Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite

Impact of antivenom administration on the evolution of cutaneous lesions in loxoscelism: A prospective observational study

BACKGROUND

Spiders of the genus Loxosceles are distributed throughout tropical and temperate regions worldwide. Loxosceles spp. bites may evolve to necrosis, with or without intravascular hemolysis. There is no consensus regarding the best treatment to prevent necrosis. The objective of this study was to evaluate the factors associated with the development of necrosis and the impact that antivenom administration has on the evolution of cutaneous loxoscelism.

METHODOLOGY/PRINCIPAL FINDINGS

This was a prospective observational study carried out at a referral center for envenoming. Over a 6-year period, we included 146 patients with a presumptive or definitive diagnosis of loxoscelism. Depending on the symptom severity, a polyvalent anti-arachnid antivenom was administered or not-in 74 cases (50.7%) and 72 cases (49.3%), respectively. Cutaneous and systemic manifestations were assessed at admission and weekly thereafter. Adverse reactions to the antivenom were also evaluated. Cutaneous loxoscelism was observed in 141 cases (96.6%), and the spider was identified in 29 (19.9%). The mean time from bite to antivenom administration was 41.6 ± 27.4 h. After discharge, 130 patients (90.9%) were treated with corticosteroids, antihistamines and analgesics being prescribed as needed. The probability of developing necrosis was significantly lower among the patients who were admitted earlier, as well as among those who received antivenom (p = 0.0245). Among the 74 patients receiving antivenom, early and delayed adverse reactions occurred in seven (9.5%) and four (5.4%), respectively. Local infection was observed only in three (2.3%) of the 128 patients for whom that information was available.

CONCLUSIONS/SIGNIFICANCE

Necrosis after a Loxosceles sp. bite appears to more common when hospital admission is delayed or when antivenom is not administered. In addition, the administration of a polyvalent anti-arachnid antivenom appears to be safe, with a relatively low rate of adverse reactions.

Hold the Chemo! Leukostasis, a Presentation of Brown Recluse Spider Bite: A Case Report

Brown recluse spiders, also known as Loxosceles reclusa, are endemic to the Southwest and Central Midwestern United States. A bite from this spider can cause a range of clinical manifestations, anywhere from a painless papular lesion to life-threatening reactions. We report a possible spider bite presenting as leukostasis initially suspected to be acute leukemia. A 22-year-old female patient presented to the emergency department with confusion and right upper arm pain, redness, and swelling after a suspected spider bite. Initial labs showed WBC count of 103.5x10e3/µL, hemoglobin of 3.3 g/dL, positive Direct Coombs’ test, creatinine of 1.8 mg/dL, transaminitis, and lactic acid of 20 mmol/L. Acute leukemia with leukostasis was suspected. She was started emergently on hydroxyurea in conjunction with prophylaxis for tumor lysis syndrome. However, peripheral smear showed left-shifted granulocytosis with lymphocytosis, monocytosis, and no blast cells or evidence of myelodysplasia. Bone marrow aspirate showed mildly hypercellular marrow with myeloid hyperplasia and no myelodysplasia. Flow cytometry analysis confirmed a left-shifted myeloid maturation pattern with 0.3% myeloblasts. BCR-ABL1 and JAK2 testing was negative. Hence, she had no evidence of leukemia but rather had leukostasis from a spider bite. Hydroxyurea was stopped and follow-up labs normalized. Sphingomyelinase D in the brown recluse spider venom is unique to Loxosceles and Sicarius and may be responsible for the unique clinical presentation of loxoscelism. The presentation of hyperleukocytosis complicated by shock with an unclear history poses a diagnostic challenge. In diagnostic uncertainty, consider delaying chemotherapy until a diagnosis can be confirmed to avoid potential harm.

Local Dermonecrosis with Generalized Urticaria Probably Due to Loxosceles rufescens Bite

BACKGROUND: The spiders of the Loxosceles genus, commonly denoted as “brown spiders” or “Mediterranean recluse” or “brown recluse,” belong to the spider family Sicariidae, suborder Labidognatha, order Araneida, class Arachnida, and phylum Arthropoda. This spider is widespread in Africa and South/Central America, but it is also distributed in North America, in the West Indies, in the Mediterranean Europe, and in China. CASE REPORT: Here, we report the case of a severe dermonecrotic loxoscelism identified in Southern Italy, probably due to the bite of Loxosceles rufescens. The patient was a women admitted at hospital ER because of a little skin erythema that evolved toward a severe necrosis and ulceration within 20 days. After clinical and laboratory data excluded other local and systemic diseases, she was treated with a systemic and local therapy using corticosteroids and antibiotics with the diagnosis of loxoscelism. The healing from the local skin lesion occurred within 2 months, but the local pain, weakness, and discomfort lasted for a long time. CONCLUSION: It is the fisrt time that a possible case of systemic loxoscelism with skin generalized urticaria is reported in Italy.

Distribution and medical aspects of Loxosceles rufescens, one of the most invasive spiders of the world (Araneae: Sicariidae)

Loxosceles rufescens is a circum-Mediterranean spider species, potentially harmful to humans. Its native area covers the Mediterranean Basin and Near East. Easily spread with transported goods, it is meanwhile an alien and invasive species to nearly all other continents and many islands. This species occurs in semi-arid steppe-like habitats, typically under stones and in cavities, which enables it to settle inside buildings when invading the synanthropic environment. This review analyses the literature of L. rufescens bites to humans (38 publications) of which only 11 publications refer to 12 verified spider bites (11% of the reported bites). Two published allegedly deadly spider bites (Thailand 2014 and Italy 2016) involve non-verified spider bites and are thus not reliable. The symptoms and therapy of these 11 verified bites are described: only five cases showed moderate systemic effects, nine cases developed necrosis, four cases needed surgical debridement, all cases healed without complications within a few weeks. In conclusion, L. rufescens is a spider species globally spread by human activity, it rarely bites humans and the bites are less harmful than often described. There is no known fatal issue.

Rare case of dermonecrosis caused by a recluse spider bite in Europe

Spider poisoning is rare in Europe, with very few reported cases in the literature. Recluse spider (genus Loxosceles) bites may lead to cutaneous and systemic manifestations known as loxoscelism. We report the second known case of spider bite poisoning in Malta caused by Loxosceles rufescens (Mediterranean recluse spider). A young adult female presented with localised erythema and pain on her left thigh after a witnessed spider bite. Over a few days, the area developed features of dermonecrosis together with systemic symptoms, including fever, fatigue and a generalised erythematous eruption. She was managed by a multidisciplinary team and the systemic symptoms resolved within 6 days, while the skin lesion healed with scarring within 2 months. A recluse spider bite should be considered in patients with dermonecrosis. Although spider bite poisoning is uncommon in Europe, it is important to diagnose and manage it appropriately since it could lead to potentially serious sequelae.

Acute kidney injury and dermonecrosis after Loxosceles reclusa envenomation

Spiders of the Loxosceles species can cause dermonecrosis and acute kidney injury (AKI). Hemolysis, rhabdomyolysis and direct toxin-mediated renal damage have been postulated. There are very few reports of Loxoscelism from India. We report a case of AKI, hemolysis and a "gravitational" pattern of ulceration following the bite of the brown recluse spider (Loxosceles spp).

Immune-mediated mechanism for thrombocytopenia after Loxosceles spider bite

Loxoscelism, characterized by high fever, vomiting, malaise, a dermonecrotic lesion, and thrombocytopenia, was diagnosed in a 3-year-old female. Clinical laboratory and dermatological signs are described. Blood test showed a transient hypercoagulable state and the presence of IgG antibodies against platelets, suggesting an immune-mediated mechanism for platelet destruction, in addition to the direct toxic effect of the spider venom. The finding of platelet antibodies after a Loxosceles spider bite has not been previously reported.

Spider envenomation in North America

In North America, spider envenomation is perceived to be a greater threat than in actuality; however, it still is a valid source of morbidity and, very rarely, mortality. Only 2 groups (widows, recluses) are medically important on this continent. Widow bites affect the neuromuscular junction, have minor dermatologic expression, and are treated with analgesics and antivenom. Recluse bites vary from mild, self-limiting rashes to extensive dermonecrosis. Recent awareness of methicillin-resistant Staphylococcus aureus as a ubiquitous cause of skin injury that is often mistaken as attributable to recluse bites has questioned the credence of spiders being the cause of idiopathic wounds.

Neurological effects of venomous bites and stings: snakes, spiders, and scorpions

Snake and spider bites, as well as scorpion sting envenoming, are neglected diseases affecting millions of people all over the world. Neurological complications vary according to the offending animal, and are often directly related to toxic effects of the venom, affecting the central nervous system, the neuromuscular transmission, the cardiovascular system, or the coagulation cascade. Snake bite envenoming may result in stroke or muscle paralysis. Metalloproteinases and other substances (common in vipers and colubrids) have anticoagulant or procoagulant activity, and may induce ischemic or hemorrhagic strokes. The venom of elapids is rich in neurotoxins affecting the neuromuscular transmission at either presynaptic or postsynaptic levels. The clinical picture of scorpion sting envenoming is dominated by muscle weakness associated with arterial hypertension, cardiac arrythmias, myocarditis, or pulmonary edema. These manifestations occur as the result of release of catecholamines into the bloodstream or due to direct cardiac toxicity of the venom. Cerebrovascular complications have been reported after the sting of the Indian red scorpion. Intracranial hemorrhages occur in the setting of acute increases in arterial blood pressure related to sympathetic overstimulation, and cerebral infarctions are related to either cerebral hypoperfusion, consumption coagulopathy, vasculitis, or cardiogenic brain embolism. Three main syndromes result from spider bite envenoming: latrodectism, loxoscelism, and funnel-web spider envenoming. Latrodectism is related to neurotoxins present in the venom of widow spiders. Most cases present with headache, lethargy, irritability, myalgia, tremor, fasciculation, or ataxia. Loxoscelism is caused by envenoming by spiders of the family Sicariidae. It may present with a stroke due to a severe coagulopathy. The venom of funnel-web spiders also has neurotoxins that stimulate neurotransmitter release, resulting in sensory disturbances and muscle paralysis. Proper management of the envenomed patient, including prompt transport to the hospital, correction of the hemostatic disorder, ventilatory support, and administration of antivenom, significantly reduce the risk of neurological complications which, in turn, reduce the mortality and improve the functional outcome of survivors.

Clinical picture and laboratorial evaluation in human loxoscelism

Loxosceles spiders are found globally, especially in South and North America. In Brazil, approximately 10,000 cases of Loxosceles spp. spider bites are reported annually. Herein we analyzed 81 patients diagnosed as either cutaneous or cutaneous-hemolytic loxoscelism, in a geographical area where most accidents are caused by Loxosceles gaucho, and we report their clinical and laboratory data obtained during week 1 and 2 after the bite. Massive hemolysis was noticed in only 2 cases, but high serum bilirubin and LDH levels, suggestive of hemolysis, were noticed in 25 cases on admission. Anemia was not frequent (14.7%), and reticulocytosis was particularly noticed during week 2 (in 56% of patients). High D-dimer levels were suggestive of endothelial cell activation and intravascular thrombin generation, but thrombocytopenia was noticed in only 17.6% of patients in week 1. Acute kidney injury (AKI) only occurred in patients with massive hemolysis. The definitive diagnosis of overt disseminated intravascular coagulation (DIC) could not be established on admission. Fever was associated with the presence of hemolysis (p = 0.03). Altogether, these findings provide evidence that mild hemolysis is frequent in loxoscelism and suggest that AKI is uncommon, exclusively occurring in patients with massive hemolysis.

Brown recluse spider (Loxosceles reclusa) envenomation in small animals

OBJECTIVE

To provide a comprehensive review of relevant literature regarding the brown recluse spider (BRS) and to define those criteria that must be satisfied before making a diagnosis of brown recluse envenomation.

ETIOLOGY

The complex venom of the BRS contains sphingomyelinase D, which is capable of producing all the clinical signs in the human and some animal models.

DIAGNOSIS

There is no current commercially available test. In humans there are many proposed guidelines to achieve a definitive diagnosis; however, there are no established guidelines for veterinary patients.

THERAPY

Currently, no consensus exists for treatment of BRS envenomation other than supportive care, which includes rest, thorough cleaning of the site, ice, compression, and elevation.

PROGNOSIS

Prognosis varies based on severity of clinical signs and response to supportive care.

Atypical ischemic lower extremity ulcerations: a differential diagnosis

Severe peripheral artery disease (PAD) is the predominant cause of ischemic ulcerations involving the lower extremities. PAD-associated ulcerations are typically distally located involving the feet, toes, and sometimes the calves. In contradistinction, atypical ischemic ulcerations of the lower extremity are often non-atherosclerotic in etiology, involve the proximal leg (thigh/buttocks), can evolve despite palpable distal pulses, and may coexist with other cutaneous aberrations (e.g. macules, purpura, nodules, and livedo reticularis). A differential diagnosis of atypical ischemic ulcerations involving the legs is presented.