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Spider Envenomation, Widow: Follow-up

Author: Sean P Bush, MD, FACEP, Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center
Coauthor(s): Jennifer C Smith, MD, Fellow in Envenomation Medicine, Department of Emergency Medicine, Loma Linda Medical Center
Contributor Information and Disclosures

Updated: Jul 24, 2008

Follow-up

Further Inpatient Care

  • Admission to the hospital is indicated to the following patients:
    • Severely symptomatic children
    • Pregnant women
    • Patients with a history of hypertension or heart disease
    • Patients with intractable pain and contraindications to antivenom
    • Patients with unusual complications of envenomation
    • Patients who develop anaphylaxis to antivenom
  • Discharge patients who experience relief with opioid analgesics, sedative-hypnotics, and/or antivenom (after a period of observation). Antivenom administration may reduce the need for hospitalization.

Further Outpatient Care

  • Instruct patients to return if any of the following symptoms occur:  
    • Hematuria
    • Rash
    • Joint pain
    • Swollen lymph nodes
    • Difficulty breathing
    • Signs of infection
  • Advise patients that if treated symptomatically with pain medications and benzodiazepines, pain may come and go for up to days to weeks after envenomation.
  • If patients have been treated with antivenom, discuss signs of serum sickness (as noted above) and warn them of its possible occurrence in 3-14 days.

Inpatient & Outpatient Medications

  • Antihistamines and steroids should be given if serum sickness to antivenom develops. This is rare because treatment of widow spider envenomation usually requires only 1-2 vials of antivenom, and serum sickness usually occurs when more antivenom is given.

Deterrence/Prevention

  • Pesticides may prevent exposures to widow spiders at home.

Complications

  • Respiratory difficulty, reactive airway exacerbation
  • Spontaneous abortion or preterm labor
  • Hypertensive emergency with or without associated seizures (isolated normotensive seizures have not been described), acute myocardial infarction
  • Rhabdomyolysis
  • Priapism (rare)
  • Compartment syndrome (rare)
  • Toxic myocarditis (rare)
  • Antivenom-associated complications
    • Anaphylaxis, a type I (immediate) hypersensitivity reaction that may be life threatening, is characterized by urticaria, wheezing, and shock. It may occur to some degree in as many as 25% of patients given antivenom. Risk factors may include previous exposure to horse serum or antivenom or a history of reactive airways. It is treated with epinephrine, antihistamines, steroids, and ventilatory/circulatory support. One death has been reported from anaphylaxis to widow spider antivenom in the United States. The patient had a history of asthma and, after antivenom was administered, developed severe bronchospasm unresponsive to medical therapy.
    • Serum sickness, a type III (delayed) hypersensitivity reaction characterized by fever, urticaria, lymphadenopathy, and arthritis, may occur 5 days to 3 weeks after antivenom administration. It usually is benign, self-limited, and treated with antihistamines and steroids. Serum sickness is dose related and uncommon following administration of widow spider antivenom because of the small amounts generally needed (1 or 2 vials).

Prognosis

  • The vast majority of patients with widow spider envenomations recover fully.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Sending a patient home who subsequently returns with persistent symptoms requiring antivenom and/or admission is a pitfall.
  • Obtain informed consent before antivenom administration, if possible.

Special Concerns

  • Envenomation is an uncommon occurrence with an extremely variable presentation.
    • Treatment of envenomation often is based on speculation and anecdote, and much of the literature is contradictory.
    • This article attempts to keep recommendations in agreement with the most current standards of care.
 


More on Spider Envenomation, Widow

Overview: Spider Envenomation, Widow
Differential Diagnoses & Workup: Spider Envenomation, Widow
Treatment & Medication: Spider Envenomation, Widow
Follow-up: Spider Envenomation, Widow
Multimedia: Spider Envenomation, Widow
References
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References

  1. Allen RC, Norris RL. Delayed use of widow spider antivenin. Ann Emerg Med. Sep 1995;26(3):393-4. [Medline].

  2. Boyer Hassen LV, McNally JT, Binford GJ. Spider bites. In: Auerbach PS, ed. Wilderness Medicine. 4th ed. St. Louis: Mosby-Year Book; 2001:807-838.

  3. Bush SP, Thomas TL, Chin ES. Envenomations in children. Pediatr Emerg Med Rep. 1997;2:1-12.

  4. Bush SP, Naftel J. Injection of a whole black widow spider. Ann Emerg Med. Apr 1996;27(4):532-3. [Medline].

  5. Bush SP. Black widow spider envenomation mimicking cholecystitis. Am J Emerg Med. May 1999;17(3):315. [Medline].

  6. Clark RF, Wethern-Kestner S, Vance MV, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. Jul 1992;21(7):782-7. [Medline].

  7. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med. Apr 2005;45(4):414-6. [Medline].

  8. Gonzalez Valverde FM, Gomez Ramos MJ, Menarguez Pina F, Vazquez Rojas JL. [Fatal latrodectism in an elderly man]. Med Clin (Barc). Sep 22 2001;117(8):319. [Medline].

  9. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wild Environ Med. 1997;8:8-16.

  10. Pneumatikos IA, Galiatsou E, Goe D, Kitsakos A, Nakos G, Vougiouklakis TG. Acute fatal toxic myocarditis after black widow spider envenomation. Ann Emerg Med. Jan 2003;41(1):158. [Medline].

  11. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Youniss J, Reid N, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].

  12. Woestman R, Perkin R, Van Stralen D. The black widow: is she deadly to children?. Pediatr Emerg Care. Oct 1996;12(5):360-4. [Medline].

  13. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].

  14. Hoxha R. Two Albanians die from black widow spider bites. BMJ. Aug 5 2006;333(7562):278. [Medline].

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Further Reading

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Keywords

black widow spider, spider bite, black widow spider bite, spider envenomation, Latrodectus, Latrodectus mactans mactans, brown widow, Latrodectus geometricus, red-legged widow, Latrodectus bishopi, redback spider, Latrodectus hasselti, button spider, Latrodectus indistinctus, Latrodectus variolus, Latrodectus hesperus, Latrodectus mactans tredecimguttatus, Latrodectus pallidus

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Contributor Information and Disclosures

Author

Sean P Bush, MD, FACEP, Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center
Sean P Bush, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Society on Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Protherics Consulting fee Consulting; Nycomed (formerly Fougera) Grant/research funds Speaking and teaching; Rare Disease Therapeutics Grant/research funds Research; Bioclon Grant/research funds Research

Coauthor(s)

Jennifer C Smith, MD, Fellow in Envenomation Medicine, Department of Emergency Medicine, Loma Linda Medical Center
Jennifer C Smith, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Robert L Norris, MD, Associate Professor, Department of Surgery; Chief, Division of Emergency Medicine, Stanford University Medical Center
Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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