Widow Spider Envenomation

Widow spiders belong to the genus Latrodectus and are found throughout the world. In the United States, arguably the most famous is the Southern black widow spider (Latrodectus mactans mactans). The term widow spider is preferred because not all species in the genus Latrodectus are black. Other widow spiders in North America include the red-legged widow (Latrodectus bishopi), the Northern black widow (Latrodectus variolus), the Western black widow (Latrodectus hesperus), and the brown widow (Latrodectus geometricus), which has a worldwide distribution.

The redback spider (Latrodectus hasselti) is endemic to Australia. The katipo (Latrodectus katipo) is native to New Zealand. The Mediterranean black widow (Latrodectus tredecimguttatus) is found in Europe. The white widow spider (Latrodectus pallidus) can be found in North Africa, Central Asia, and the Middle East. The button spider (Latrodectus indistinctus) is one of several widow spiders native to South Africa.

The adult female black widow spider is approximately 2 cm in length and shiny black with a red-orange hourglass or spot on the ventral abdomen. The male is much smaller and brown. Juvenile females are also brown but have the general body morphology of the adult. Males and juveniles have a pale hourglass shape, similar to adult females. The female sometimes eats the male during or after copulation. Webs are irregular, low-lying, and commonly seen in garages, barns, outhouses, and foliage. Other widow spiders are generally black but may have red spots, such as Latrodectus tredecimguttatus, or a dorsal red stripe, such as the redback spider. L geometricus is brown with red and yellow markings.

See the images below.

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. This article serves as a guideline, and the clinician should use judgment for individual patient encounters.

See Arthropod Envenomation: From Benign Bites to Serious Stings and Venomous Spider Bites: Keys to Diagnosis and Treatment, Critical Images slideshows, for help identifying and treating various envenomations.

Alpha-latrotoxin causes the toxic effects observed in humans by opening cation channels (eg, calcium channels) presynaptically, causing increased release of multiple neurotransmitters. This results in excess stimulation of motor endplates with resultant clinical manifestations. Clinically, the predominant effects are neurological and autonomic, in contrast to the dermonecrotic local effects associated with spiders causing necrotic arachnidism (eg, brown spiders from the genus Loxosceles).

Between January 1, 2016 and December 31, 2018, there were 3,691 widow spider envenomations reported to the American Association of Poison Control Centers (AAPCC).[1, 2, 3] There were 278 patients younger than 6 years, 189 patients aged 6-12 years, and 271 patients aged 13-19 years old.

Minor symptoms were experienced by 121 of the victims. Moderate toxicity, meaning the patient required treatment but did not have life-threatening signs and or residual disability or disfigurement, was observed in 1,139 patients. Major toxicity, in which there were life-threatening signs and/or the exposure resulted in permanent disability or disfigurement, was reported in 743 patients. No deaths were reported. In fact, no deaths from widow spiders have been reported to the AAPCC since it began producing its annual report in 1983. However, deaths have been attributed to widow spider envenomations in Spain (2001), Greece (2003), and Albania (2006), where two deaths were reported.[4, 5, 6]

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

For patient education resources, see Black Widow Spider Bite and Brown Recluse Spider Bite.

Initial pain at the bite site is generally trivial and may go unnoticed. It commonly is described as a pinch or pinprick; however, infants may present with unexplained crying.[7, 8]  Within about 1 hour, systemic symptoms begin and may last for a few days.

Muscle cramping may occur locally or extend into large muscle groups, such as the abdomen, back, chest, and thighs. Case reports suggest involvement of smooth muscles in the bronchi and endometrium.

Other symptoms may include nausea and vomiting, headache, and anxiety. Some patients describe pavor mortis, a feeling of impending doom.

Abnormal vital signs may include hypertension, tachypnea, tachycardia, and, occasionally, hyperthermia.

Diaphoresis, locally and/or remote from the site of envenomation, may occur.

Tiny fang marks may be visible at the bite site

Local effects are usually limited to a small circle of redness and/or induration around the immediate bite site. A central reddened fang puncture site surrounded by an area of blanching and an outer halo of redness is described as a having a target appearance.

Severe muscle cramping, the hypertoxic myopathic syndrome, is common, generally localized to the same half of the body as the envenomation. Abdominal rigidity following lower extremity bites may mimic an acute abdomen.

Neurologic effects, including mild weakness, fasciculations, and ptosis, have been described.

Latrodectus facies, characterized by spasm of facial muscles, edematous eyelids, and lacrimation may occur. This can be mistaken for an allergic reaction.

Bronchorrhea and pulmonary edema have been described in Europe and South Africa.[9]

Complications may include the following:

• Complications may include the following:
• 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
• Ileus ^[10]
• Priapism, rarely ^{[11, 12]}
• Compartment syndrome (rare) ^[13]
• Electrocardiographic abnormalities ^[14]
• Toxic myocarditis (rare) ^[15]

Also see Treatment/Complications.

Laboratory tests should be obtained if the diagnosis is uncertain to exclude alternative diagnoses (eg, acute abdomen, myocardial infarction[16] ). The authors recommend the following, as appropriate:

• Complete blood cell count
• Cardiac markers (eg, troponin)
• Pregnancy test when applicable
• Comprehensive metabolic profile
• Lipase
• Urinalysis
• Creatine kinase

Laboratory studies also may be necessary to evaluate for end-organ damage following widow spider envenomation.

It is common for the creatine kinase and peripheral white blood cell count to be elevated following widow spider envenomations.

Consider performing an acute abdominal series or an abdominal CT scan if the diagnosis is unclear in a patient presenting with abdominal pain.

Patients with focal neurologic deficits in the setting of severe hypertension following widow envenomation may require neuroimaging (eg, head CT).

Skin testing variably may predict immediate hypersensitivity to antivenom and may influence the decision regarding its administration. Antivenom-induced anaphylaxis may be more life-threatening than the envenomation itself.

Obtain an electrocardiogram in patients with comorbid conditions such as hypertension, coronary artery disease, and congestive heart failure, and in patients with chest pain or respiratory symptoms.

Support the airway, breathing, and circulation per advanced cardiac life support (ACLS) protocols with oxygen, monitors, and intravenous fluid resuscitation.

Negative-pressure venom extraction devices (eg, the Extractor, Sawyer Products) have not been evaluated for treatment of widow spider envenomation.

Electric shock and various folk and herbal remedies lack therapeutic value and are potentially harmful.

Do not give antivenom in the field because of the risk of severe allergic complications.[17]

Attempts to secure the spider may be helpful in confirming widow spider envenomation as long as it can be done safely and does not delay transport.

Because these envenomations are exceptionally painful, analgesia is essential. Intravenous opioids are preferred initially.

Supportive care is the mainstay of treatment. Ensure a patent airway and adequate oxygenation and ventilation. Maintain euvolemia. Symptomatic treatment of pain and muscle cramping can be accomplished with opioids and benzodiazepines.

Hypertension is common but usually resolves once the pain and muscle cramping are relieved. Intravenous antihypertensives such as nitroprusside, nicardipine, or labetalol are recommended for patients with conditions in which hypertension must be avoided (eg, coronary artery disease).

Envenomation severity can be classified as outlined below.

Grade 1—Mild—is characterized by the following:

• Local pain at envenomation site

• Normal vital signs

Grade 2—Moderate— is characterized by the following:

• Muscular pain in the envenomated extremity

• Extension of muscular pain to the abdomen if bitten on a lower extremity or to the chest if envenomated on an upper extremity

• Local diaphoresis of envenomation site or involved extremity

• Normal vital signs

Grade 3—Severe—is characterized by the following:

• Generalized muscular pain in the back, abdomen, and chest

• Diaphoresis remote from envenomation site

• Abnormal vital signs (blood pressure >140/90 mm Hg, pulse >100)

• Nausea and vomiting

• Headache

Antivenom should be given for pain unresponsive to opioid analgesia and/or imminent risk of severe complication of envenomation (see Treatment/Complications). The risk of allergy to antivenom must be weighed against the benefit of relieving prolonged discomfort, avoiding hospitalization, and preventing complications.[17]

Admission to the hospital is generally indicated for the following patients, subject to clinical judgment:

• Severely symptomatic children ^[8]
• 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.

Local poison control centers may assist management of difficult envenomations.

The Antivenom Index, published by the American Zoo and Aquarium Association and the American Association of Poison Control Centers, lists the locations, amounts, and various types of antivenom stores.

Antivenom-associated complications

Anaphylaxis, a type I (immediate) hypersensitivity reaction that may be life threatening, is characterized by urticaria, wheezing, and shock. Physician/provider fear of anaphylaxis often precludes appropriate antivenom treatment for widow spider envenoming; however, estimates of adverse reactions suggest a rate of only 3.5%.[18] Nevertheless, some dramatic cases are reported. 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. Two deaths have been reported from anaphylaxis to widow spider antivenom in the United States. One case involved the death of an asthmatic patient after undiluted antivenom was given as an intravenous bolus. The patient developed bronchospasm refractory to medical therapy.[19] The second case also involved an asthmatic patient, but the anaphylaxis occurred during an appropriately diluted antivenom infusion. A subcutaneous test dose had been given prior to the infusion, and no reaction was found. Several minutes into the infusion, the patient developed anaphylaxis and cardiac arrest, required a prolonged resuscitation, and eventually died.[20]

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 (1-2 vials) needed.

Also see Presentation/Complications.

Pesticides may prevent exposures to widow spiders at home.

Eliminate spider food and habitat.

Shake sheets, shoes, and clothing before donning, which may shake out a spider.

Keep beds away from walls, which may prevent spiders from crawling into bed.

Brush, do not crush. If a spider is seen on the body or clothing, it should be brushed off rather than crushed. Crushing the spider is more likely to elicit a bite response.

Use plastic bags with slide-lock closure (eg, Ziploc) for garage-stored clothes rather than twist-tie closure mechanism.

Do not leave children’s toys outside.

 

 

 

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 3-21 days.

Most widow spider envenomations may be managed with opioid analgesics and sedative-hypnotics. Antihypertensives are recommended for refractory hypertension in pregnancy and in patients with coronary artery disease, cerebrovascular disease, or other severe vascular disease.

Antivenom may be indicated for patients who have severe envenomations with pain refractory to these measures. Antivenom should be considered when envenomation seriously threatens pregnancy or precipitates potentially limb- or life-threatening effects (eg, severe hypertension, unstable angina, priapism, compartment syndrome).[13] On average, antivenom administration results in resolution of most symptoms within 60 minutes of administration, and it has been shown to decrease the need for hospitalization.

However, the Redback Antivenom Evaluation II (RAVE-II) study from Australia in 2014 reported that adding antivenom to standard analgesia did not significantly improve systemic symptoms or pain in patients with redback spider bite and severe pain, with or without systemic symptoms.[21] After 2 hours, 38 (34%) of 112 patients from the antivenom group had clinically significant improved pain, versus 26 (23%) of 112 in the placebo group (95% confidence interval, -1.1% to 22.6%; P = .10). For systemic symptoms, they resolved after 2 hours in 9 (26%) of 35 patients in the antivenom group, versus 9 (22%) of 41 in the placebo group (95% confidence interval, -15% to 23%; P = .79). 

A new antivenom, Latrodectus immune F(ab’)2 (or Anawidow, previously known as Analatro, manufactured by Instituto Bioclon) has undergone phase 3 clinical trials in the United States but has not yet been approved for general use.[22] It may be associated with less risk of allergic reaction than the existing antivenom, so its indications for use may differ from the current indications.[22, 23]

Calcium gluconate is no longer recommended for widow spider envenomation.

Studies suggest benzodiazepines are more efficacious than other muscle relaxant agents for the treatment of muscle pain related to widow spider envenomation.

Prophylactic antibiotics are not indicated.

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort and promotes pulmonary toilet. Most analgesics have sedating properties that are beneficial for patients who have sustained trauma.

Morphine sulfate (Duramorph, Infumorph, Astramorph injections)

Morphine sulfate is the drug of choice for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated to the desired effect.

Class Summary

By binding to specific receptor sites, these agents appear to potentiate the effects of gamma-aminobutyrate (GABA) and to facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Lorazepam (Ativan)

Lorazepam is a sedative hypnotic in the benzodiazepine class that has a short onset of effect and relatively long half-life. By increasing the action of GABA, a major inhibitory neurotransmitter in the brain, it may depress all levels of the CNS, including the limbic and reticular formation.

Diazepam (Valium)

Diazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA. It is a third-line agent for agitation or seizures because of a shorter duration of anticonvulsive effects and accumulation of active metabolites that may prolong sedation.

Midazolam (Versed)

Midazolam is used as an alternative in the termination of refractory status epilepticus. Because it is water soluble, it takes approximately 3 times longer than diazepam to peak EEG effects. Thus, the clinician must wait 2-3 minutes to fully evaluate the sedative effects before initiating a procedure or repeating a dose. Midazolam has twice the affinity for benzodiazepine receptors than diazepam. It may be administered intramuscularly if vascular access cannot be obtained. Intranasal midazolam is an option for pediatric widow spider envenomation.

Class Summary

These are used to neutralize the toxin of a widow spider bite. Obtain informed consent before antivenom administration, if possible.

Antivenin, black widow spider

Black widow spider antivenin is derived from horse serum and produced by Merck & Co., Inc. Consider it for patients with grade 2 or grade 3 envenomations who are refractory to opiates and sedative-hypnotics and do not have risk factors for immediate hypersensitivity reactions. Some authorities advocate antivenom administration for certain patient groups, such as children and elderly persons. The package insert recommends skin testing for possible allergic reaction to the antivenom.

To mix the antivenom, dissolve 1 vial in 2.5 mL of sterile diluent with gentle agitation, then dilute this into a total volume of 50 mL normal saline. The package insert recommends intravenous injection over 15 minutes. Symptoms have been shown to improve within 1 hour of antivenom administration and for as long as 48 hours or more after envenomation.

In Australia, antivenom for Latrodectus envenomation is available from Commonwealth Serum Laboratories and, in South Africa, from the South African Institute of Medical Research. Indications for antivenom use and routes of administration vary around the world.

Class Summary

Tetanus immunization should be instituted following a black widow spider bite. Tetanus results from elaboration of an exotoxin from Clostridium tetani. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. Patients who may not have been immunized against C tetani products (eg, immigrants, elderly persons) should receive tetanus immune globulin (Hyper-Tet).

Diphtheria-tetanus toxoid (dT)

Diphtheria-tetanus toxoid is used for the passive immunization of any person with a wound that might be contaminated with tetanus spores.

Class Summary

Antihistamines prevent the histamine response in sensory nerve endings and blood vessels. They are more effective in preventing the histamine response than in reversing it.

Antihistamines act by competitive inhibition of histamine at the H1 receptor, which mediates the wheal and flare reactions, bronchial constriction, mucous secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.

In the treatment of black widow spider envenomations, antihistamines are used before antivenom administration to reduce acute adverse reactions to the antivenom.

Diphenhydramine (Benadryl)

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