Brown recluse bites

Last October, a report of death by loxoscelism was reported in Annals. It’s a sad story about a previously healthy 3 year old girl who was bitten by a witnessed brown recluse in Tennessee. She went to a rural ED, was evaluated and discharged. Only physical finding at that time was small red patch on the right breast. Later that evening she developed signs of systemic loxoscelism, then the following morning evidence of myoglobinuria. Went to Vanderbilt ED, where her initial labs of WBC 20.7, Hgb 9.5, 2+ spherocytes, and platelets of 54 were concerning. INR was 1.8. CMP was hemolyzed of course. They started transfusing, but sadly, she became apneic and pulseless shortly after, and was unable to be resuscitated. Autopsy was consistent with systemic loxoscelism.

• Rosen JL, Dumitru JK, Langley EW, Meade Olivier CA. Emergency department death from systemic loxoscelism. Ann Emerg Med. 2012 Oct;60(4):439-41. [PMID 22305333]

Thankfully, loxoscelism deaths are rare (or rarely diagnosed!) in the US. Current recommendations for treatment of systemic loxoscelism are aggressive supportive care, with blood products as needed. No antivenom available in the US, but may help those in South America.

What about treating the more common incidences of cutanous loxoscelism? Sadly, the literature abounds with interesting if not useful papers that misdiagnose MRSA (and other) cutaneous abscesses as recluse bites. Thus, it is hard to get good data on appropriate treatment as there are so many confounders. Things that may work for all other necrotic wounds may not work for cutaneous loxoscelism and vice versa. The list of potential treatments is large, and the following list is not all-encompassing:

• Cold packs
• Heat packs
• Electric shock
• Hyperbarics
• Nitroglycerin
• Steroids
• Surgical excision
• Symptomatic treatment
• Dapsone

So what does work? Truthfully, not a lot. Very little human evidence for any treatments.

Cold packs might help, and heat packs might worsen lesions. Not a lot of data to this effect, and in one letter to the editor the authors reference their other papers, which doesn’t mention heat or cold at all.

• King LE Jr. Brown recluse spider bites: stay cool. JAMA. 1985 Nov 22-29;254(20):2895-6. [PMID 4057509]

Electric shock certainly isn’t helpful in animal studies, but probably is entertaining. Why every type of envenomation needs a trial of electric shock is beyond me.

• Barrett SM, Romine-Jenkins M, Fisher DE. Dapsone or electric shock therapy of brown recluse spider envenomation? Ann Emerg Med. 1994 Jul;24(1):21-5. [PMID 8010544]

Hyperbaric oxygen therapy helps many wounds. Unclear benefit in humans, in animal studies no benefits were observed. This paper doesn’t have clearly identified spider bites, and has a small sample size.

• Maynor ML, Abt JL, Osborne PD. Brown Recluse Spider Bites: Beneficial Effects of Hyperbaric Oxygen. J. Hyperbaric Med 1992; 7(2):89-102.

Topical nitroglycerin has theoretical benefit of decreased vasoconstriction, but no actual benefit in rabbits. It may actually worsen systemic effects by dispersing venom instead of keeping it localized.

• 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. [PMID 11174233]

Steroids don’t decrease ulcer size, but may help with systemic symptoms such as pruritis.

• Dillaha CJ et al. North American Loxoscelism: Necrotic Bite of the Brown Recluse Spider. JAMA. 1964 Apr 6;188:33-6. [PMID 14107209]

Surgical excision helps if done late (like, 6 weeks later), but will cause worsening local effects if done early in the process.

• Rees RS, Altenbern DP, Lynch JB, King LE Jr. Brown recluse spider bites. A comparison of early surgical excision versus dapsone and delayed surgical excision. Ann Surg. 1985 Nov;202(5):659-63. [PMC1250983]

Dapsone is the old standby. Theoretically prevents PMN infiltration, but in practice is incredibly harmful. It causes hemolysis in all patients, as well methemoglobinemia to a degree in all, profound in certain patients. It also has side effects of headaches, GI upset, hepatitis, exfoliative dermatitis, agranulocytosis, and motor neuropathy. There have also not been any prospective trials on humans with any benefit. Just don’t use it.

• Swanson DL, Vetter RS. Loxoscelism. Clin Dermatol. 2006 May-Jun;24(3):213-21. [PMID 16714202]

Symptomatic treatment, e.g. antihistamines and analgesics, are probably most effective at what they do, but they don’t do much for ulcers or systemic pathology. Just don’t expect a lot of evidence on their behalf.

So what to do if someone comes in and says they have a brown recluse bite? If you live in an endemic area, 99 times out of 100 it’s still MRSA. If you live somewhere they don’t live, which is anywhere east of Tennessee, north of Missouri, or the small region near the Mexican border from Texas to California, it’s always MRSA. In the off chance you do have an identified spider and a small red lesion, rest assured that it will become necrotic less than 10% of the time. However, you may want to check a urine as it’s an easy and non-invasive way to check for hemolysis. While you’re at it, put a cold pack on the area. And by cold pack I mean ice pack, not the chemical variety. Beyond that, the evidence for anything is lacking. Just supportive care.