite of the Brown Recluse Spider

Clinician Reviews. 2010 December;20(12):14-17

References

1. Wilson JR, Hagood CO Jr, Prather ID. Brown recluse spider bites: a complex problem wound. A brief review and case study. Ostomy Wound Manage. 2005;51(3):59-66.

2. Rhoads J. Epidemiology of the brown recluse spider bite. J Am Acad Nurse Pract. 2007; 19(2):79-85.

3. Arnold TC. Spider envenomation, brown recluse. http://emedicine.medscape.com/article/772295-overview. Accessed November 23, 2010.

4. Vetter RS, Hinkle NC, Ames LM. Distribution of the brown recluse spider (Araneae: Sicariidae) in Georgia with comparison to poison center reports of envenomations. J Med Entomol. 2009;46(1):15-20.

5. Pagac BB, Reiland RW, Bolesh DT, Swanson DL. Skin lesions in barracks: consider community-acquired methicillin-resistant Staphylococcus aureus infection instead of spider bites. Mil Med. 2006;171(9):830-832.

6. Frithsen IL, Vetter RS, Stocks IC. Reports of envenomation by brown recluse spiders exceed verified specimens of Loxosceles spiders in South Carolina. J Am Board Fam Med. 2007;20(5):483-488.

7. Swanson DL, Vetter RS. Loxoscelism. Clin Dermatol. 2006;24(3):213-221.

8. CDC. Necrotic arachnidism: Pacific Northwest, 1988-1996. MMWR Morb Mortal Wkly Rep. 1996;45(21):433-436.

9. Gertsch WJ, Ennik F. The spider genus Loxosceles in North America, Central America, and the West Indies (Araneae, Loxoscelidae). Bull Am Museum of Nat Hist. 1983;175:265-360.

10. Andersen RJ, Campoli J, Johar SK, et al. Suspected brown recluse envenomation: a case report and review of different treatment modalities. J Emerg Med. 2010 Apr 2. [Epub ahead of print]

11. Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med. 2005;352(7):700-709.

12. Nunnelee JD. Brown recluse spider bites: a case report. J Perianesth Nurs. 2006;21(1):12-15.

13. Naidu DK, Ghurani R, Salas RE, et al. Osteomyelitis of the mandibular symphysis caused by brown recluse spider bite. Eplasty. 2008 Aug 28;8:428-433.

14. Osterhoudt KC, Zaoutis T, Zorc JJ. Lyme disease masquerading as brown recluse spider bite. Ann Emerg Med. 2002;39(5):558-561.

15. Russell FE, Gertsch WJ. For those who treat spider or suspected spider bites. Toxicon. 1983;21(3):337-339.

16. Vetter RS, Bush SP. Reports of presumptive brown recluse spider bites reinforce improbably diagnosis in regions of North America where the spider is not endemic. Clin Infect Dis. 2002;35(4):442-445.

17. McGlasson DL, Green JA, Stoecker WV, et al. Duration of Loxosceles reclusa venom detection by ELISA from swabs. Clin Lab Sci. 2009;22(4):216-222.

18. Wendell RP. Brown recluse spiders: a review to help guide physicians in non-endemic areas. South Med J. 2003;96(5):486–90.

19. Rees RS, Altenbern DP, Lynch JB, King LE Jr. Brown recluse spider bites: a comparison of early surgical excision versus dapsone and delayed surgical excision. Ann Surg. 1985;202 (5):659-663.

20. Webster GF. Is topical dapsone safe in glucose-6-phosphate dehydrogenase-deficient and sulfonamide-allergic patients? J Drugs Dermatol. 2010;9(5):532-536.

21. Merchant ML, Hinton JF, Geren CR. Effect of hyperbaric oxygen on sphingomyelinase D activity of brown recluse spider (Loxosceles reclusa) venom as studied by 31P nuclear magnetic resonance spectroscopy. Am J Trop Med Hyg. 1997;56(3):335-338.

22. Bennett RG, Vetter RS. An approach to spider bites: erroneous attribution of dermonecrotic lesions to brown recluse or hobo spider bites in Canada. Can Fam Physician. 2004;50:1098-1101.

23. MedlinePlus, US National Library of Medicine, NIH. Brown recluse spider. www.mdconsult.com/das/patient/body/225048384-2/0/10041/32560.html. Accessed November 23, 2010.

Follow-Up
Daily wound checks should be performed until the lesion is noted to be improving or no longer worsening. At each follow-up for the initial 72 hours, it is recommended that patients undergo a CBC, including platelet level, to detect progression of the infection or systemic involvement, and urinalysis to check for hematuria. Renal function should be monitored as needed.^1,2

Patient Education
Regarding brown recluse spider bites, patients should be advised to keep five points in mind:

• Diagnosis is made by confirmation that the spider is a brown recluse, ideally with the capture and expert evaluation of the spider²²

• Workup will focus on history, geographic locale, and environ of patient when supposed bite occurred^4,7,8

• Treatment varies but may include a tetanus shot, antibiotics, dapsone, steroids, hyperbaric oxygen therapy, and in severe cases of necrosis, surgery^1,2,7,19,20

• Follow-up will occur routinely during the initial 72 hours^1,2

• Prevention of bites includes avoiding piles of clutter in garages, sheds, and under beds; and wearing long sleeves when working in these areas.¹²

Finally, because the venom of the brown recluse spider is poisonous, the NIH encourages exposed persons to contact the National Poison Control Center at (800) 222-1222.²³

Conclusion
Brown recluse spider bites, though most likely overdiagnosed, do occasionally occur in areas where the creature is endemic. However, a brown recluse spider bite should be considered a diagnosis of exclusion and other possibilities considered first in light of their limited presence in North America and their nonaggressive nature.

Any patient who calls to report a suspected brown recluse spider bite should be instructed to bring the spider to the office, if possible, for identification. The spider should then be identified with certainty as a brown recluse by the appropriate expert so that treatment for the patient can be based on a correct diagnosis rather than one of presumption.