Brown Recluse Spider Envenomation Follow-up

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

Further Inpatient Care

Admit patients to the hospital for observation if they have rapidly expanding lesions or show evidence of systemic toxicity.

  • Patients with rapidly expanding lesions require good conservative wound care, including splinting and elevation. Appropriately treat any bacterial superinfection that occurs.
  • Carefully manage fluid and electrolytes in patients with evidence of systemic loxoscelism. Monitor patients' renal status and provide blood transfusions as needed. A short course of oral prednisone may reduce hemolysis. These patients may be discharged when their renal and hematologic statuses are stable.
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Further Outpatient Care

  • Before discharging patients from the hospital, instruct them on proper wound care techniques and in proper cooling of the lesion for the first 72 hours. Schedule patients for daily wound checks until the lesion is stable or improving.
  • At each follow-up visit for the first 72 hours, perform a urine bedside test for blood and a CBC with platelet count to assess for any evidence of systemic toxicity.
  • Inform patients that the development of fever or dark urine necessitates immediate return to the ED or a call to their primary physician.
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Deterrence/Prevention

  • Persons living in endemic areas should wear protective clothing and remain attentive when venturing into habitats of the brown recluse spider.
  • Cobwebs and spiders should carefully be removed from under and behind beds. One should use caution when putting on clothing that has been kept in storage and not worn for some time.
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Complications

  • Delayed skin grafting may be necessary after 4-6 weeks of standard therapy.
  • Losses of digits and amputations have been reported.
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Patient Education

For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education articles, Black Widow Spider Bite and Brown Recluse Spider Bite.

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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

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  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].

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  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].

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  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].

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  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].

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  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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