Is it Really A Brown Recluse Bite?

Link to the article?

A lot of things coming into the ED that are diagnosed as "spider bites" may be MRSA.

 

While I am only a 4th yr, the attendings I have worked with say that spider bites account for a very, very small amount of the actual "spider bite" complaints in the ED. docB nice call on the self citation by the author.. That is a good way to define arrogance.

 

There's a link to the article right there in the post

 

It wasn't there earlier. All is good.

 

Arrogance is saying things like this:

"It shouldn’t take a math whiz to realize that the medical community is overdiagnosing brown recluse spider bites."

"I have even seen specimens from ...."

"I have been identifying spiders that people THINK are or might be brown recluses and have received nearly 1,700 spiders as of October 2004..."

"I have heard of several verifications of brown recluses ..."

"If you wish a copy of either or both of these articles, contact me and I will send one to you electronically in PDF form or as a paper copy."

"Finally, many people have contacted me and explained in detail the progression of their wounds. Considering that the medical profession continues to misdiagnose skin conditions all the time and they see the wounds in person, there is little chance that I am going to be able to provide much more information from your written description over the internet other than the information I offer below."

"If you print out this website, try to educate your doctor and he/she refuses to listen to your concerns of alternative diagnoses, find another doctor who is more willing to be educated or who already knows there are no recluses in your area."

"I have been contacted by prisons in San Francisco, Los Angeles, San Diego, Ohio, Texas, and Arkansas"

Keep in mind he has a masters and has not gone to medical school.....so his expertise in diagnosis is limited.

It is also a good idea to not misspell words in an article....

Atleast he knows his limitations:
"Please don’t ask me what insects it might be, I don’t know much about them."

 

He may be arrogant, but he does make some good points.....

 

This actually isn't the only article on the topic. I'll look around to see if I can find the other ones I read a few years back. [edit: I think I read a few of the articles he cites] I find that when I mention it to people they usually have examples of friends with "brown recluse bites" who they insist were bitten though no spider was found, so the problem is probably fairly widespread.

Out of curiousity, has anybody here ever seen a brown recluse bite? How about other spider bites?

(Oh, and while I certainly agree that the tone is arrogant, perhaps he cites many of his own articles because he is one of the few people writing about this topic? He may simply not want to have to repeat everything he's written before, as this is a summary rather than a full academic treatment of the subject, so he simply refers to his earlier papers.)

 

Brown recluse bites are overdiagnosed. People frequently assume that they have been bit when they develop a skin abscess.

bkn

 

I'm frequently amazed at what patients purport to be spider bites. And they all seem to think that their *spider bite* is automatically a serious condition.

 

My residency "scholarly project" will prove that invisible spiders are actually the vector for community acquired MRSA abcesses.

 

LOL Are you sure it isn't the storage building behind the apartment complex owned by That One Guy that harbors the nest?

I've never seen a true brown recluse bite, but I did see a case of a black widow bite. God that looked like it sucked to be the patient.....

 

I can't help but wonder if all of this "misdiagnosis" business isn't just a issue of differentiating chief complaints from diagnoses. As an MS4 I've seen innumerable patients with CC of spider bite yet I have never diagnosed a spider bite -- it's always something else or something less specific than spider bite.

 

I've seen several actual brown recluses... but never a bite. I grew up in Missouri, endemic to the BR - and never met anyone who actually had suffered the classic necrotic bite.

People just think that "spider bite" sounds like a better reason to go to the ED than "mosquito bite." And anytime "spider bite" shows up on the board, it means MRSA absess until proven otherwise.

I remind/teach people all the time that the BR is not found here in Florida... not that it matters.

We had a case of a Black Widow bite last year. Only knew for sure because the guy presented the now-dead spider that bit him. (And despite the resident asking him to leave it, the guy insisted on keeping it as a trophy.) He was a grocery stocker and the spider had hitchhiked here in a crate of bananas.

 

Word is you are at ORMC, I was there in July. I had a guy who worked with meat at some grocery store and he flat out said it was a mosquito bite and he has a nasty looking abscess. I drained that puppy. Of course 90% of abscesses are due to the old BR which no one has seen.

 

A BR *is* a serious spider bite. Ever seen skin falling off a hand from a BR bite? It's ... icky.

 

I've seen a real one before, but not in the ER.

I know that brown recluse bites are serious, but with a few exceptions other spider bites are not.

 

Word is correct. I don't know if I met you or not... I spent July doing L&D at APH. You probably don't have any questions, but if you do, you can pm me. I know more about the off-service rotations than anything else, as I've done most of them at this point. If I don't get back to you right away, it's because I'm on the trauma surg service this month.

 

I had a patient come in with what I suspected was a brown recluse bite. He was a homeless individual who was sleeping underneath a freeway when he felt a sharp pain in his left calf. He presented the next day with a 2 cm circular area of white pus with slight necrosis, and 5cm surrounding tender area of errythema.

, and the attending quoted some obscure article which stated that brown recluses were not found in California at all. This article seems to suggest the same thing...

"fact that the brown recluse spider (Loxosceles reclusa) is native only to the South and central midwestern states (circumscribed by southeastern Nebraska south to Texas, east to Georgia/westernmost tip of South Carolina and southernmost Ohio with additional rare finds being made beyond this area"

 

Although the brown recluse does not live in California, we do have four species of native recluse spiders. The most common Californian recluse spider is the desert recluse, L. deserta. It is found mostly in the Sonoran and Mojave deserts, in the foothills of the lower San Joaquin Valley, and in adjacent areas of Mexico, all of which are sparsely populated by humans.
There are fewer than 10 documented cases of the spider being collected in California, spanning more than 4 decades, typically in facilities that receive goods from out of state. Searching the immediate area yielded no additional brown recluses and therefore they were considered to be individual stowaways. Undoubtedly, more brown recluses have been inadvertently brought into the state via commerce and the relocation of household belongings; however, amazingly few specimens have ever been collected.

art ref

 

I saw a few cases when I worked in Texas that fit the classic description, and one patient that brought in the brown recluse as proof. In my years in Florida and California, I have yet to see one.

 

I'm fortunate to have an exterminator here (we have problems with carpenter ants...) who is a retired college professor with a Ph.D. in entomology. He discovered that there's more money to be had in ridding homes of insects than in teaching about them. More on point, though, he mentioned to me that despite frequent reports of BR spider bites here, the spider is not native to the Pacific Northwest (SE Washington in particular) and none have ever been confirmed here. With thousands of other biting or venomous insects and arachnids living around us, it may be that the BR spider is a convenient "whipping boy" for people who lack the time, expertise and need to find a more precise cause of injury.

 

Ah yes, the "pit bull of spider-dom".

 

Tell him to try the Inyokern/Ridgecrest/Trona area near Death Valley. I lived there less than a year and saw four in situ. Identification was confirmed by an aquaintance who as in WU's entomology department at the time, because he flat refused to believe some observational claims, and I sent him specimens to prove them (black widows in huge numbers in open and relatively heavily trafficed areas with female samples having abdominal diameters almost twice the size considered "possible" by standard description, BR existing in that area at all, and samples of the "banana scorpion" [great desert scorpion, local name due to coloration] exceeding 9" in overall length).

They may be imports, but they live out there.

However, WA state, where I currently live, has an admited issue with misdiagnosis of "hobo spider" bites as BR bites, because the noticable symptoms of a hobo spider's bite resemble fairly early symptoms of a Fiddleback bite, and the spider itself is somewhat similar in appearance, to a layman, and AZ, where I've spent quite a bit of time, docs will admit they have a proliferate number of spider bites from the family of spiders known THERE as "wolf spiders" which are often misdiagnosed as BR bites, despite the incredible rarity of actual specimens of the BR...it's simply that when the patient is bit by a large spider, they often insist that it had to be a BR bite (especially if it was a spooky looking critter like the ones known in AZ as "wolf spiders"), and, doctors themselves not being immune to various levels of commonplace arachnophobia, many of them will look at an otherwise unexplicable abscess or MSRA, and pan up the simplest and most acceptable explanation available..."you musta been bit by a nasty li'l spider, and never noticed until it progressed"....docs are human, too, folks, and have their prejuduices, and HATE having to say "duuuuhhh...I dunno" to someone looking up to them, and expecting them to provide a solid answer, as much as anyone else would, guys...I don't like sayign "I don't know" to my kids, and most doctors don't like having to admit they don't know when someone goes to them and expects a solid answer, either, folks.

 

It just occurred to me that I should make clear that only ONE of the four sppiders I identified as BR was confirmed by an expert...the others, I wasn't about to try to collect, as the valve bunkers they were in were not big enough to get the mason jar (kill jar for my butterflies) into, nor was I going to try a fishtank net or anythign else the things might be able to bite me through or that placed them in range of a scamper onto my hands, but they looked exactly like the one I DID send in, to me...same basic coloration and markings.

So it could have been one transplanted one living in a valve vault/bunker/hole/whateverit'scalled, and three others doing a creditable lookalike gig in similar venues, but I'm not thinking so (obviously).

 

I figured I'd bump this blast from the past as our rental house has a recluse infestation (we live in the Midwest/endemic area) and they have, for some reason, become really active in the last few days (I've seen three - I ID based on morphology, violin pattern, and three dyad eye pattern). I am a new parent with new-parent neurosis which means, I've spent the last two days getting smart on an insect that is shrouded in so much lore (most of which seems to be urban legends).

I also contacted the individual mentioned in the OP with a question, and he was helpful to me. There simply isn't a lot of literature/experts about the spider, so I can understand him citing himself. I can also understand his consternation when physicians far outside the natural habitat insist on diagnosing skin lesions as BR bites - which means some other medical condition is getting missed. According to what literature there is, 90% of confirmed bites self resolve with self care and with little damage to the affected area.

At any rate, I am going to stick out about 20 glue traps tomorrow and I'll stick a few pictures up here if I am not too lazy.

On a related note - I can't wait to move out of this P.O.S. rental house.

Respectfully,

Creepy Spider Guy

 

Dear Creepy Spider Guy;
At least it is not as bad as a house that my parents were looking at renting, (I was 4 at the time, so lets just say many years ago). In the middle of West Texas. One look thru the living room window from the porch was enough to decide for them, NO. I remember my dad turning to look at the real estate guy, and asking him "What the **** where you thinking?" The guy turned kinda red, and said something to the effect that they could have the house sprayed....My dad never cussed! So I had to look....the entire living room was a huge spider web, with tons of black widows. It was surreal. I still have nightmares!!

So see, your house isn't so bad after all!

 

FWIW I grew up in an area with millions of those damn things and learned a healthy fear of them. A close friend was bitten in bed by one (they found it dead in the AM) and had pretty nasty necrosis on her back. My dad was cleaning out the garage, reached down and accidentally grabbed one. His thumb looked like it was going to fall off, nasty black necrosis all around the end. He ended up on Keflex and 'roids and made a full recovery. So pretty much the only two "real" BR bites I have seen were nasty and could be spotted a mile away. That said, every single person that has a little red bump on their legs seems to think a spider caused it.

I was told by an entomologist at my undergrad that our area had a particularly nasty type of BR that was a little more aggressive. Still, they would only bite if you pressed on them. He claimed that you could let one walk all over your arm and it would never do anything, but if you pressed on its back it would bite. I never did any research on any of that nonsense.

 

I have a healthy respect for them, but really the only thing you can do is be cautious. They are so fastidious in this region, you are always going to have to deal with them (the state Conservation Department estimates that they are present in 70% of homes here based on a study they have done). There is a good article by a dermatologist (Dr. Phillip Anderson) that has studied 1000 cases of confirmed bites, and that is where the 90% number comes from. As far as I know, there is not better or more comprehensive evidence-based approach to brown recluses.

It's common sense that if the spider (or any spider) is on you, flick it off. If you mash it, you are certainly going to get bitten. That's just logical. Most cases of BR bites are, as with your friend, people who have been in a position where they have applied pressure to the back of the spider (rolling over in the bed or putting a foot in a shoe).

I don't know why the spider is popular in medical lore among patients. There is another thread on here from a medical student who was talking about how his father had been hospitalized for a "Brown Recluse Bite". His father lived in Philidelphia, which is far outside of the zone where recluses are found. I suppose it's possible he got bitten by a spider that had hitch hiked in a box that just came in from the midwest, but it's unlikely.

Here's a pic of one in a glue trap I set out. The picture isn't great, but if you look carefully you can see the six eye pattern (three sets of dyads) at the base of the fiddle marking that points to the abdomen. There are no unusual markings on the abdomen or spikes on the legs and the spider isn't large (all the criteria that the experts use for identification).

The picture if mine, so feel free to share it or whatnot.

 

Ugh. I grew up on a farm, and I was running a seed machine once. I put my hand on the PTO switch and a Black Widow ran out of a crack and across my hand. It creeped me out. I think that is the only time I have encountered one. They seem the be less prevalent here than BRs.

One nice thing (comparatively) about Black Widows is that they are web-based spiders. Meaning, (with rare exceptions like my story) you most likely aren't going to encounter them unless you run into their web. On the other hand, Brown Recluses hunt on the ground and don't use a web, which means they are moving around a lot at night, which is why people seem to run into them.

But, yeah, our P.O.S. rental house isn't as bad as that.

 

Spiders are great. Don't mess with them, they won't mess with you.

Flies, with their dung covered hairs, is another story.

You city slickers ought to live out more. Snakes and spiders are man's best friends.

 

Dear Marine,
I will happily coexist with the little fuzzy black and white mosquito eaters, and the humongous wolf spiders. However, the black widows need to go far far far away!! And take all these stupid scorpions with them. Don't have to worry too much about snakes on our property tho, as the pair of owls and two pair of hawks keep it nice and clear.

 

You can tell this dude is from the south (not by the subject matter of which he writes, but how).

To non-southerners, "mash" means to smush, crush, grind up - like "mashed potatoes".

In this usage, when he says "mash", he simply means "push", like "mash the button" - "push the button".

 

Guilty!

Nice catch!

 

See plenty of old, skin grafted BR bites down here in South Texas.

 

Ironically, I went to college in rural Virginia, but never heard that. The first time was in 1998, with a cardiologist from Ch-huh-ha-haleston (Charleston), who referred to detonating a defibrillator ("you mash the two buttons at the same time"), and that threw people off.

However, it was just that word choice - nothing was anything but well-written.

 

Have yet to see one in NC to OH... They may be here according to the range, but no.... They're all just MRSA abscesses.

 

Yep.

Remember, if you got a spider problem... then you really got an bug (insect) problem. Remove the bugs and you spiders move on to better hunting grounds.

 

.

 

That mirrors my experience: I've had so many folks in my ED in Maine w/ claims of spider bites from a "brown recluse".

They either did a internet search or a well meaning friend who's either a nurse, paramedic, EMT, or "a doctor" diagnosed it over the phone, webcam, etc...

 

-slow clap-

 

Of all the "spider bites", there was exactly one that actually WAS - because the patient brought it with her. It was a black widow (Latrodectus mactans).

I've always asked "what spider?", and the response, save the one above, has always been "I didn't see it" or "it was - look at it! That's what a spider bite looks like!"

20 years ago, when my best friend moved to northeast South Carolina (where the movie "The Patriot" was based and filmed), in his apartment, there was a brown recluse just sitting there, and he told me "just don't mess with it". So I didn't. The fiddle was clearly evident.

 

My problem is that people come into the ED insisting that their red spot or abscess is a spider bite and not understanding that *even if* they have a brown recluse bite there is no proven-beneficial early treatment. I've actually had a complaint filed against me as I "didn't treat their brown recluse bite."

We definitely have brown recluse around here. We also have black widows. I've seen a couple of real-deal brown recluse bites after they've necrosed and I've seen a black widow bite...they brought in the spider and presented pretty clasically.

I've seen a handful of "spider bites" on day 1 or 2 that may or may not have been the real deal but weren't abscesses and looked more like an early spider bite.

My most recent insistent patient was a pimple, not a spider bite. I could barely calm the patient down. The night before that, though, I saw a patient with what I believe was likely true loxoscelism...fever, vomiting, achiness after a plausible spider bite story/presentation. In an average shift I'd say I have 2-3 people check in with CC of spider bite.

 

Yeah, that's really the only reason I would consider spraying. As I understand it, it's virtually impossible to kill of BR with spray. They are just too tough and hide too well. But, as you noted, if you kill off their food source, you indirectly solve the problem.

 

I do remember a case of loxoscelism at Children's of Alabama when I was in medical school. I was on tox, and we actually gave antivenom.
The kid had everything, rigid abdomen, fever, vomiting.
Parents found the BW on his person.

 

Black widow or brown recluse? BW is latrodectus, and BR is loxosceles reclusa.

 

You're right. It was a BW, and it was lactrodectism. Shouldn't post after work I suppose.