Brown Recluse Spider Envenomation Clinical Presentation

  • Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 21, 2010
 

History

  • The brown recluse spider, living up to its name, is naturally nonaggressive toward humans and prefers to live in undisturbed attics, woodpiles, and storage sheds.
  • Brown recluse spiders vary in size and can be up to 2-3 cm in total length. They are most active at night from spring to fall.
  • Characteristic violin-shaped markings on their backs have led brown recluse spiders to also be known as fiddleback spiders.
  • Envenomation from the brown recluse spider elicits minimal initial sensation and frequently goes unnoticed until several hours later when the pain intensifies.
  • An initial stinging sensation is replaced over 6-8 hours by severe pain and pruritus as local vasospasm causes the tissue to become ischemic.
  • Symptoms of systemic loxoscelism are not related to the extent of local tissue reaction and include the following:
    • Morbilliform rash
    • Fever
    • Chills
    • Nausea
    • Vomiting
    • Joint pain
    • Hemolysis
    • Disseminated intravascular coagulation (DIC)
    • Renal failure
    • Seizures
    • Coma
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Physical

Edema around the ischemic bite site produces the appearance of an erythematous halo around the lesion.

  • The erythematous margin around the site continues to enlarge peripherally, secondary to gravitational spread of the venom into the tissues.
  • Typically, at 24-72 hours, a single clear or hemorrhagic vesicle develops at the site, which later forms a dark eschar (see the image below). Classic finding of a vesicle with surrounding erytClassic finding of a vesicle with surrounding erythema at 24 hours following brown recluse envenomation. Photo by Thomas Arnold, MD.
  • Necrosis is more significant in the fatty areas of the buttocks, thighs, and abdominal wall (shown in the image below).Spider bite, brown recluse. Within an hour, the biSpider bite, brown recluse. Within an hour, the bite area swelled to the size of a quarter. The area turned blue and dark red by the evening of the first day, exceeding the boundaries of a circle drawn around the area of initial swelling by the patient's physician. Courtesy of Dale Losher.
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Causes

Dermonecrotic arachnidism has been described in association with several species of Loxosceles spiders, but, in the United States, L reclusus venom is the most potent and the most commonly involved.

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Contributor Information and Disclosures
Author

Thomas C Arnold, MD, FAAEM, FACMT  Professor and Chairman, Department of Emergency Medicine, Section of Clinical Toxicology, Louisiana State University School of Medicine in Shreveport; Medical Director, Louisiana Poison Control Center

Thomas C Arnold, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Louisiana State Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert L Norris, MD  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.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and 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.

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

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.

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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Miller LG, Spellberg B. Spider bites and infections caused by community-associated methicillin-resistant Staphylococcus aureus. Surg Infect. Fall 2004;5(3):321-2. [Medline].

  2. McGlasson DL, Green JA, Stoecker WV, Babcock JL, Calcara DA. Duration of Loxosceles reclusa venom detection by ELISA from swabs. Clin Lab Sci. Fall 2009;22(4):216-22. [Medline].

  3. Maynor ML, Moon RE, Klitzman B, Fracica PJ, Canada A. Brown recluse spider envenomation: a prospective trial of hyperbaric oxygen therapy. Acad Emerg Med. Mar 1997;4(3):184-92. [Medline].

  4. de Roodt AR, Estevez-Ramírez J, Litwin S, Magaña P, Olvera A, Alagón A. Toxicity of two North American Loxosceles (brown recluse spiders) venoms and their neutralization by antivenoms. Clin Toxicol (Phila). Sep 2007;45(6):678-87. [Medline].

  5. Carlton PK Jr. Brown recluse spider bite? Consider this uniquely conservative treatment. J Fam Pract. Feb 2009;58(2):E1-6. [Medline].

  6. Barrett SM, Romine-Jenkins M, Fisher DE. Dapsone or electric shock therapy of brown recluse spider envenomation?. Ann Emerg Med. Jul 1994;24(1):21-5. [Medline].

  7. Burton KG. Nitroglycerine patches for brown recluse spider bites. Am Fam Physician. May 1 1995;51(6):1401. [Medline].

  8. Dyachenko P, Ziv M, Rozenman D. Epidemiological and clinical manifestations of patients hospitalized with brown recluse spider bite. J Eur Acad Dermatol Venereol. Oct 2006;20(9):1121-5. [Medline].

  9. Graham WR Jr. Adverse effects of dapsone. Int J Dermatol. Sep 1975;14(7):494-500. [Medline].

  10. Hobbs GD, Anderson AR, Greene TJ, Yealy DM. Comparison of hyperbaric oxygen and dapsone therapy for loxosceles envenomation. Acad Emerg Med. Aug 1996;3(8):758-61. [Medline].

  11. King LE Jr, Rees RS. Dapsone treatment of a brown recluse bite. JAMA. Aug 5 1983;250(5):648. [Medline].

  12. Lowry BP, Bradfield JF, Carroll RG, Brewer K, Meggs WJ. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Ann Emerg Med. Feb 2001;37(2):161-5. [Medline].

  13. Mack RB. The bite of the spider woman. Loxosceles reclusa (the brown recluse). N C Med J. May 1992;53(5):200-3. [Medline].

  14. Phillips S, Kohn M, Baker D, Vander Leest R, Gomez H, McKinney P, et al. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptadine. Ann Emerg Med. Mar 1995;25(3):363-8. [Medline].

  15. Rees R, Campbell D, Rieger E, King LE. The diagnosis and treatment of brown recluse spider bites. Ann Emerg Med. Sep 1987;16(9):945-9. [Medline].

  16. Sams HH, Hearth SB, Long LL, Wilson DC, Sanders DH, King LE. Nineteen documented cases of Loxosceles reclusa envenomation. J Am Acad Dermatol. Apr 2001;44(4):603-8. [Medline].

  17. Vetter RS. Arachnids misidentified as brown recluse spiders by medical personnel and other authorities in North America. Toxicon. Sep 15 2009;54(4):545-7. [Medline].

  18. Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in nonendemic areas. J Med Entomol. Nov 2002;39(6):948-51. [Medline].

  19. Vetter RS, Bush SP. Reports of presumptive brown recluse spider bites reinforce improbable diagnosis in regions of North America where the spider is not endemic. Clin Infect Dis. Aug 15 2002;35(4):442-5. [Medline].

  20. Wille RC, Morrow JD. Case report: dapsone hypersensitivity syndrome associated with treatment of the bite of a brown recluse spider. Am J Med Sci. Oct 1988;296(4):270-1. [Medline].

  21. Wright SW, Wrenn KD, Murray L, Seger D. Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med. Jul 1997;30(1):28-32. [Medline].

 
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Classic finding of a vesicle with surrounding erythema at 24 hours following brown recluse envenomation. Photo by Thomas Arnold, MD.
Illustration of a brown recluse spider with the fiddle displayed prominently on its dorsum.
Spider envenomations, brown recluse. Envenomation site on inner thigh untreated at 1 week. Photo by Thomas Arnold, MD.
Typical appearance of a male brown recluse spider. Photo contributed by Michael Cardwell, Victorville, Calif.
Female brown recluse with size scale. Photo contributed by Michael Cardwell, Victorville, Calif.
Spider envenomations, brown recluse. Close-up image of dorsal violin-shaped pattern. Photo contributed by Michael Cardwell, Victorville, Calif.
Spider bite, brown recluse. Within an hour, the bite area swelled to the size of a quarter. The area turned blue and dark red by the evening of the first day, exceeding the boundaries of a circle drawn around the area of initial swelling by the patient's physician. Courtesy of Dale Losher.
Spider bite, brown recluse. The third day after the bite. The skin continues to die. Courtesy of Dale Losher.
Spider bite, brown recluse. Another view of the wound 3 days after the bite. Courtesy of Dale Losher.
Spider bite, brown recluse. Nine days after the bite. The patient endured 8 days with an open wound to drain the spider's toxins and needed intravenous antibiotics and pain medication almost 24 hours a day. Courtesy of Dale Losher.
Spider bite, brown recluse. Eleven days after the bite. A 5-inch wide area of dead tissue was excised, necessitating skin grafting. Courtesy of Dale Losher.
Spider bite, brown recluse. Waiting to see skin graft results 38 days after the bite. Courtesy of Dale Losher.
Spider bite, brown recluse. Skin graft results 38 days after the bite. Courtesy of Dale Losher.
Spider bite, brown recluse. View of healed wound approximately 10 months after bite. Courtesy of Dale Losher.
Dermonecrotic arachnidism represents a local cutaneous injury with tissue loss and necrosis.
Brown recluse spider. Courtesy of US Centers for Disease Control and Prevention.
Brown recluse spider. Courtesy of US Centers for Disease Control and Prevention.
 
 
 
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