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Can Spider Bites Flare Up Again

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Acute and recurrent skin ulceration later on spider bite

Med J Aust 1999; 171 (2): 99-102.
Published online: 19 July 1999

Notable Case

Acute and recurrent skin ulceration later spider bite

We reviewed the records of the Australian Venom Research Unit and The Alfred Hospital Department of Hyperbaric Medicine from January 1992 to July 1998 and found 15 cases of skin ulceration after spider seize with teeth that could be followed upward with the patient and the treating physician. 14 patients had skin ulceration attributed to white-tailed spider bites but in only three was this confirmed. One patient had skin necrosis after a confirmed black firm spider bite. Recurrent skin ulceration occurred in nine of the 15 patients.

Steven J Pincus, Kenneth D Winkel,
Gabrielle 1000 Hawdon and Struan K Sutherland

MJA 1999; 171: 99-102
Meet also White

Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
- - More articles on Insects, bites and stings

Introduction Spider bite is the unmarried commonest reason for inquiries to the Victorian Poisons Data Eye, with over 1300 calls recorded in 1997. ane Near people with spider bite require no specific handling and suffer but minor symptoms, but a modest number develop necrotic skin lesions associated with significant morbidity. 2-iv I series reported no significant illnesses in 36 bites, 5 and but seven definite cases of pare necrosis after spider bite have been published in Australia. 3,4,6,vii This paucity of reports has led to debate as to the ability of Australian spiders to cause skin necrosis (necrotising arachnidism).

Nosotros performed a retrospective assay of case records of suspected necrotising arachnidism in Australia to better ascertain its clinical features and to compare information technology with loxoscelism, a well-recognised cause of peel ulceration in the Americas.

Methods Patients were identified from records of inquiries from clinicians between January 1992 and July 1998 held by the Australian Venom Inquiry Unit of measurement and cases referred to the Hyperbaric Unit of the Alfred Hospital, Melbourne. Initial example-finding criteria were a history of spider bite with subsequent ulceration or necrosis at the seize with teeth site. Only cases in which both the patient and principal treating physician were contactable by telephone were included (with the informed consent of both patient and doctor).

In the patient interview we asked for demographic details, the method of identification of the spider, details of ulcerative or necrotic lesions and whatever other related problems, handling, result details and relevant by medical history. This information was confirmed with the patient's md, who was also asked about details of investigations, treatments and outcomes.

Results Xv cases were identified from more than 600 patients with peel lesions just without confirmed spider bite. In fourteen cases (Box 1) the spider was said to be a white-tailed spider (Lampona species) but in only three cases was this identification confirmed. One instance involved two black firm or black window spiders (Badumna species; encounter Box 2).

All of the spider bites were to the limbs, and involved baking, ulceration or necrosis of the skin. 13 were described as painful. Five patients experienced ongoing disability, and one required amputation of the paw and distal forearm. Four of the xv patients experienced systemic symptoms (fever), and three had ulcers that were culture-positive for Staphylococcus species (i positive for Streptococcus species besides). 9 patients had recurrent lesions, involving recurrent breakup or blistering of the pare afterward healing, or breakdown of skin grafts used to care for non-healing ulcers.

Oral or intravenous antibiotics (including doxycycline, penicillin or flucloxacillin) were given to 14 patients. Other treatments included dressings, antihistamines, topical and oral corticosteroids, hyperbaric oxygen therapy and pare grafting.

Discussion A major difficulty in the clinical report of spider bite is accurately identifying the spiders involved. Our series included eleven cases in which a spider was witnessed to seize with teeth the patient but was not captured for identification, one case where the spider was captured and identified by a clinician, and three cases where the spider was captured and identified by an good arachnologist. White-tailed spiders are distinctive, but in near of these cases absolute attribution to Lampona is not possible. Window spiders are relatively nondescript, and therefore less likely to be correctly identified unless captured and formally identified by an arachnologist.

4 cases of skin loss attributed to bites from Lampona take been previously reported. 3,four,seven Two of these (Cases 5 4 and 13 7 ) are included in this written report, equally both patients were reported to the AustralianVenom Inquiry Unit independently.

Several cases of bites from Badumna species take been published. These patients mostly experienced significant sickness, without skin loss. two,8 Some skin loss was reported in the instance of a male black house spider bite. 6 The case presented hither (Box 2) is the beginning to link the female spider to skin necrosis.

It has been suggested that many cases of suspected necrotising arachnidism in Australia may be the issue of bites from spiders of the genus Loxosceles, a grouping associated with necrotising arachnidism on several continents. ix While it is likely that some Australian cases of necrotising arachnidism might be attributed to this spider, it would exist hard to implicate Loxosceles in the cases reported hither.

The lesions reported in this series bear witness similarities but also significant differences from those acquired by Loxosceles. Every bit with Loxosceles, the initial seize with teeth appears to exist relatively painless, with pain developing over the next 12-24 hours, accompanied by local erythema and oedema, then blister formation and ulceration. 10 However, Loxosceles produces a deep ulcer, with a rolled edge and necrotic base of operations, extending into and sometimes through subcutaneous fatty to expose underlying muscle. 10,11 By contrast, most ulcers reported here were superficial, beingness bars to the epidermis and dermis. Another of import departure appears to exist the site of bites that progress to significant ulceration. Pregnant Loxosceles lesions occur in areas of abundant subcutaneous fat, with involvement extending beyond the margins of the skin necrosis. 11 The lesions reported here occurred in areas of little or no subcutaneous fat.

An infectious aetiology has been proposed for necrotising arachnidism in Australia, 12 but the concept that Mycobacterium ulcerans might be such an agent 13 was afterward challenged. 14 Bacillus, Staphylococcus and Penicillium species have been cultured from several spider venoms, including that of a Lampona species. 14 Merely three of the xv patients in our series had ulcers which grew whatsoever microorganisms, but, every bit 14 patients had been treated with antibiotics, infective organisms may have been cleared before cultures were prepared. Nonetheless, the absence of cultured organisms and poor clinical response to antibody therapy seen in many patients suggests that this condition is more than circuitous than simple pare infection.

9 of the 15 patients in our example series had recurrent ulceration. This problem had not been reported in Australia until very recently. 7 There are several American reports of lesions attributed to Loxosceles that take resulted in chronic not-healing ulcers and recurrent ulceration. These were felt to be secondary to consecration of a pyoderma gangrenosum-like disease process. 15 Pyoderma may follow a minor injury and may exist aggravated by surgery. 16 Information technology is typically associated with systemic immune abnormalities, simply up to fifty% of cases are described as "idiopathic". Spider bite may act every bit a trigger to precipitate this condition in susceptible individuals.

Several patients in our case series had histological findings consistent with pyoderma, and surgical intervention may have been associated with a poorer upshot. Although no patient in this series received corticosteroids at the doses recommended for pyoderma, long term topical corticosteroids may have slowed progression of the lesion in case 14. Prospective written report of the value of this treatment in cases of necrotising arachnidism should be considered.

Management of necrotising arachnidism remains an area of debate, and there is limited information upon which to make recommendations for the Australian situation.

At least for Loxosceles envenomations, conservative direction appears to be the all-time primary treatment. This should include tetanus prophylaxis and routine wound care. Early ice water application to bites is recommended to counter inflammation. Initial studies proposed early on excision and grafting of ulcers, 11 but more than contempo experience suggests that this may worsen the lesion and delay healing. 17

Hyperbaric oxygen therapy is gaining popularity in general wound direction. Animal models have produced conflicting results on the value of this type of treatment for Loxosceles lesions. xviii,19 Treating ulcers attributed to Lampona bites with hyperbaric oxygen therapy appears to have a marked clinical do good. 4


Acknowledgements
We thank Mr Albert Ong, of the Pathology Department, Gladstone Base Infirmary, for permission to reproduce his photograph of a patient, Dr Robert Raven and Mr Phil Lawless of the Arachnology Department of the Queensland Museum, and Ms Catriona McPhee and Dr Ken Walker of the Museum of Victoria for spider identification and photographs, and Dr Ian Miller, Managing director of the Hyperbaric Unit of measurement at the Alfred Hospital in Melbourne, for assist in collecting patient information. This study would not have been possible without the assistance of the many other clinicians and patients involved. We give thanks the Victorian Department of Human Services, CSL Express, BHP Community Trust and Snowy Nominees for financial support, and Dr Anna Young and Dr Tony Pennington for helpful discussion.
Telephone call NASTY!

To address the paucity of clinical data on necrotising arachnidism the Australian Venom Research Unit, together with the Monash Medical Centre's Section of Emergency Medicine, is conducting a long term prospective written report of the outcome of spider seize with teeth. Clinicians and the public are encouraged to study definite spider bites (with spider captured) immediately after the bite. The on-call investigator can be contacted via the Monash Medical Center switch (phone: 03 9550 1111) equally the NASTY Study (Necrotising Arachnidism Study). Definitive identification of the spider involved by an arachnologist is essential to accelerate our understanding of this condition.

References
  1. Victorian Poisons Information Centre Annual Report 1997. Melbourne: Royal Children's Hospital, 1998.
  2. Sutherland SK. Australian animal toxins. The creatures, their toxins and care of the poisoned patient. Melbourne: Oxford Academy Press, 1983.
  3. Gray Grand. A significant illness that was produced by the white-tailed spider, Lampona cylindrata. Med J Aust 1989; 151: 114-116.
  4. Skinner MW, Butler CS. Necrotising arachnidism treated with hyperbaric oxygen. Med J Aust 1995; 162: 372-373.
  5. White J, Hirst D, Hender E. 36 cases of bites past spiders, including the white-tailed spider, Lampona cylindrata. Med J Aust 1989; 150: 401-403.
  6. Macmillan DL. Envenomation past a window spider [letter]. Med J Aust 1989; 150: 16.
  7. Chan S. Recurrent necrotising arachnidism [alphabetic character]. Med J Aust 1998; 169: 642-643.
  8. Tingate TR. Envenomation by the mutual blackness window spider [letter]. Med J Aust 1991; 154: 291.
  9. White J, Cardoso J, Fan H. Clinical toxicology of spider bites. In: Meier J, White J, editors. Clinical toxicology of animate being venoms and poisons. Boca Raton: CRC Press, 1995.
  10. Atkins JA, Wingo CW, Sodeman WA, Flynn JE. Necrotic arachnidism. Am J Trop Med Hyg 1957; vii: 165-184.
  11. Auer AI, Hershey FB. Proceedings: Surgery for necrotic bites of the dark-brown spider. Arch Surg 1974; 108: 612-618.
  12. Harvey MS, Raven RJ. Necrotising arachnidism in Commonwealth of australia: a elementary instance of misidentification [letter]. Med J Aust 1991; 154: 856.
  13. Oppenheim B, Taggart I. More in spider venom than venom? Lancet 1990; 335: 228.
  14. Atkinson RK, Farrell DJ, Leis AP. Evidence against the interest of Mycobacterium ulcerans in most cases of necrotic arachnidism. Pathology 1995; 27: 53-57.
  15. Rees RS, Fields JP, King LE. Do chocolate-brown recluse spider bites induce pyoderma gangrenosum? South Med J 1985; 78: 283-287.
  16. Callen JP. Pyoderma gangrenosum. Lancet 1998; 351: 581-585.
  17. Rees RS, Altenbern DP, Lynch JB, King LE, Jr. Brown recluse spider bites. A comparison of early on surgical excision versus dapsone and delayed surgical excision. Ann Surg 1985; 202: 659-663.
  18. Strain GM, Snider TG, Tedford BL, Cohn GH. Hyperbaric oxygen effects on brownish recluse spider (Loxosceles reclusa) envenomation in rabbits. Toxicon 1991; 29: 989-996.
  19. Maynor ML, Moon RE, Klitzman B, et al. Brown recluse spider envenomation: a prospective trial of hyperbaric oxygen therapy. Acad Emerg Med 1997; 4: 184-192.

(Received 19 Oct 1998, accepted 1 Jun 1999)
Authors' details Australian Venom Inquiry Unit, Department of Pharmacology, The University of Melbourne, VIC.
Steven J Pincus, MB BS, BSc(Hons), Research Registrar.
Kenneth D Winkel, MB BS, FACTM, Managing director.
Gabrielle M Hawdon, MB BS, MPH, Deputy Managing director.
Struan K Sutherland, Dr. DSc, Honorary Main Fellow.

Reprints: Dr K D Winkel, Australian Venom Research Unit, Section of Pharmacology, The University of Melbourne, Parkville, VIC 3052.
Email: k.winkelATpharmacology.unimelb.edu.au

1: Xiv cases of acute and recurrent pare ulceration afterwards suspected or confirmed white-tailed spider bite*

Spider identity confirmed
1. A 27-twelvemonth-old woman in Queensland was bitten on the leg by a female white-tailed spider (positively identified by one of the authors, SKS). She developed a pimple-similar lesion that blistered and bankrupt down to course a 2x2cm ulcer. She was treated with doxycycline, and healed over one month.
2. A 38-twelvemonth-old man in Victoria was bitten on the calf past a female white-tailed spider (positively identified by the Victorian Museum). The seize with teeth was painful, itchy, erythematous and blistered, and progressed to shallow ulcers, while he became feverish. He was treated with doxycycline and antihistamines, and the original lesion healed over 10 days. He has since had multiple episodes of like lesions, with a gradual subtract in frequency.
3. A 33-year-one-time homo in New Due south Wales was bitten on the leg by a white-tailed spider (too sighted by the local medical officeholder). Initially the seize with teeth produced a modest, red, painful lesion. Culture produced a scant growth of S. aureus. The patient was treated with doxycycline, and the lesion healed, then broke downward at ane month into a 6x6cm ulcer that healed over 4 months. Spider identity not confirmed (patient reported white-tailed spider bite, but no formal identification)
4. A 39-twelvemonth-old man in Queensland was bitten on the shin. The seize with teeth was painful and progressed speedily to a 20x10cm ulcer. He presented at one calendar week, febrile with secondary infection. Staphylococcus and Streptococcus were cultured from the wound. He was treated with intravenous and oral antibiotics, but presented again three weeks later requiring further antibiotic handling. The ulcer healed over the next month. 5.·A 38-year-old man in Tasmania was bitten at the base of the pinkie. The lesion adult initially every bit a reddened disc with central darkening, progressing to a painful ulcer (1x2cm). S. aureus was cultured from the lesion. He was treated with intravenous and oral antibiotics without response. Hyperbaric oxygen therapy was practical five times, until the lesion developed a granulating base.
6. A 46-year-old homo in New Southward Wales was bitten on the dorsum of the hand past a white-tailed spider. The seize with teeth resulted in a painful, erythematous 5x5cm area of blisters that progressed to a chronic ulcer. He was unsuccessfully treated with routine wound dressings, oral and intravenous antibiotics, developed a hook hand and underwent amputation at the wrist.
7. A 46-year-onetime man in New South Wales was bitten on the shin. The bite resulted in an itchy, painful swelling with a 1cm necrotic area, and the patient became febrile. He was treated with flucloxacillin and penicillin, just the ulcer slowly increased in size with central necrosis, before eventually healing over one month.
eight. A 51-twelvemonth-old man in Queensland was bitten on the dorsum of the paw. Blisters at the seize with teeth site progressed to a painful ulcer that had non healed two months afterwards the bite, when the wound was debrided and repaired with a split skin graft. Two weeks later on in that location was blistering and loss of the graft. Regrafting was also unsuccessful, leaving a persistent 15x8cm ulcer that took 6 months to heal. The lesion recurred once three years subsequently.
ix. A 35-year-old human in Victoria was bitten on the palm of the paw. The bite resulted in a painful lesion with central blistering. He was treated with antibiotics. The blister broke downwardly to a shallow ulcer that resolved slowly over a calendar month. The patient experienced several episodes of superficial blisters over the next year.
White tailed Spider A white-tailed spider (Lampona cylindrata, actual length one-2 cm) -- the probable suspect in almost of these cases of serious injury after spider bite. "Lampona group spiders are establish throughout Australia; Fifty. cylindrata is particularly common in disturbed and urban areas. These spiders live in crevices, under bark, rocks and leaf litter and oftentimes in houses. They set on and eat other spiders including blackness house spiders."

-- Australian Museum online
<http://www.austmus.gov.au/is/sand/whitspi.htm>
Accessed 11 June 1999.

ten. A 33-year-one-time adult female in Victoria was bitten on the medial malleolus. Initially a reddish spot, the seize with teeth site blistered on Day 1, progressing to increasing inflammation and spreading ulceration resulting in multiple ulcers on the lower leg. A biopsy showed perivascular infiltration with polymorphic neutrophils and lymphocytes. The patient was unsuccessfully treated with antibiotics and routine dressings for four months earlier being referred for hyperbaric oxygen therapy. Twelve sessions of hyperbaric oxygen therapy led to resolution of the ulcer, but the patient experienced several recurrences of ulcers (1-2cm self-healing) per twelvemonth thereafter.
11. A 69-yr-former adult female in Victoria was bitten on the medial malleolus. The bite resulted in pain, erythema, oedema, multiple blisters, progressing to dry shallow ulcers, with fever. The patient was treated with intravenous antibiotics and routine wound dressings without response. Blisters and swelling increased for x days, then healed over three weeks. Iii months afterward the bite the patient experienced multiple episodes of small blisters that healed in 5-seven days.
12. A 25-twelvemonth-one-time woman in Victoria was bitten on the foot. The bite resulted in an ulcer and erythema in the start web space and swelling to the talocrural joint. The patient was treated with oral antibiotics. The lesion healed over i month, only recurred iv times in the adjacent 6 months, after which the patient had 10 sessions of hyperbaric oxygen therapy. At that place was a small recurrence 1 year after the bite.
13. A 35-yr-old human in Victoria was bitten on the shin. The bite resulted in painful, erythematous, bloated, multiple superficial ulcers. A biopsy showed dermal necrosis and vasculitis infiltrated by polymorphic neutrophils. The patient was treated with intravenous flucloxacillin and penicillin, oral augmentin, immobilisation and (subsequently 2 months) with a dissever skin graft. The graft healed over i month, simply the patient presented again a year later the seize with teeth with rapid breakdown of the graft. A regraft gave a poor result and recovery was tiresome.vii
14. A 40-year-old woman in New Southward Wales was bitten on the arm. The bite resulted in a red spot that grew to 2cm and developed a necrotic eye at seven days, progressing to shallow ulcers in the mid-forearm (6x3cm). Biopsy showed dermal necrosis and mixed perivascular infiltrate. Treatment with tetracycline was ineffective, only topical and oral prednisolone appeared to irksome the progression of the ulcer. The patient underwent hyperbaric oxygen therapy, with resolution of the ulcer, but she has experienced subsequent recurrences.

*Identified from the Australian Venom Research Unit medical informational service records and from the Alfred Hospital Department of Hyperbaric Medicine records.

Dorsum to text
2: Pare necrosis post-obit bites from two Badumna spiders
This is the first report of peel necrosis after the seize with teeth of a female person black firm spider. A previously well 55-year-old woman was bitten four times past two spiders that fell onto her forearm after she had sprayed them with insecticide. She felt an firsthand stinging pain afterwards the bite. The spiders were captured and later identified as female person Badumna spiders (species indeterminate) (Dr Robert Raven, Museum Scientist, Arachnology, Queensland Museum, personal communication). She presented to hospital four days afterward with a painful, swollen forearm, was admitted and, although systemically well, was treated with intravenous flucloxacillin.
Over the next three days, several ragged ulcers with necrotic bases developed within the bloated area. Microscopy of a swab of the ulcer showed numerous leukocytes, but no organisms were seen on gram stain nor subsequently cultured. After debridement, the ulcers were immune to heal by secondary intention. The wounds healed slowly over the adjacent few months and have non recurred.
A black house window spider A blackness house or black window spider (Badumna insignis, actual length i-1.5 cm). "Blackness house spiders are widely distributed in southern and eastern Australia. They are common in urban areas. Other Badumna group spiders are found throughout Commonwealth of australia. Black house spider webs grade untidy, lacy silk sheets with funnel-similar entrances. They are found on tree trunks, logs, stone walls and buildings (in window frames, wall crevices, etc.). Badumna longinquus ofttimes builds webs on foliage."

-- Australian Museum online
<http://world wide web.austmus.gov.au/is/sand/widspi.htm>
Accessed 11 June 1999.

Dorsum to text

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Source: https://www.mja.com.au/journal/1999/171/2/acute-and-recurrent-skin-ulceration-after-spider-bite

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