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Brown Recluse Spider Envenomation Medication

  • Author: Thomas C Arnold, MD, FAAEM, FACMT; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Feb 24, 2016
 

Medication Summary

Utilize tetanus prophylaxis, analgesics, and antipruritics as needed. Reserve antibiotics for evidence of true infection and do not administer prophylactically. Carlton recommends antihistamines and observation alone as treatment for brown recluse spider bites.[17]

Although no antivenom is currently approved for use in the United States, several groups in other countries are developing a Loxosceles antivenom.[18] It is only a matter of time before a suitable antivenom may be available in the United States.

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Antibiotics

Class Summary

Antibiotics may minimize the local inflammatory component of cutaneous loxoscelism and decrease resulting skin necrosis.

Dapsone (Avlosulfon)

 

Dapsone is bactericidal and bacteriostatic against mycobacteria strains. The mechanism of action is similar to that of sulfonamides where competitive antagonists of p-aminobenzoic acids (PABA) prevent the formation of folic acid, causing bacterial growth inhibition.

If used, initiate the treatment with small doses followed by gradual increments. Monitor patients carefully because hypersensitivity, methemoglobinemia, and hemolysis in the presence of G-6-PD deficiency have been reported.

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Corticosteroids

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Use of corticosteroids is controversial, but some evidence supports their use in systemic loxoscelism because of their RBC membrane–stabilizing effects.

Methylprednisolone (Solu-Medrol)

 

Methylprednisolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Prednisone (Deltasone, Orasone, Meticorten)

 

Prednisone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

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Antihistamines

Class Summary

Antihistamines are used to treat minor allergic reactions and anaphylaxis. Diphenhydramine may be used to pretreat patients with prior documentation of minor allergic reactions. These agents may control itching by blocking effects of endogenously released histamine.

Diphenhydramine (Benadryl)

 

Diphenhydramine is used for symptomatic relief of allergic symptoms caused by histamine released in response to allergens.

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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 Health Sciences Center-Shreveport; Medical Director, Louisiana Poison 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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Norris, MD Professor, Department of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, International Society of Toxinology, American Medical Association, California Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

References
  1. Gehrie EA, Nian H, Young PP. Brown Recluse spider bite mediated hemolysis: clinical features, a possible role for complement inhibitor therapy, and reduced RBC surface glycophorin A as a potential biomarker of venom exposure. PLoS One. 2013. 8(9):e76558. [Medline]. [Full Text].

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

  3. 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. 2002 Nov. 39(6):948-51. [Medline].

  4. 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. 2002 Aug 15. 35(4):442-5. [Medline].

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

  6. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline]. [Full Text].

  7. McDade J, Aygun B, Ware RE. Brown recluse spider (Loxosceles reclusa) envenomation leading to acute hemolytic anemia in six adolescents. J Pediatr. 2010 Jan. 156(1):155-7. [Medline].

  8. Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency Department Death From Systemic Loxoscelism. Ann Emerg Med. 2012 Feb 1. [Medline].

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

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

  11. 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. 1995 Mar. 25(3):363-8. [Medline].

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

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

  14. 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. 2001 Feb. 37(2):161-5. [Medline].

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

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

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

  18. 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). 2007 Sep. 45(6):678-87. [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.
Complete distribution range of wild and domestic Loxosceles reclusa (brown recluse spider). Courtesy of Wikimedia Commons (By ReliefUSA_map.gif: Public domain, U.S. government derivative work: Bob the Wikipedian).
 
 
 
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