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Brown Recluse Spider Bites: A Case Report
Brown Recluse Spider Bites: A Case Report Janice D. Nunnelee, PhD, RN, CVN, ANP
The brown recluse spider is found more commonly in the Southeast and the Central Midwest. Its bite is not common because it is a shy spider that only bites if cornered. A severe bite may necrose a large area that requires skin grafting; systemic reactions rarely occur. This article discusses the brown recluse spider and presents a case study of a patient with two spider bites that did require extensive grafting. © 2006 by American Society of PeriAnesthesia Nurses.
BROWN RECLUSE SPIDERS (Loxosceles reclusa) are found primarily in the Southeast and Central Midwest United States, in basements, closets, sheds, garages, undisturbed linens or papers, under wood piles, leaves, and any other place that is dark and relatively unused.1 Clothing stored in a basement or shed may be a perfect hiding place.
Brown recluse spiders are active at night, eating insects and other spiders. Between February and October the spiders mate, and they lay eggs in the summer months. These eggs are laid in sacks that are about one-half inch long. Once hatched, the babies become adult size in about one year and can live for three years.
The length of the spider’s body is about one-fourth to one-half inch. With the legs extended the spider is about the size of a quarter. Females are slightly larger than males. Brown recluse spiders range in color from tan to dark brown, but the most distinctive feature is the violin shape on the thorax. In addition these spiders have six eyes rather than four. There are many more bites attributed to brown recluse spiders than actually occur2; health care providers may attribute a bite to the brown recluse without confirmation of the source of the bite. The spiders are not aggressive, but bite if cornered, particularly in the daytime. Most people are bitten on the hands or feet when they disturb a spider in a quiet location. Currently, there is no diagnostic test to establish the certainty of the origin of the bite.
Primary prevention is to remove the environment where the spiders live. However, this is virtually impossible. Thorough housecleaning on a regular basis is the first step. Cleaning under beds and not storing items under them is important. Clothing that has not been worn in some time should be shaken out. Reducing clutter in attics, garages, and sheds makes a less desirable environment for spiders. Gloves and other protective clothing must be worn while performing any of these tasks. If spiders or egg sacks are vacuumed, the bag should be disposed of outside.
Janice D. Nunnelee, PhD, RN, CVN, ANP, is an Adult Nurse Practitioner, Deaconess College of Nursing, St. Louis, MO. Address correspondence to Janice D. Nunnelee, PhD, RN, CVN, ANP, 126 Plant Ave, St. Louis, MO 63119; e-mail address: [email protected]. © 2006 by American Society of PeriAnesthesia Nurses. 1089-9472/06/2101-0004$32.00/0 doi:10.1016/j.jopan.2005.08.006 12
Prevention/Control
Wood piles and logs should not be kept next to the house. By reducing bushes next to the house there are fewer routes for the spiders to climb into the house. Storage boxes are safer when taped shut because a spider’s chance of entry into them is decreased. There is much controversy over the use of pesticides to control spiders.
Bite The bite from a brown recluse is seldom fatal.3 The deaths that are reported cannot always be confirmed because there is no laboratory test for envenomation. The initial bite is usually Journal of PeriAnesthesia Nursing, Vol 21, No 1 (February), 2006: pp 12-15
BROWN RECLUSE SPIDER BITES
13
Treatment
Fig 1. bites.
Two bites on the upper arm at about 20 hours after the
painless1,4,5 or may be accompanied by a slight burning sensation. Pain or itching begins within 2 to 8 hours. If there is an extensive reaction, the pain may be intense. First a small white pustule appears with surrounding erythema. Within 24 hours the bite may erupt into a volcano lesion with a dark sunken center and raised edges. The center is free of inflammation, but the surrounding area is inflamed.6,7 Depending on the extent of the reaction, and the amount of venom injected, the surrounding area will become necrotic and slough. Healing can take months and may require excision and grafting.3 Diabetic patients heal more slowly than nondiabetics.4 Severe reactions occur in less than 10% of bites, affecting primarily the very young or old. There is no correlation between the severity of the bite reaction and systemic responses. Systemic reactions may include fever, chills, nausea and vomiting, skin rash, joint pain, and hemolysis. Patients should be instructed to call their health care provider if they develop fever or dark urine because these may be signs of a systemic reaction. Rarely, intravascular coagulopathy (with jaundice and hematuria), renal failure, seizures, and coma may occur.3,7 Clowers hypothesizes that extremity bites may have more severe reactions than others, but this study lacked the power to determine if this hypothesis is accurate.8
The initial treatment after a bite is to calm the patient, wash the bite with soap and cool water, and place ice on the area. Cold or cool compresses should be kept on the bite for the first 72 hours. Medical attention should be sought and identification of the spider made by an entomologist or pathologist. The patient is encouraged to collect the spider, even one that has been killed. This is necessary to ascertain if the bite is truly a brown recluse bite. If the spider is seen but not caught, a careful description of the spider should be given. There is no antivenom available at this time. Rapid surgical intervention is not recommended because envenomation may continue to spread for up to two weeks. However, once the lesion has demarcated, the entire area should be carefully excised. Many bites are not serious and require no surgical intervention. Of the ones requiring excision, there may be extensive scarring and many will need skin grafts. Steroids are often used early in the treatment, but there is some controversy over their use; the few studies are contradictory. Dapsone (avlosulfon, a sulfone used for leprosy) may be recommended but is not universally used,4,5,9 and if so, it must be used within hours of the bite. Reactions to dapsone include dose-related hemolysis, agranulocytosis, and aplastic ane-
Fig 2. Necrosis more extensive at 2 weeks, but not clearly demarcated.
JANICE D. NUNNELEE
14
BOX 1
Fig 3.
The bites have demarcated and coalesced at 7 weeks.
mia.7 Because of these possible adverse responses, dapsone should be reserved for the most severe bites. In fact, Wright et al states that the risk of using dapsone outweighs the possible benefits.10 Lowry et al examined the use of topical nitroglycerin for bites on rabbits.11 They found no significant difference with or without use. There have been no randomized clinical trials in humans. Hyperbaric oxygen has been used, but there are not enough studies to determine efficacy. Antihistamines are usually prescribed. Antibiotics are used only if the wound becomes infected. Topical antibiotics and a dressing may be used to keep the wound moist and protected. It may take weeks or months to demarcate and heal.
Preoperative Care In the preoperative period the wound is kept clean and granulation tissue is allowed to form. The eschar must be debrided chemically or surgically. A bacteriostatic cream, paste, or gel is applied to the wound to enhance healing and keep the area moist. At dressing changes, the wound must be cleaned completely with normal saline. Before surgery the site must be thoroughly cleaned of the cream, paste, or gel to ensure a surface appropriate for a skin graft. Intraoperative Care The graft is not planned until the wound has obviously demarcated. The patient must be informed there will be a separate site from which the graft will be obtained. Intraoperatively the nurse must assure that the recipient site is, indeed, clean. The donor site is prepped with provodone iodine, alcohol, or other solution. The donor site may be shaved first. Surgery is generally done under local anesthesia. After prepping and application of anesthesia, a dermatome or other similar instrument is used to harvest the graft. The graft may be “pie crusted” (fenestrated) to allow spreading of the graft surface. After applying to the recipient space and carefully smoothing in place, the graft may or may not be sutured. A pressure dressing is securely applied and the patient is free to be released, unless sedation or general anesthesia was used in addition to the local anesthesia. Postanesthesia Care In the postoperative period the patient is instructed not to remove or disrupt the dressings. He is taught to observe for bleeding at the donor or recipient site, and to call the doctor if there is excessive bleeding, redness, or purulent drainage. The graft dressing may be changed anywhere from 3 to 7 days and a new dressing applied. Care of the graft continues in the outpatient office until the graft is healed and capable of being left open to the air.
Case Report
Fig 4. bites.
Postsplit thickness graft to upper arm at 10 weeks after the
A 32-year-old man presented with two bites on his right upper arm (Fig 1) and a brown recluse spider in a jar. He was a graduate student who had been cleaning out old papers from his basement. He felt no pain until late afternoon and made an appointment for the following morning. About 20 hours had elapsed since the bite, and some focal and distant necrosis was seen. He was prescribed dapsone and steroids and given instructions on how to cover the
BROWN RECLUSE SPIDER BITES
15
wound with a dressing and silver sulfadiazine. He was seen 2 days later and the necrosis was worse, and continued to progress. At 2 weeks (Fig 2) the wounds were indolent, and he was prescribed a cephalosporin for infection control. He was seen weekly until 7 weeks (Fig 3) when the wounds were clearly demarcated. Surgery for excision and skin grafting was scheduled. Figure 4 is at 10 weeks when the skin graft is virtually healed and, despite a concave section in his upper arm, he was pleased with the result. He had good functional use of the arm and required no physical therapy.
Nursing Implications Patients with severe spider bites may have much fear regarding cosmetic and functional outcomes. This is particularly true of patients requiring excision and grafting. Emotional support is essential, but a realistic picture of the clinical course should be presented. Patients with minor reactions may be frightened that their case will get worse. The nurse is in a good position to provide emotional support. Counseling for altered body image may help. The nurse will also be the one to teach proper wound care both preoperatively and postoper-
atively. The use of silver sulfadiazine or other topical ointment should be demonstrated with a redemonstration by the patient or responsible adult. In the operating room the nurse will assist in procuring the skin graft. Postoperative instructions should emphasize the importance of not disturbing the graft dressing, the need for follow-up visits, and the signs and symptoms of infection. If antibiotics or other medications are prescribed, the patient should receive exact instructions on dosage as well as potential side effects. See Box 1 for preanesthesia, intraoperative, and postanesthesia care.
Conclusion A brown recluse spider bite is an uncommon occurrence. When it does occur, the bite may be inconsequential or result in extensive tissue death. The patient may suffer from altered body image or fear of complications. Medical treatment alone may suffice. If surgical intervention occurs, it is usually performed after 6 to 10 weeks, when the necrotic edges are well demarcated. The nurse assesses the patient in the preanesthesia setting, assists in care during the intraoperative period, and provides postanesthesia care after surgical treatment. The nurse also educates the patient on any treatment plans, preoperative surgical events, and discharge instructions.
References 1. Potter M: Brown recluse spider. (2004) Available at: www.uky.edu/agriculture/entomology/entfacts/struct/ef631. htm. Accessed August 16, 2004. 2. Vetter R, Ross S: Additional considerations in presumptive brown recluse spider bites and dapsone therapy. Am J Emerg Med 27;494-495, 2004 3. Arnold T: Spider envenomations, brown recluse. (2005) Available at: www.emedicine.com/emerg/topic547.htm. Accessed May 25, 2005 4. Mold J, Thompson D: Management of brown recluse spider bites in primary care. J Am Board Fam Pract 17:347-352, 2004 5. Ohio State University: Ohio State University Extension Factsheet. Available at: http://ohioline.osu.edu/hyg-fact/2000/ 2061.html. Accessed August 18, 2004
6. Nunnelee J: Bites and stings. RN 68:56-62, 2005 7. Zeglin D: Brown recluse spider bites. Am J Nurs 105:6468, YEAR 8. Clowers T: Wound assessment of the Loxosceles recluse. J Emerg Med 22:283-287, 1996 9. DermNet NZ: TITLE http://dermnetnz.org/treatments/ dapsone.html 2004. Accessed August 18, 2004 10. Wright S, Wrenn K, Murray L, et al: Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med 30:28-32, 1997 11. Lowry B, Bradfield J, Carrol R, et al. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Ann Emerg Med 37:161165, 2001
The brown recluse spider is found more commonly in the Southeast and the Central Midwest. Its bite is not common because it is a shy spider that only bites if cornered. A severe bite may necrose a large area that requires skin grafting; systemic reactions rarely occur. This article discusses the brown recluse spider and presents a case study of a patient with two spider bites that did require extensive grafting. © 2006 by American Society of PeriAnesthesia Nurses.
BROWN RECLUSE SPIDERS (Loxosceles reclusa) are found primarily in the Southeast and Central Midwest United States, in basements, closets, sheds, garages, undisturbed linens or papers, under wood piles, leaves, and any other place that is dark and relatively unused.1 Clothing stored in a basement or shed may be a perfect hiding place.
Brown recluse spiders are active at night, eating insects and other spiders. Between February and October the spiders mate, and they lay eggs in the summer months. These eggs are laid in sacks that are about one-half inch long. Once hatched, the babies become adult size in about one year and can live for three years.
The length of the spider’s body is about one-fourth to one-half inch. With the legs extended the spider is about the size of a quarter. Females are slightly larger than males. Brown recluse spiders range in color from tan to dark brown, but the most distinctive feature is the violin shape on the thorax. In addition these spiders have six eyes rather than four. There are many more bites attributed to brown recluse spiders than actually occur2; health care providers may attribute a bite to the brown recluse without confirmation of the source of the bite. The spiders are not aggressive, but bite if cornered, particularly in the daytime. Most people are bitten on the hands or feet when they disturb a spider in a quiet location. Currently, there is no diagnostic test to establish the certainty of the origin of the bite.
Primary prevention is to remove the environment where the spiders live. However, this is virtually impossible. Thorough housecleaning on a regular basis is the first step. Cleaning under beds and not storing items under them is important. Clothing that has not been worn in some time should be shaken out. Reducing clutter in attics, garages, and sheds makes a less desirable environment for spiders. Gloves and other protective clothing must be worn while performing any of these tasks. If spiders or egg sacks are vacuumed, the bag should be disposed of outside.
Janice D. Nunnelee, PhD, RN, CVN, ANP, is an Adult Nurse Practitioner, Deaconess College of Nursing, St. Louis, MO. Address correspondence to Janice D. Nunnelee, PhD, RN, CVN, ANP, 126 Plant Ave, St. Louis, MO 63119; e-mail address: [email protected]. © 2006 by American Society of PeriAnesthesia Nurses. 1089-9472/06/2101-0004$32.00/0 doi:10.1016/j.jopan.2005.08.006 12
Prevention/Control
Wood piles and logs should not be kept next to the house. By reducing bushes next to the house there are fewer routes for the spiders to climb into the house. Storage boxes are safer when taped shut because a spider’s chance of entry into them is decreased. There is much controversy over the use of pesticides to control spiders.
Bite The bite from a brown recluse is seldom fatal.3 The deaths that are reported cannot always be confirmed because there is no laboratory test for envenomation. The initial bite is usually Journal of PeriAnesthesia Nursing, Vol 21, No 1 (February), 2006: pp 12-15
BROWN RECLUSE SPIDER BITES
13
Treatment
Fig 1. bites.
Two bites on the upper arm at about 20 hours after the
painless1,4,5 or may be accompanied by a slight burning sensation. Pain or itching begins within 2 to 8 hours. If there is an extensive reaction, the pain may be intense. First a small white pustule appears with surrounding erythema. Within 24 hours the bite may erupt into a volcano lesion with a dark sunken center and raised edges. The center is free of inflammation, but the surrounding area is inflamed.6,7 Depending on the extent of the reaction, and the amount of venom injected, the surrounding area will become necrotic and slough. Healing can take months and may require excision and grafting.3 Diabetic patients heal more slowly than nondiabetics.4 Severe reactions occur in less than 10% of bites, affecting primarily the very young or old. There is no correlation between the severity of the bite reaction and systemic responses. Systemic reactions may include fever, chills, nausea and vomiting, skin rash, joint pain, and hemolysis. Patients should be instructed to call their health care provider if they develop fever or dark urine because these may be signs of a systemic reaction. Rarely, intravascular coagulopathy (with jaundice and hematuria), renal failure, seizures, and coma may occur.3,7 Clowers hypothesizes that extremity bites may have more severe reactions than others, but this study lacked the power to determine if this hypothesis is accurate.8
The initial treatment after a bite is to calm the patient, wash the bite with soap and cool water, and place ice on the area. Cold or cool compresses should be kept on the bite for the first 72 hours. Medical attention should be sought and identification of the spider made by an entomologist or pathologist. The patient is encouraged to collect the spider, even one that has been killed. This is necessary to ascertain if the bite is truly a brown recluse bite. If the spider is seen but not caught, a careful description of the spider should be given. There is no antivenom available at this time. Rapid surgical intervention is not recommended because envenomation may continue to spread for up to two weeks. However, once the lesion has demarcated, the entire area should be carefully excised. Many bites are not serious and require no surgical intervention. Of the ones requiring excision, there may be extensive scarring and many will need skin grafts. Steroids are often used early in the treatment, but there is some controversy over their use; the few studies are contradictory. Dapsone (avlosulfon, a sulfone used for leprosy) may be recommended but is not universally used,4,5,9 and if so, it must be used within hours of the bite. Reactions to dapsone include dose-related hemolysis, agranulocytosis, and aplastic ane-
Fig 2. Necrosis more extensive at 2 weeks, but not clearly demarcated.
JANICE D. NUNNELEE
14
BOX 1
Fig 3.
The bites have demarcated and coalesced at 7 weeks.
mia.7 Because of these possible adverse responses, dapsone should be reserved for the most severe bites. In fact, Wright et al states that the risk of using dapsone outweighs the possible benefits.10 Lowry et al examined the use of topical nitroglycerin for bites on rabbits.11 They found no significant difference with or without use. There have been no randomized clinical trials in humans. Hyperbaric oxygen has been used, but there are not enough studies to determine efficacy. Antihistamines are usually prescribed. Antibiotics are used only if the wound becomes infected. Topical antibiotics and a dressing may be used to keep the wound moist and protected. It may take weeks or months to demarcate and heal.
Preoperative Care In the preoperative period the wound is kept clean and granulation tissue is allowed to form. The eschar must be debrided chemically or surgically. A bacteriostatic cream, paste, or gel is applied to the wound to enhance healing and keep the area moist. At dressing changes, the wound must be cleaned completely with normal saline. Before surgery the site must be thoroughly cleaned of the cream, paste, or gel to ensure a surface appropriate for a skin graft. Intraoperative Care The graft is not planned until the wound has obviously demarcated. The patient must be informed there will be a separate site from which the graft will be obtained. Intraoperatively the nurse must assure that the recipient site is, indeed, clean. The donor site is prepped with provodone iodine, alcohol, or other solution. The donor site may be shaved first. Surgery is generally done under local anesthesia. After prepping and application of anesthesia, a dermatome or other similar instrument is used to harvest the graft. The graft may be “pie crusted” (fenestrated) to allow spreading of the graft surface. After applying to the recipient space and carefully smoothing in place, the graft may or may not be sutured. A pressure dressing is securely applied and the patient is free to be released, unless sedation or general anesthesia was used in addition to the local anesthesia. Postanesthesia Care In the postoperative period the patient is instructed not to remove or disrupt the dressings. He is taught to observe for bleeding at the donor or recipient site, and to call the doctor if there is excessive bleeding, redness, or purulent drainage. The graft dressing may be changed anywhere from 3 to 7 days and a new dressing applied. Care of the graft continues in the outpatient office until the graft is healed and capable of being left open to the air.
Case Report
Fig 4. bites.
Postsplit thickness graft to upper arm at 10 weeks after the
A 32-year-old man presented with two bites on his right upper arm (Fig 1) and a brown recluse spider in a jar. He was a graduate student who had been cleaning out old papers from his basement. He felt no pain until late afternoon and made an appointment for the following morning. About 20 hours had elapsed since the bite, and some focal and distant necrosis was seen. He was prescribed dapsone and steroids and given instructions on how to cover the
BROWN RECLUSE SPIDER BITES
15
wound with a dressing and silver sulfadiazine. He was seen 2 days later and the necrosis was worse, and continued to progress. At 2 weeks (Fig 2) the wounds were indolent, and he was prescribed a cephalosporin for infection control. He was seen weekly until 7 weeks (Fig 3) when the wounds were clearly demarcated. Surgery for excision and skin grafting was scheduled. Figure 4 is at 10 weeks when the skin graft is virtually healed and, despite a concave section in his upper arm, he was pleased with the result. He had good functional use of the arm and required no physical therapy.
Nursing Implications Patients with severe spider bites may have much fear regarding cosmetic and functional outcomes. This is particularly true of patients requiring excision and grafting. Emotional support is essential, but a realistic picture of the clinical course should be presented. Patients with minor reactions may be frightened that their case will get worse. The nurse is in a good position to provide emotional support. Counseling for altered body image may help. The nurse will also be the one to teach proper wound care both preoperatively and postoper-
atively. The use of silver sulfadiazine or other topical ointment should be demonstrated with a redemonstration by the patient or responsible adult. In the operating room the nurse will assist in procuring the skin graft. Postoperative instructions should emphasize the importance of not disturbing the graft dressing, the need for follow-up visits, and the signs and symptoms of infection. If antibiotics or other medications are prescribed, the patient should receive exact instructions on dosage as well as potential side effects. See Box 1 for preanesthesia, intraoperative, and postanesthesia care.
Conclusion A brown recluse spider bite is an uncommon occurrence. When it does occur, the bite may be inconsequential or result in extensive tissue death. The patient may suffer from altered body image or fear of complications. Medical treatment alone may suffice. If surgical intervention occurs, it is usually performed after 6 to 10 weeks, when the necrotic edges are well demarcated. The nurse assesses the patient in the preanesthesia setting, assists in care during the intraoperative period, and provides postanesthesia care after surgical treatment. The nurse also educates the patient on any treatment plans, preoperative surgical events, and discharge instructions.
References 1. Potter M: Brown recluse spider. (2004) Available at: www.uky.edu/agriculture/entomology/entfacts/struct/ef631. htm. Accessed August 16, 2004. 2. Vetter R, Ross S: Additional considerations in presumptive brown recluse spider bites and dapsone therapy. Am J Emerg Med 27;494-495, 2004 3. Arnold T: Spider envenomations, brown recluse. (2005) Available at: www.emedicine.com/emerg/topic547.htm. Accessed May 25, 2005 4. Mold J, Thompson D: Management of brown recluse spider bites in primary care. J Am Board Fam Pract 17:347-352, 2004 5. Ohio State University: Ohio State University Extension Factsheet. Available at: http://ohioline.osu.edu/hyg-fact/2000/ 2061.html. Accessed August 18, 2004
6. Nunnelee J: Bites and stings. RN 68:56-62, 2005 7. Zeglin D: Brown recluse spider bites. Am J Nurs 105:6468, YEAR 8. Clowers T: Wound assessment of the Loxosceles recluse. J Emerg Med 22:283-287, 1996 9. DermNet NZ: TITLE http://dermnetnz.org/treatments/ dapsone.html 2004. Accessed August 18, 2004 10. Wright S, Wrenn K, Murray L, et al: Clinical presentation and outcome of brown recluse spider bite. Ann Emerg Med 30:28-32, 1997 11. Lowry B, Bradfield J, Carrol R, et al. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Ann Emerg Med 37:161165, 2001