Approach to the patient with a suspected spider bite: An overview Authors Richard S Vetter, MS David L Swanson, MD Section Editors

Daniel F Danzl, MD Stephen J Traub, MD Deputy Editor James F Wiley, II, MD, MPH

MEDICALLY IMPORTANT SPIDERS Spiders are arachnids (a group of arthropods), which have four pairs of legs, similar to scorpions, mites, and ticks (figure 1). They use sharp fangs at the end of their chelicerae to bite prey (typically insects, other arthropods, or small vertebrates) and inject paralyzing venom. Most spiders pose no threat to humans. The venom of most spiders has little or no effect on mammalian tissues [2]. In addition, only a few species have cheliceral muscles powerful enough to penetrate human skin, and most of these spiders bite humans only in rare and extreme circumstances (eg, as they are being fatally crushed between skin and some object). The spiders most likely to inflict medically significant bites in humans include widow and false black widow spiders, recluse spiders, Australian funnel web spiders, and Phoneutria spiders. Each of these spiders are described briefly below, and their appearance and geographical distribution are summarized in the table (table 1). Widow spiders Latrodectus, or widow spiders (found worldwide), include the Southern black widow (picture 1) and Western black widow in the United States, and the Australian redback spider. Although less toxic than the black widows, the brown widow (picture 2) is causing increased interest because of its novelty as a non-native spider quickly spreading throughout the Southern US. Widow bites cause unremarkable local lesions that are sometimes accompanied by a characteristic systemic reaction with prominent, proximally-spreading pain and localized diaphoresis surrounding the site of the bite. Antivenoms are available for several species. (See "Bites of widow spiders".) False black widow spiders Steatoda, or false black widow spiders (found worldwide) are less often implicated in human bites, and cause less severe symptoms that those of widows (picture 3). Recluse spiders Loxosceles, or recluse spiders are found predominantly in North and South America (picture 4). Their bites are notorious for becoming necrotic, although this happens in a minority of cases. Systemic reactions to bites are usually mild, and consist of nonspecific systemic signs and symptoms. (See "Bites of recluse spiders".) Australian funnel web spiders Australian funnel web spiders are found in limited areas of eastern coastal Australia. Their bites can cause dramatic systemic reactions that mimic organophosphate poisoning and include salivation, diaphoresis, muscle spasms,

Last literature review version 19.1: January 2011 | This topic last updated: March 16, 2010 (More)

INTRODUCTION Spider bites are rare medical events. Of the thousands of spider species that exist around the world, only a handful cause problems in humans [1]. There are a variety of more common disorders that can mimic a spider bite, some of which represent a far greater threat to the patient if not recognized and treated appropriately. Thus, accurate diagnosis is the initial goal of the clinician evaluating a patient with a lesion that might represent a spider bite. Discerning among the various conditions in the differential diagnosis of a spider bite requires familiarity with these disorders, as well as a rudimentary understanding of the distribution and behavior of medically important spiders. The spiders of medical importance, the clinical manifestations, and diagnosis and differential diagnosis of spider bites will be reviewed here. The treatment of spider bites is discussed separately. (See "Bites of recluse spiders" and "Bites of widow spiders".)

tachycardia, hypertension, and pulmonary edema. An antivenom is available. South American Phoneutria Phoneutria or armed spiders are large spiders found in South America, especially urban areas of Brazil. The bites of these spiders can lead to severe systemic reactions, with occasional fatalities in children. An antivenom is available. TYPES OF REACTIONS A spider bite usually presents acutely as a solitary papule, pustule, or wheal. Systemic symptoms can accompany some envenomations, particularly those of widow spiders, funnel web spiders, and less often, recluse spiders. Allergic reactions typically result from contact with spiders (rather than bites). Local reactions Photographs of verified spider bites are rare in the medical literature, although dramatic images of necrotic lesions attributed to spider bites are commonplace in both medical journals and on the Internet. In reality, the majority of spider bites result in unremarkable wheals, papules, or pustules (picture 5). Local redness with a tender nodule at the site of the bite appears within minutes. The lesions are similar to those induced by a bee sting. In some cases, the markings of the fangs (one or two small puncture marks) are visible. Some bites also itch or burn. Spider bites may or may not be painful, and some go unnoticed. Pain can develop gradually over the ensuing hours after a bite, and can range from a slight prickly sensation to severe pain. The variability among bites and patients limits the clinical utility of this information in implicating a specific type of spider. Most local reactions to spider bites resolve spontaneously in approximately 7 to 10 days. They occasionally become secondarily infected with skin-derived bacteria. Necrotizing local reactions Recluse (Loxosceles) spiders inflict bites that may become necrotic, although this is an uncommon complication. Other types of spiders have been implicated in causing necrotic bites, but this is based largely upon circumstantial evidence. The management of necrotic recluse spider bites is discussed separately. (See "Bites of recluse spiders".) Systemic reactions Systemic symptoms are reported in a minority of patients, and occur when venom enters the circulation in sufficient amounts. The bites of certain spiders are known for distinct and potentially severe systemic reactions, including bites of the widow, Australian funnel web, and Phoneutria spiders.

Allergic reactions Allergic reactions to spiders are rare and have been reported mostly in response to contact with spiders [3-6]. In the United States, tarantulas are increasingly popular pets (picture 6). These nonaggressive spiders rarely bite. When threatened, they dislodge small (about 1 mm long) barbed hairs at the posterior of their abdomens and launch them at their attacker. These hairs, as well as airborne material from crushed tarantulas, may cause irritation or urticaria if they come in contact with skin, eyes, or mucous membranes [1,6]. In addition, airborne material from tarantulas can cause foreign body reactions in the eye [7]. Contact with tarantulas has also induced rare anaphylactic reactions in sensitized individuals [8]. The acute management of anaphylaxis (from any cause) is reviewed separately. (See "Anaphylaxis: Rapid recognition and treatment".) DIAGNOSIS A presumptive diagnosis of a spider bite is most often based on the history and clinical presentation. However, the diagnosis of a spider bite can be considered definitive ONLY if both of the criteria below are fulfilled: A spider was observed inflicting the bite.The spider was recovered, collected, and properly identified by an expert entomologist. If these criteria are not met, then other conditions such as vasculitis, infection, vascular problems, or other relevant disorders must be ruled out. (See 'Differential diagnosis' below.) Unfortunately, the criteria above are rarely met, even in published medical reports. This has resulted in a body of literature and considerable media attention falsely attributing various lesions and symptoms to spider bites [1]. The extent of this problem was illustrated in a review of 600 cases of suspected spider bites, which found that 80 percent of presumed bites could be more reasonably attributed to other causes [9]. These other causes included bites of different arthropods such as ants, fleas, bedbugs, ticks, mites, mosquitoes, and biting flies, as well as erysipelas, cellulitis, ecthyma, vasculitis, pyoderma, ophthalmic zoster, urticaria, angioedema, and burns. (See 'Differential diagnosis' below.) History Most patients' reports of spider bites are unreliable. The bite history is often speculative and retrospective and a spider was never visualized, either inflicting the bite or even present [10]. Even when a bite is witnessed by the patient, the "spider" is commonly found to be some other arthropod [9].

The diagnosis of a spider bite is thus highly suspect unless the patient actually observed a spider inflicting the bite and can retrieve it for identification. In the absence of this history and supporting evidence, another explanation should be sought. The setting in which the patient sustained the alleged bite should be carefully reviewed to see if it is consistent with the known habitat and behavior of the toxic spiders that live in the area. People may worry about the possibility that a toxic spider was transported into a non-indigenous area on fruit or other produce. However, it is rare for spiders to survive intact through the many steps involved in produce transportation, and then end up in a situation in which they would bite. The risk may be more significant for people working in food transport and handling, but it is minimal in the general community. (See "Bites of recluse spiders" and "Bites of widow spiders".) Clinical clues that essentially EXCLUDE the diagnosis of spider bite include the following: Multiple lesions or more than one lesion on widelyseparated parts of the body suggest another etiology. Spider bites are typically single lesions.Bites are generally not simultaneously sustained by multiple residents of the same household. Spider bites capture the imagination. Reports exist of patients both feigning spider bites as part of drug seeking behavior [11] and attempting suicide with genuine spider bites [12]. Influence of geographic location Each of the toxic spiders lives in specific parts of the world (table 1). Clinicians should know which spiders are indigenous to their area. Widows and false black widows are found worldwide. (See "Bites of widow spiders".)Recluse spiders are found predominantly in North and South America. Within the United States, they are limited to the mid-western and southern portions of the country (figure 2). (See "Bites of recluse spiders".)Phoneutria spiders are limited to South America.Australian funnel web spiders are limited to southeastern and coastal Australia. Laboratory data There are no commercially available laboratory tests for identifying the presence of spider venom. Thus, the diagnosis is made clinically. DIFFERENTIAL DIAGNOSIS A spider bite usually presents as a local lesion (possibly with necrosis in the case of recluse bites) with or without systemic symptoms. (See 'Types of reactions' above.) The differential diagnoses

for local and systemic symptoms are reviewed in this section. Disorders that can mimic the bites of specific spiders are discussed in the appropriate topic reviews. (See "Bites of widow spiders" and "Bites of recluse spiders".) As discussed previously, many other conditions are more common than spider bites and pose a more immediate threat to the patient's health if not accurately diagnosed. A patient who did not clearly witness a spider inflicting the bite should be presumed to have some other disorder, and the presence of multiple lesions essentially excludes the diagnosis of spider bite. (See 'History' above.) The clinician can usually determine whether a spider bite is possible based upon a careful history of the patient's recent activities, details of the onset and evolution of the lesion, and knowledge of biting spiders found in the area. Despite this, it is not uncommon for patients to present with nondescript lesions, suggest that it might be a spider bite because of some circumstantial detail, and have that history accepted without further questioning. A spider bite may present as a papule, pustule, wheal, plaque (possibly ecchymotic), or ulcer. The most common disorders that are mistaken for local reactions to spider bites include infections and the bites of other insects. Infections Papules and pustules should be carefully unroofed and cultured to identify infectious causes. Common infections that could be mistaken for spider bites include staphylococcus and streptococcal infections, the skin lesion of early Lyme disease, and atypical presentations of herpes zoster or herpes simplex. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections can begin with singular papules or pustules that may evolve to necrotic lesions [13]. CA-MRSA is far more prevalent than spider bites. Infections occur both sporadically and as institutional epidemics in nursing homes, prisons, military barracks, and athletic facilities. Risk factors and epidemiology of CAMRSA are discussed separately. (See "Epidemiology of methicillin-resistant Staphylococcus aureus infection in adults" and "Epidemiology and clinical spectrum of methicillin-resistant Staphylococcus aureus infections in children".)Erythema migrans, the target-like skin lesion of early Lyme disease, may be mistaken for a spider bite (picture 7). Southern tick-associated rash illness (STARI) is a similar infection with similar skin findings, which occurs in the southern United States (below Maryland). (See "Diagnosis of Lyme disease" and "Southern tick-associated rash illness (STARI)".)Herpes zoster and herpes simplex infections (especially herpetic whitlow) may occasionally present with singular lesions (picture 8). Acute onset is

associated with vesicles, vesicopustules, severe edema, erythema, or pain. Tzanck staining of vesicles will demonstrate multinucleated giant cells and viral culture will grow HSV. (See "Epidemiology and pathogenesis of varicella-zoster virus infection: Herpes zoster" and "Paronychia and ingrown toenails".) Other bites and stings A wide variety of insects sting or bite humans, including triatomid bugs, ants, fleas, bedbugs, blister beetles, ticks, mites, mosquitoes, and biting flies (table 2) [9]. Spiders are less likely to do so than many others. With the exception of tick-borne illnesses and allergic reactions, the exact insect inflicting the bite is of little clinical importance and local care suffices. Scorpion stings are more common than spider envenomations worldwide, and most stings have been reported in Africa, the Middle East, southern Asia, and Central and South America. In the United States, scorpion stings are most common in Arizona and nearby areas of the Southwest. (See "Scorpion stings in the United States and Mexico".) Stings are instantaneously painful, and so patients usually capture or at least clearly witness the scorpion inflicting the sting [14,15]. Local pain is the most common presenting symptom. Systemic symptoms include hypertension, tachycardia, diaphoresis, and salivation [14]. Other common dermatoses Poison ivy, poison oak, and other plants in the Anacardiaceae family may occasionally cause dermatitis that presents as a single lesion, although linear lesions are more typical (picture 9). These lesions tend to be pruritic, rather than painful. (See "Poison ivy (Toxicodendron) dermatitis".) SUMMARY AND RECOMMENDATIONS Spider bites are uncommon medical events, since there are limited number of spiders worldwide with fangs strong enough to pierce human skin, and most spiders bite humans only as a final defense when being crushed between skin and another object. Thus, most lesions attributed to spider bites are caused by some other etiology. (See 'Introduction' above.) The spiders that can cause medically significant bites include widow and false widow spiders (worldwide), recluse spiders (mostly North and South America), Australian funnel web spiders (eastern coastal Australia), and Phoneutria spiders (Brazil) (table 1). (See 'Medically important spiders' above.)Acute spider bites most commonly result in a solitary papule, pustule, or wheal (picture 5). Systemic symptoms can accompany envenomations of widow, funnel web, and Phoneutria spiders, and less often, those of recluse spiders. The bites of recluse spiders can become necrotic, although most bites do not necrose. Allergic reactions to contact with

spiders (rather than bites) occur most often in response to tarantulas. (See 'Types of reactions' above.)Clinicians should know which of the biting spiders (if any) are found in the areas in which they practice, and have a basic understanding of the entomology of those species (table 1). (See 'Influence of geographic location' above.)The working diagnosis of a spider bite is based upon suggestive history and clinical presentation. However, definitive identification of a spider bite requires all of the following: a spider was observed inflicting the bite, the spider was recovered, collected, and properly identified by an expert entomologist, and other disorders have been ruled out. (See 'Diagnosis' above.)In the majority of cases, another etiology is responsible for the lesion, other than a spider bite. The differential diagnosis includes infections, bites and stings of other arthropods, and several other more common dermatoses. A culture should be performed in most cases. (See 'Differential diagnosis' above.) Use of UpToDate is subject to the Subscription and License Agreement REFERENCES
1. Vetter RS, Isbister GK. Medical aspects of spider bites. Annu Rev Entomol 2008; 53:409. 2. Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med 2005; 352:700. 3. Isbister GK. Acute allergic reaction following contact with a spider. Toxicon 2002; 40:1495. 4. Hasan T, Mkinen-Kiljunen S, Brummer-Korvenkontio H, et al. Occupational IgE-mediated allergy to a common house spider (Tegenaria domestica). Allergy 2005; 60:1455. 5. Castro FF, Antila MA, Croce J. Occupational allergy caused by urticating hair of Brazilian spider. J Allergy Clin Immunol 1995; 95:1282. 6. Cooke JA, Miller FH, Grover RW, Duffy JL. Urticaria caused by tarantula hairs. Am J Trop Med Hyg 1973; 22:130. 7. Hered RW, Spaulding AG, Sanitato JJ, Wander AH. Ophthalmia nodosa caused by tarantula hairs. Ophthalmology 1988; 95:166. 8. Wong RC, Hughes SE, Voorhees JJ. Spider bites. Arch Dermatol 1987; 123:98. 9. Russell FE, Gertsch WJ. For those who treat spider or suspected spider bites. Toxicon 1983; 21:337. 10. Vetter RS, Bush SP. Additional considerations in presumptive brown recluse spider bites and dapsone therapy. Am J Emerg Med 2004; 22:494. 11. Spiller HA, Schultz OE. Envenomations as a novel drugseeking method. Vet Hum Toxicol 2002; 44:297. 12. Fisher DP. Letter: Attempted suicide by black widow spider bite. JAMA 1976; 235:2718. 13. Dominguez TJ. It's not a spider bite, it's community-acquired methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract 2004; 17:220. 14. Al-Asmari AK, Al-Saif AA. Scorpion sting syndrome in a general hospital in Saudi Arabia. Saudi Med J 2004; 25:64. 15. Isbister GK, Volschenk ES, Seymour JE. Scorpion stings in Australia: five definite stings and a review. Intern Med J 2004; 34:427.

Bites of recluse spiders Authors Richard S Vetter, MS David L Swanson, MD Section Editors Daniel F Danzl, MD Stephen J Traub, MD Deputy Editor James F Wiley, II, MD, MPH

The most accurate method of identifying a recluse spider involves counting the eyes. Most spiders have eight eyes in two rows of four. In contrast, recluse spiders have six eyes, with a pair in front, a pair on both sides, and a gap between the pairs (picture 3). Identifying a recluse spider on the basis of body markings is less reliable. The brown recluse is described as having a violin pattern on its anterior cephalothorax, although this has led to widespread misidentification of common, harmless spiders as brown recluse when nonarachnologists creatively interpret many dark markings on spiders' bodies as violins [7,8]. Additionally, the violin marking is absent in many juvenile and recently-molted brown recluses and absent altogether in some other recluse species. Other features of recluse spiders include monochromatic legs, a monochromatic abdomen, and fine hairs (but not conspicuous spines) on the legs (picture 2). The most common spider mistaken for Loxosceles is Kukulcania (picture 4), which has a darkened pattern on the cephalothorax near the eyes of the tan males that can be mistaken for a violin pattern [9]. Female Kukulcania are black or dark brown, velvety in texture, and resemble small tarantulas, although people still mistake them for brown recluse spiders. Kukulcania spiders are found in the southern third of the United States from the San Francisco Bay through southern California, east through Texas to Florida and north to North Carolina and Virginia. They are frequently found in homes, although verified bites from these spiders are virtually unknown. Geographic location There are 100 Loxosceles species in the world, although only a few have extensive distributions and also exist where humans live. The majority is found in North and South America (table 1) [9]. Recluse bites are rare elsewhere, although they have been reported in South Africa and Australia. In the United States, recluse spiders are found in limited areas of the South, West, and Midwest (figure 1) and rarely outside these endemic areas [10]. The brown recluse, L. reclusa, is the most widespread and the best known of North American recluse spiders. It is a synanthropic spider (ie, its population numbers increase in association with humans) and these spiders are commonly encountered within homes in endemic areas [11,12].In South America, Loxosceles spiders of medical importance are found in Brazil and Chile. The most common species involved in envenomations are L. laeta, L. intermedia, and L. gaucho. Loxosceles laeta is often considered the most dangerous of the recluse spiders, in part because it is the species that attains the largest body size.The Mediterranean recluse, L. rufescens, has been transported around the world and continues to establish isolated populations inside buildings

Last literature review version 19.1: January 2011 | This topic last updated: August 12, 2010 (More) INTRODUCTION The entomology of recluse spiders (Genus Loxosceles) and the clinical manifestations, diagnosis, differential diagnosis, and management of their bites will be reviewed here. An overview of spider bites and the management of bites of other spiders are discussed separately. (See "Approach to the patient with a suspected spider bite: An overview".) ENTOMOLOGY OF RECLUSE SPIDERS Spiders of the genus Loxosceles are known colloquially as recluse spiders, violin spiders, fiddleback spiders, and in South America, by the nonspecific name "brown spiders." Loxosceles spiders have gained notoriety in the medical literature and lay press because their bites sometimes become necrotic [1,2]. However, this is a relatively uncommon sequela, and is largely limited to areas of the United States where these spiders are endemic (figure 1). Outside of these regions, the vast majority of necrotic skin lesions are caused by other disorders [3-6]. (See "Approach to the patient with a suspected spider bite: An overview".) Appearance and identification Recluse spiders are rather nondescript brown spiders (picture 1 and picture 2).

on many continents. It has been found in many American cities, where these spiders tend to develop dense populations within isolated buildings. However, despite these infestations, verified bites from Mediterranean recluse are exceedingly rare. Habitat Recluses are found mostly inside homes, in basements, in attics, behind bookshelves and dressers, and in cupboards. As their name implies, these spiders prefer dark, quiet areas that are rarely disturbed (table 1). Out of doors, they are found under objects, such as rocks or the bark of dead trees. CLINICAL MANIFESTATIONS OF BITES Loxoscelism is the term for the medical manifestations of bites by recluse spiders. In this review, the term is used to refer to both local and systemic symptoms resulting from bites, although toxicologists sometimes use the term to refer exclusively to the systemic symptoms. Venom properties Loxosceles venom contains a large number of enzymes and biologically active substances, of which sphingomyelinase D is the most important. This enzyme is unique in nature to Loxosceles and its sister genus, Sicarius, but is absent in all other spiders including other closely related haplogyne spiders [13]. Sphingomyelinase is believed responsible for skin necrosis and the systemic manifestations of Loxosceles envenomation. It activates complement, induces neutrophil chemotaxis, induces apoptosis of keratinocytes and other cells, and initiates the generation of potent collagen and elastin-degrading metalloproteinases [14]. Clinical history Recluse spiders (like most spiders) typically bite humans only as a desperate last line of defense as they are being crushed between flesh and some object. This happens most frequently indoors, as a result of rolling over on the spider in bed or putting on clothing or footwear that has been left in closets or on the floor, in which the spider has sought refuge. Recluse spider bites typically occur on the upper arm, thorax, or inner thigh. Bites on the hands or face (ie, uncovered areas) are rare. Recluse bites can be sustained out of doors, although these spiders are rarely found in living vegetation. Patients reporting a painful bite while reaching into living foliage are more likely to have sustained an insect sting or puncture by thorns or other sharp plant matter. Symptoms following bites Symptoms may be divided into acute local symptoms, systemic symptoms, and, in a subset of bites, necrosis of the bite site.

Acute local symptoms The initial bite of a Loxosceles spider is usually painless, although they can occasionally be painful or cause a burning sensation. The site can sometimes be identified by two small cutaneous puncture marks with surrounding erythema. The bite is usually a red plaque (picture 5) or papule, which often develops central pallor. The pain typically increases over the next two to eight hours, and may become severe. In most cases, this lesion is self-limited and resolves without further complications in approximately one week [15]. In some, however, the lesion will develop a dark, depressed center over the ensuing 24 to 48 hours, culminating in a dry eschar that subsequently ulcerates. (See 'Necrosis' below.) Some patients develop urticaria or a morbilliform rash in the hours after the bite; this has been suggested by some as evidence of a prior bite, although the phenomenon has not been studied formally. Systemic symptoms Systemic symptoms are an infrequent complication of recluse bites, and do not correlate to local findings. Small children may be more susceptible to systemic symptoms. The following nonspecific signs and symptoms may appear over several days following a recluse bite: MalaiseNausea and vomitingFeverMyalgias Rare complications include acute hemolytic anemia, disseminated intravascular coagulopathy, rhabdomyolysis, myonecrosis, renal failure, coma, and death [16]. The risk of these complications from Loxosceles bites is extremely low in the United States [15]. (See "Extrinsic nonautoimmune hemolytic anemia due to drugs and toxins", section on 'Insect, spider, and snake bites'.) Case reports of Loxosceles bites during pregnancy have documented no adverse effects on infant outcome [15]. In contrast, these complications are more common with loxoscelism from the South American species L. laeta [17]. (See 'Antivenoms for South American recluses' below.) Necrosis A minority of lesions become necrotic, usually over the course of several days. The original papule or plaque develops a dusky red or blue color in the center of the lesion, and a dry, depressed center may herald necrosis. There may be anesthesia in the center. An eschar forms and subsequently breaks down to form an ulcer. The lesion may enlarge in a gravitational manner [17]. A fully developed necrotic lesion is usually 1 to 2 cm in diameter, although skin loss can be more extensive and ulcers as large as 40 cm or more have rarely been

described. These most typically occur over fatty tissue on the buttocks and thighs. Lesions usually stop extending within 10 days of the bite, and most lesions heal by secondary intent over several weeks, without scarring [17]. Some necrotic lesions take months to heal fully. Permanent scarring or requirement for surgical repair is uncommon [18]. (See 'Prevention and treatment of necrosis' below.) DIAGNOSIS A presumptive diagnosis of a spider bite is most often based on the history and clinical presentation. An assay for Loxosceles venom has been developed but is not commercially available [19]. Of note, the diagnosis of a spider bite can be considered definitive only if both of the following criteria are fulfilled: A spider was observed inflicting the bite.The spider was recovered, collected, and properly identified by an expert entomologist. If both of the above conditions are not met, then other conditions such as vasculitis, infection, vascular problems, or other relevant disorders must be excluded. The general approach to a patient suspected of having a spider bite, as well as the differential diagnosis of an uncomplicated (lacking signs of necrosis) spider bite, are reviewed separately. (See "Approach to the patient with a suspected spider bite: An overview".) DIFFERENTIAL DIAGNOSIS Numerous conditions have been mistaken for a necrotic recluse spider bite (table 2). The most common disorders in the differential diagnosis are presented in this section. Solitary ulcerated lesion Conditions that can cause single ulcerated lesions include infections, trauma, vascular diseases, pyoderma gangrenosum, and vasculitides. Infections Common infections that can become necrotic include staphylococcus and streptococcal infections, deep fungal infections, and atypical mycobacterial infections (table 2). Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections can begin with singular papules or pustules that may evolve to necrotic lesions [20,21]. CA-MRSA is far more prevalent than spider bites. CA-MRSA strains both in the United States and in Europe have an enhanced virulence that has resulted in the more striking clinical manifestations, compared with non-MRSA. Infections occur both sporadically and as institutional epidemics in nursing homes, prisons, military barracks, and athletic facilities. Risk factors and epidemiology of CA-

MRSA are discussed separately. (See "Epidemiology of methicillin-resistant Staphylococcus aureus infection in adults" and "Epidemiology and clinical spectrum of methicillin-resistant Staphylococcus aureus infections in children".) A patient who had recently traveled to the tropics and presented with a skin ulcer would require evaluation for the various infections that can cause ulcerating lesions (table 3). (See "Skin lesions in the returning traveler".) Vascular disease Foot and ankle ulcers can be seen in patients with chronic venous insufficiency, arterial insufficiency, or diabetes mellitus, and a history of the underlying disease should alert clinicians to this possibility. These ulcers are distinguishable by various characteristics (table 4). (See "Diagnostic evaluation of chronic venous insufficiency".) Pyoderma gangrenosum Pyoderma gangrenosum is an idiopathic disorder in which dark, blue-red papules progress to necrotic ulcerating lesions. Patients may report a history of antecedent trauma at the site or have signs of systemic illness. Borders are typically irregular and the lesion may have a purulent base (picture 6 and picture 7). (See "Neutrophilic dermatoses".) Vasculitides Vasculitis and necrotizing vasculitis may present with singular lesions (picture 8). (See "Diseases with eosinophilic involvement of specific organs".) Systemic reactions The systemic symptoms of recluse spider envenomation (eg, malaise, nausea and vomiting, fever, and myalgias) are sufficiently nonspecific that an accompanying lesion, preferably with an identifiable spider, is essential for making the diagnosis of a spider bite. TREATMENT The treatment of a recluse spider bite involves local wound care, pain management, and tetanus prophylaxis if indicated. Dapsone may be administered in some cases, both to prevent progression to necrosis, and to reduce pain. An array of other interventions have been reported in the medical literature, although most are based upon animal studies or isolated human case reports. Local wound care Initial treatment measures following any spider bite include: Clean the bite with mild soap and water.Apply cold packs, taking care not to freeze the tissue.Maintain the affected body part in an elevated or neutral position (if possible). General measures following bites

Administer pain medication as needed. Some patients will respond to non-steroidal antiinflammatory medications, while others may require opioids.Administer tetanus prophylaxis if indicated (table 5). Most bites can be managed with minimal intervention and heal without scarring. Resolving bites should be monitored for the development of secondary bacterial infection. Indications for antibiotics Antibiotics are prescribed only if there are signs of infection such as increased erythema, fluctuation, and suppuration. If infection is suspected, it should be treated with antibiotics for cellulitis, as outlined in the table (table 6). (See "Cellulitis and erysipelas".) Prevention and treatment of necrosis Dapsone may be administered for the purpose of preventing the development of necrosis, provided the patient does not have glucose-6-phosphate dehydrogenase (G6PD) deficiency. Dapsone may be also be helpful for reducing pain in lesions with established necrosis, in one author's (DLS) unverified personal experience. It is proposed to act by inhibiting neutrophil chemotaxis and lysosomal free radical generation. Early animal studies of dapsone demonstrated marked reduction of ulceration in rabbits and guinea pigs [22,23], although subsequent studies have not shown clear benefit [24,25], and no controlled trials in humans have been performed. Potential recipients of dapsone should be screened for G6PD deficiency because hemolytic anemia is a more common complication of dapsone in patients with reduced activity of this enzyme and they should not receive this agent [26]. The results of screening tests are usually available within 24 hours, and we await confirmation that the patient is not G6PD deficient before administering dapsone. Even patients with normal G6PD activity will commonly experience a drop in hemoglobin by 1 to 2 g/dL during therapy. Other uncommon but serious side effects of dapsone include aplastic anemia, methemoglobinemia, and dapsone hypersensitivity syndrome. (See "Diagnosis and treatment of glucose-6-phosphate dehydrogenase deficiency" and "Clinical features, diagnosis, and treatment of methemoglobinemia".) We administer dapsone if the lesion has developed a dusky center indicating that it may be progressing to necrosis. Dapsone may be dosed initially (in adults) at 50 mg twice daily, and increased to 100 mg twice daily if the lesion appears to progress further towards necrosis [10,23]. Pediatric dosing is based upon weight. We usually administer a 10 day course. Once the lesion is demarcated and clinically stable, debridement and wound care may assist healing. A small minority of necrotic lesions later require surgical revision of scars, including skin grafting.

Several other therapies have been proposed or performed but are not recommended: Insufficiently studied treatments Therapies which have not been adequately studied in humans include antihistamines, glucocorticoids, empiric administration of topical or systemic antibiotics, vasodilators, heparin, nitroglycerin, hyperbaric oxygen, dextran, and local electric shock [27-29]. Tetracycline Application of topical tetracycline has been shown to reduce the progression of dermonecrotic lesions in rabbits exposed to Loxosceles intermedia venom but awaits further study in humans [28]. Role of surgical interventions Early surgical excision and/or curettage of a necrotic lesion is potentially harmful [27,30-32]. One retrospective study of 31 patients with bites affecting the upper extremity or hand concluded that painful and recurrent wound breakdown occurred more often with early surgical excision [31]. Antivenoms for South American recluses Antivenoms for the treatment of recluse spider bites are available in Brazil, Mexico, and Peru, although not in the United States. As mentioned previously, the bites of South America Loxosceles species (eg, L. gaucho) are more severe than those of recluse spiders found in the United States. Observational studies in humans and animal trials suggest that South American recluse antivenoms may reduce the risk of dermatonecrosis, as well as systemic envenomation and its severe complications (eg, hemolysis, renal failure, and disseminated intravascular coagulation). However, definite benefit in humans is not well established [33-36]. DISCHARGE INSTRUCTIONS AND AFTER CARE Patients should be counseled about how to care for the bite site and advised to watch the site for signs of secondary bacterial infection (eg, fever, spreading redness, pus formation or drainage), as well as progressive skin changes that suggest early necrosis (ie, enlargement of the lesion or black/blue color changes). Patients who are concerned about avoiding future recluse bites should be counseled to shake out clothes, shoes, gloves, and other items that have been unused or lying on the floor before putting them on. Beds should be modified so that only the legs of the bed touch the floor: beds should be moved away from the wall, bedding should be tucked in and bed ruffles removed, and items should not be stored beneath the bed. Insecticides may be effective for controlling recluse populations within the home; however, these must be properly administered by a pest control professional. Placement of sticky traps next to baseboards but out of

reach of curious children and pets is another useful method to eliminate brown recluse spiders from a building. SUMMARY AND RECOMMENDATIONS Recluse spiders (Genus Loxosceles) are one of a handful of spiders throughout the world which are capable of inflicting medically significant bites in humans. They are found mostly in certain parts of North and South America. In the United States, recluse spiders are limited to areas of the South, West, and Midwest (figure 1). (See 'Entomology of recluse spiders' above.) Entomology and clinical features of bites Recluse spiders are nondescript brown spiders (picture 1) that can be more reliably identified by their distinctive eye pattern (three pairs) (picture 3). (See 'Entomology of recluse spiders' above.)Recluse spider bites are usually sustained indoors, as a result of rolling over on the spider in bed or putting on clothing or footwear in which the spider has sought refuge. These spiders are not aggressive and generally bite humans only when being crushed between flesh and some object. (See 'Habitat' above and 'Clinical history' above.)Patients presenting with possible spider bites should always be questioned carefully regarding the circumstances surrounding the bite. Other disorders are responsible for most lesions attributed to spider bites (table 2), unless the patient witnessed the spider inflicting the bite and can retrieve the spider for identification by an entomologist. (See "Approach to the patient with a suspected spider bite: An overview" and 'Diagnosis' above.)Loxoscelism is the term for the medical manifestations of bites by recluse spiders. The initial bite of a Loxosceles spider is usually painless, although some are painful or have a burning quality. The bite is usually a red plaque (picture 5), which can sometimes be identified by two small cutaneous puncture marks with surrounding erythema. In most cases, this lesion is self-limited and resolves without further complications. (See 'Acute local symptoms' above.)Systemic symptoms are more common in small children than adults. These may appear over several days following a bite and include malaise, nausea and vomiting, fever, and myalgias. (See 'Systemic symptoms' above.)A minority of lesions become necrotic, usually over the course of several days. These generally heal by secondary intent over several weeks, without scarring. (See 'Necrosis' above.) Treatment summary Immediate management includes local wound care, pain medication if needed, and possible administration of tetanus prophylaxis (table 5). (See 'Local wound care' above and 'General measures following bites' above.)Antibiotics for cellulitis are indicated only if

there are signs or symptoms of infection, such as increased erythema, fluctuation, and/or suppuration (table 6). (See 'Indications for antibiotics' above.)For patients with bites that have a dusky center or other signs of developing necrosis, we suggest administration of dapsone (Grade 2C). After screening for glucose-6-phosphate dehydrogenase deficiency, we give adults 50 mg to 100 mg twice daily, for 10 days. (See 'Prevention and treatment of necrosis' above.)We suggest not performing early surgical excision and/or curettage of a necrotic lesion (Grade 2C). However, once the lesion is demarcated and clinically stable, debridement and wound care may assist healing. (See 'Prevention and treatment of necrosis' above.) Use of UpToDate is subject to the Subscription and License Agreement REFERENCES 1. Macchiavello, A. Cutaneous arachidism or gangrenous spot of Chile. Puerto Rico J Pub Health Trop Med 1947; 22:425. 2. ATKINS JA, WINGO CW, SODEMAN WA. Probable cause of necrotic spider bite in the Midwest. Science 1957; 126:73. 3. Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown recluse spider bites (loxoscelism) greatly outnumber actual verifications of the spider in four western American states. Toxicon 2003; 42:413. 4. Vetter RS, Edwards GB, James LF. Reports of envenomation by brown recluse spiders (Araneae: Sicariidae) outnumber verifications of Loxosceles spiders in Florida. J Med Entomol 2004; 41:593. 5. Bennett RG, Vetter RS. An approach to spider bites. Erroneous attribution of dermonecrotic lesions to brown recluse or hobo spider bites in Canada. Can Fam Physician 2004; 50:1098. 6. Frithsen IL, Vetter RS, Stocks IC. Reports of envenomation by brown recluse spiders exceed verified specimens of Loxosceles spiders in South Carolina. J Am Board Fam Med 2007; 20:483. 7. Vetter R. Identifying and misidentifying the brown recluse spider. Dermatol Online J 1999; 5:7. 8. Vetter RS. Arachnids submitted as suspected brown recluse spiders (Araneae: Sicariidae): Loxosceles spiders are virtually restricted to their known distributions but are perceived to exist throughout the United States. J Med Entomol 2005; 42:512. 9. Swanson DL, Vetter RS. Loxoscelism. Clin Dermatol 2006; 24:213. 10. Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med 2005; 352:700.

Bites of widow spiders Authors Richard S Vetter, MS David L Swanson, MD Julian White, MB, BS, MD, FACTM Section Editors Stephen J Traub, MD Daniel F Danzl, MD Deputy Editor James F Wiley, II, MD, MPH Last literature review version 19.1: January 2011 | This topic last updated: November 15, 2010 (More) INTRODUCTION This topic will review the entomology of widow spiders (genus Latrodectus) and the clinical manifestations, diagnosis, differential diagnosis, and management of their bites. An overview of spider bites, and the management of bites of other spiders are discussed separately. (See "Approach to the patient with a suspected spider bite: An overview" and "Bites of recluse spiders".) ENTOMOLOGY Both widow spiders and false widow spiders are of medical importance, although the bites of widow spiders are generally of greater concern. Widow spiders (Genus Latrodectus) Widow spiders belong to the family Theridiidae, genus Latrodectus. Latrodectism is the term for the medical manifestations of bites by widow spiders [1,2]. (See "Approach to the patient with a suspected spider bite: An overview".) There are approximately 30 species of widow spiders found worldwide [3]. Not all have been implicated in human bites, although this may be partly due to the remote distribution of the spiders away from human populations. Female widow spiders are responsible for most significant bites. Males have less venom, smaller fangs, and weaker biting muscles. Spider identification Most adult widow spiders are shiny black with red markings on the body, although this is not universal. The most common species of medical importance are the following: The American species has a red hourglass or anvil-shaped mark on the ventral portion of the abdomen, which can range from a perfect hourglass to two separated triangles, to one triangle and a barely perceptible lower red mark (picture 1 and picture 2).The eastern black widow has a red dot just dorsal to the anal region.The Mediterranean species has a smattering of 13 red dots on the dorsum of the abdomen but lacks ventral red markings.The Australian redback is notable for a conspicuous dorsal red stripe running from the anal region forward to about halfway the distance of the abdomen (picture 3 and picture 4).

Other widow species are not black. The brown widow has an orange hourglass and a series of white stripes on a tan abdomen, giving it a mottled appearance. Other species in the eastern hemisphere are nearly white. In addition to color variations among species, immature widow spiders often look very different from the adults (picture 5). Worldwide distribution Widow spiders are found in warm climates worldwide but can exist in colder climates with routine winter snows such as Colorado and in Canada (table 1). In the United States (US), two species are most commonly implicated in envenomations: the eastern black widow spider, L. mactans, and the western black widow spider, L. hesperus. The western black widow spider is very abundant throughout the southwestern United States where it is not uncommon to collect 60 or more an hour in supportive habitats. This species seems more tolerant of cold temperatures than eastern relatives as it is a common species in urban Colorado and in the dry interior region of Washington State. There are three other widow species in the US, which are of less concern: L. variolus in the northern Midwest, the red-legged widow L. bishopi, in palmetto habitats of Florida, and brown widows. The brown widow, L. geometricus, is found in Florida, and more recently in the deep South, from Texas to South Carolina, and in coastal southern California [4]. Brown widow spiders are also found in many parts of the world. Their bite is usually mild and does not typically cause symptoms of latrodectism [5]. Verified bites predominantly hurt upon fang penetration and have slight erythema at the bite site [6], although there have been anecdotal reports of more severe injuries and even death [7-9].The redback spider, L. hasselti, is found throughout Australia, except in the hottest deserts and coldest mountains, and is the only widow species on that continent (picture 3 and picture 4). It also has become established in Japan in the Osaka Prefecture and has been reported in Europe and Dubai [10]. In New Zealand, L. katipo is typically only found very close (<1 km) to the coast in native habitat and is also being supplanted by a South African spider and colonies of the Australian redback spider [11].In South America, L. curacaviensis is widespread and L. geometricus has also caused significant bites [8].In the circum-Mediterranean region, L. tredecimguttatus is the most common biting widow spider. Because the Mediterranean species is found in many countries, it is known by a colorful array of

common names, some of which translate into "black hag" (Yugoslavia) and "black wolf" (Russia) [1]. Habitat Widow spiders typically live outdoors in the clutter surrounding homes and garages, in woodpiles, in rarely used garden equipment, in pots, and in tools. It is rare to find a widow spider indoors unless there is significant insect traffic inside a structure. Before indoor plumbing, many American and Australian bites by widow spiders occurred in outhouses. Victims were often men, and bites often occurred predominantly on the penis, scrotum, or buttocks [1,3]. This has become such common-place knowledge that it was enshrined in song in Australia ("There's a redback on the toilet seat"). In Europe, widow bites were considered an occupational hazard of wheat farmers who compressed the spider against their bodies as they harvested the crop and by other out-ofdoors workers, including farm laborers, and greenhouse keepers [2,5]. However, with the advent of indoor plumbing, there was a shift in bite location from the central genitalia to the peripheral limbs. Bites now typically occur as people place their hands into gardening gloves or feet into boots, or compress spiders under potted plants, patio furniture, toys, etc. False black widow spiders (Genus Steatoda) False black widow spiders are found around the world and have a bite that causes mild symptoms of latrodectism, sometimes called steatodism. Appearance and identification Steatoda spiders are in the same family (Theridiidae) as the black widows and, hence, share a similar body form which may cause confusion in identification (picture 6 and picture 7). They are typically chocolate brown to black in color and may have some tan stripes or markings on the abdomen. Unlike black widows, they do not have red markings on their bodies. There are many species in the genus Steatoda. Most are too small to inflict a medically-important bite, due to small fang size, low venom gland content, or inability of musculature to cause fang penetration in human skin, or a combination of these traits.

Colorado. Steatoda grossa (picture 6) is the largest of this genus and is the most frequent culprit in bites.In Europe, S. paykulliana is the most medical important species, although S. grossa also exists [1].In Australia, S. grossa is the medically important species. Habitat Like black widow spiders, false black widows are found in trash and clutter. In contrast to black widows, however, they are much more likely to be found inside homes. They do not appear to have the same high food requirement as black widows and can thus survive indoors where insect traffic is greatly diminished. Steatoda spiders prefer places that are not disturbed and are often found under and within cupboards. CLINICAL MANIFESTATIONS OF BITES Black widow spiders Latrodectism is the medical term for the manifestations (both local and systemic) of bites by widow spiders [1,2]. Clinical history Patients presenting with widow bites typically have a recent (<8 hours) history of an at risk activity such as gardening, chopping wood, or cleaning out a garage. Three quarters of bites are on the extremities, particularly the lower extremities. Lesion and local symptoms The typical black widow bite is a mild lesion consisting of a blanched circular patch with a surrounding red perimeter and a central punctum (picture 8). Some bites resemble a wheal and flare reaction. Most bites are either asymptomatic or cause local pain at the site of the bite [12]. The time of onset of more generalized symptoms is typically 40 minutes (20 to 120 minutes range) from the time of the bite, but may be longer on occasion [13]. Significant envenomation causes acute muscle pain and often localized diaphoresis in the affected limb, and this presentation is highly suggestive of a widow bite. If the bite is on the lower extremities, the muscular pain may extend to the abdomen; upper extremity pain may extend to the chest. The pain may be accompanied by tremor, weakness, myoclonus, and local paresthesias. Diaphoresis may extend to involve the whole extremity, the body, or may be limited to areas distant from the bite. There may also be local lymphadenopathy [14]. Black widow bites do not become necrotic. Systemic symptoms Vital signs are usually normal with moderate envenomation, although patients may be anxious and tachypneic. With more extensive envenomation, patients may experience some or all of the following systemic symptoms [5]:

Worldwide distribution False black widows are found in Europe, the US, and Australia (table 1). In North America, the false black widow is found commonly along the Pacific Coast from southern California through Washington State into British Columbia. It is also found in

Generalized musculoskeletal, abdominal, or back painHypertension and tachycardiaNausea and/or vomitingGeneralized or regional diaphoresisHeadacheFacial swelling, which can be mistaken for an allergic reaction Pain is usually the most prominent feature in systemic reactions. Severe abdominal pain with abdominal wall rigidity but normal bowel sounds is characteristic. Abdominal pain from a widow bite has been mistaken for a variety of abdominal emergencies, including acute cholecystitis [15]. (See 'Differential diagnosis' below.) Other case reports have described cardiovascular collapse, pulmonary edema, and ileus [16,17]. Additional reported complications include hematuria, Horner's syndrome, compartment syndrome, rhabdomyolysis, and toxic epidermal necrolysis [18-21]. Death is unusual, even in children, who are generally more affected by envenomations [22]. The few cases of latrodectism with documented rhabdomyolysis do not show a large rise in serum creatine phosphokinase. In patients presenting late with latrodectism, irrespective of the bite location, principal symptoms may devolve to burning pain in the soles of the feet, pain in the legs, below the knee, and profuse sweating below knees. In infants, latrodectism may present as an inconsolable child, very distressed, refusing food/drink, sometimes with a generalized erythematous appearance. A classic story would be of a newborn brought home and placed in a cot that had been stored in a garage, who develops the above clinical findings. In such cases a squashed widow spider may be found on searching the area in which the infant was lying or sleeping. Venom properties Black widow venom contains neurotoxins of the latrotoxin type, including a vertebratespecific toxin called alpha-latrotoxin, a large protein toxin (120 kDa) that triggers massive exocytosis from presynaptic nerve terminals and in a variety of neurosecretory cells [23]. Acetylcholine, norepinephrine, dopamine, glutamate, and enkephalin systems are all susceptible to the toxin [6,7,23-26]. It appears this toxin is present in the venom of all medically important widow spiders and this has clear implications for cross reactivity of anti-Latrodectus antivenoms. Laboratory abnormalities Abnormal laboratory studies are present in up to half of cases upon presentation and most frequently include elevations in white blood cell counts and serum concentrations of creatine phosphokinase, glucose, and/or liver enzymes

[12]. However, laboratory tests are not necessary to make the diagnosis of latrodectism. False black widow spider Steatoda bites cause symptoms that are similar but less severe than black widow bites, as the venoms have similar properties. Clinical history The false black widow is found in trash and clutter, and is much more likely to be found inside homes. In an Australian series that included 23 verified Steatoda bites, 78 percent of bites occurred indoors, often while dressing [27]. Bites occurred throughout the year and mostly during waking hours. Symptoms Nearly all bites are painful, and pain may increase during the first hour [5,27]. In the Australian series, one-third of victims seeking medical attention had systemic symptoms including nausea, headache, lethargy, and malaise [27]. DIAGNOSIS A presumptive diagnosis of a spider bite is most often based on the history and clinical presentation. Of note, the diagnosis of a spider bite can be considered definitive only if both of the following criteria are fulfilled: A spider was observed inflicting the biteThe spider was recovered, collected, and properly identified by an expert arachnologist/entomologist If both of the above conditions are not met, then other conditions such as vasculitis, infection, vascular problems, or other relevant disorders must be considered and, where appropriate, excluded. However, latrodectism has a number of distinctive features. In regions where widow spiders are common, it is acceptable for clinicians to make a diagnosis of latrodectism without formal sighting of a confirmed widow spider. The general approach to a patient suspected of having a spider bite, as well as the differential diagnosis of a nonnecrotic spider bite, are reviewed separately. (See "Approach to the patient with a suspected spider bite: An overview".) DIFFERENTIAL DIAGNOSIS The painful muscle spasms of latrodectism may mimic a variety of other painful conditions. Surgical abdomen - Abdominal muscle spasms and pain may be mistaken for a surgical abdomen, as mentioned previously [15]. Other signs and symptoms may help distinguish latrodectism from other entities. For example, patients with a surgical abdomen (eg, appendicitis) tend to be tired, have constant pain, and are often hypotensive when peritonitis is present. Patients with latrodectism are

more likely to be hypertensive, hyperactive, and have intermittent muscle spasms. (See "Diagnostic approach to abdominal pain in adults" and "Emergent evaluation of the child with acute abdominal pain".)Myocardial ischaemia/infarction - The severe pain of systemic latrodectism can cause severe chest pain, with hypertension, sweating and nausea, that can simulate myocardial ischemia or infarction. Serial ECG and cardiac enzymes adequately differentiate the etiology of chest pain.Rabies - Latrodectism may also be confused with rabies. Patients with rabies present with excessive motor activity, excitation, and agitation with seizures and a characteristic "fear of water" (hydrophobia) due to a painful, violent, involuntary contraction of pharyngeal and laryngeal muscles. In most cases of rabies, patients can report a definite bite or at least direct contact with an animal. (See "Clinical manifestations, diagnosis, and treatment of rabies".)Tetanus - Tetanus may mimic the muscle spasm associated with systemic latrodectism. Tetanus causes increased muscle tone and generalized spasms, particularly of the central muscles, and increased tone in the masseter muscle (trismus). Patients may have autonomic overactivity, presenting as irritability, restlessness, sweating, and tachycardia. In later phases of illness, profuse sweating, cardiac arrhythmias, labile hypertension or hypotension, and fever are often present. (See "Tetanus".) TREATMENT The majority of patients who sustain a widow spider bite require only local care of the lesion. Patients with moderate to severe envenomations, characterized by severe local symptoms or the presence of regional or systemic symptoms, may require supportive care and monitoring for complications. Antivenoms are also available for treatment of widow spider bites in selected cases. (See 'Widow antivenoms' below.) The current recommendations for treatment of widow bites are primarily based on case reports and retrospective series. Small randomized controlled trials of redback spider antivenom have been performed in humans [28-30]. (See 'Efficacy' below.) General measures following bites Initial treatment measures following a spider bite include [12]: Clean the bite with mild soap and water.Apply cold packs, taking care not to freeze the tissue.Elevate the affected body part (if possible).Administer pain medication, as needed. Most cases will respond to oral analgesia.Provide parenteral benzodiazepines (eg, lorazepam 0.1 mg/kg) to patients with severe muscle spasm.Administer tetanus prophylaxis, if indicated (table 2).

Most bites can be managed with minimal intervention and heal without scarring. Resolving bites should be monitored for the development of secondary bacterial infection, although this is a rare complication. Intravenous calcium does not appear to be effective for the treatment of pain after a widow spider bite based on an observational study of 163 patients [12]. In this series, 23 of 24 (96 percent) moderately or severely envenomated patients had no relief after intravenous calcium therapy and required other treatment (parenteral opioids and benzodiazepines or antivenom). Indications for antibiotics Antibiotics are prescribed only if there are signs of infection such as increased erythema, fluctuation, and suppuration. The treatment of infected bites requires antibiotics directed against skin pathogens, as indicated in the table (table 3). (See "Cellulitis and erysipelas".) Widow antivenoms The mortality associated with widow bites is low, although envenomation can cause significant pain and require hospitalization. Antivenom reduces the pain associated with bites (and may have a more prolonged effect than analgesics) and reduces the need for hospitalization [12,31]. Several widow spider antivenoms are commercially available, including the American black widow spider (L. mactans) antivenom and the Australian redback spider (L. hasselti) antivenom [32]. There is sufficient chemical similarity among widow venoms that all widow antivenoms provide some degree of relief following bites of various widow spiders. As an example, case reports describe successful use of redback antivenom in treating the bites of both the false black widow and the American southern black widow [33,34]. In the United States, it has been recommended that widow antivenom not be stockpiled [35]. Instead, clinicians can order it through hospital pharmacies by express delivery. In areas of the world in which redback spiders are prevalent, it is a routinely stocked antivenom. Currently, in Australia, more redback spider antivenom is used than all other antivenoms, including snake antivenoms, combined. Indications Consultation with a medical toxicologist or other physician with experience in managing widow spider bites is recommended prior to antivenom administration. Phone consultation with a medical toxicologist is available through a United States regional poison control center by calling 1-800-222-1222. For clinicians outside of the United States, The World Health Organization provides a listing of international poison centers at its website: www.who.int/ipcs/poisons/centre/directory/en.

We suggest that widow antivenoms be administered for moderate to severe symptoms of latrodectism that are unresponsive to other therapies. Representative symptoms include the following: Severe and persistent local pain or muscle crampingSignificant pain or diaphoresis extending beyond the immediate site of the biteAlterations in vital signsDifficulty breathingNausea and vomiting Widow antivenom has been given in pregnancy, with no adverse effects [36]. There is a clear difference in approach to treatment of latrodectism in different parts of the world. In North America, due to concerns about Latrodectus mactans antivenom safety [12], antivenom is primarily used in severe to life-threatening envenomation, which will result in patients with moderate regional or systemic symptoms suffering for a period of several days. In Australia, the antivenom is used as first line treatment for almost all cases of latrodectism that do not fully respond to a trial of oral analgesia. Observational data indicate approximately 1,000 patients receive this antivenom each year [37]. There are no confirmed fatalities from adverse reactions to the antivenom, suggesting that this antivenom is safe. Efficacy American black widow spider (Latrodectus mactans) antivenom significantly reduced the duration of all symptoms in one series of 58 treated patients [12]. Complete resolution of symptoms occurred in a mean time of 31 27 minutes after antivenom administration. The mean total duration of symptoms was 9 23 hours in patients receiving antivenom, compared with 22 25 hours in patients not receiving this intervention [12]. Admission rates were 12 and 52 percent in those receiving antivenom and controls, respectively. Another case series reported similar outcomes [31]. Australian redback spider antivenom has been given intramuscularly (IM) and intravenously (IV). One large observational study found that IM redback antivenom had effectiveness for reducing pain symptoms as high as 94 percent [38]. The intravenous route may also be effective in patients who have not responded fully to intramuscular injection and appears safe [39,40]. The intravenous route has traditionally been preferred for patients with severe systemic symptoms and for children younger than 12 years. Clinical experience and animal studies have suggested that intravenous use may be more efficacious [32].

Available evidence indicates IM absorption of antivenom, as measured by intravascular levels, is slow. There is also a small, but growing body of evidence questioning the efficacy of IM red back spider antivenom in Australia [28,29,39], despite earlier studies suggesting it was efficacious [38,41,42] and there is a discernible shift in use amongst emergency physicians towards IV administration [43]. The relative efficacy of IV or IM Australian redback spider antivenom administration has been examined in small randomized trials with varying results [29,30]: A multicenter trial of 31 patients found that Australian redback spider antivenom provided rapid pain relief when given IV or IM. However, patients who received IV antivenom were much more likely to be pain free at 24 hours than those treated IM (76 versus 21 percent) [29].A multicenter trial of 126 patients demonstrated slightly increased pain reduction 2 hours and 24 hours after IV Australian redback spider antivenom treatment (62 percent for IV versus 53 percent for IM at 2 hours, 84 percent for IV and 71 percent for IM at 24 hours) [30]. Approximately 20 percent of patients in both groups required opioid analgesia after emergency department discharge and were unable to sleep in the first 24 hours because of pain. Acute hypersensitivity reactions were reported in 5 percent of patients in both groups. Serum sickness was more frequent in patients receiving IM antivenom (16 percent IM versus 11 percent IV). The high number of patients with persistent pain at 24 hours and the frequency of adverse reactions caused the investigators to question the effectiveness of Australian redback spider antivenom regardless of route of administration. Given the benefit described in large observational studies of antivenom administration for Australian redback spider bites [38], we suggest that this antivenom is effective for relieving pain in selected patients. However, trials that directly evaluate antivenom therapy versus supportive care alone are indicated. Precautions concerning allergic reactions Concerns about potential allergic reactions have influenced the approach to treatment with widow antivenoms in different countries. American black widow antivenom (containing whole horse IgG) caused four mild and one fatal allergic reaction (overall reaction rate was 9 percent) in the series of 58 treated patients published in 1992 [12]. The patient who died had asthma and multiple drug allergies, and was given undiluted antivenom as a rapid intravenous push [44]. Following this report, the use of black widow antivenoms declined in the United States.In an Australian series, redback antivenom (composed of horse F[ab]2 fragments) caused 11 immediate anaphylactic reactions in

approximately 2000 administrations (0.54 percent) and there were no fatalities [14]. A retrospective review of antivenom use in Australia over a two-year period reported that redback spider antivenom was administered in about 20 percent of cases that presented for medical care [38]. In summary, it is not clear from the limited literature available that there are significant differences in the risk of allergic reactions to different antivenoms using current methods of administration, although clinicians must weigh the risks and benefits of antivenoms in each case. The risk of an allergic reaction should be discussed with the patient or guardian whenever possible. It is important for the patient/guardian to understand that latrodectism is unlikely to be a fatal disease process. Thus, antivenom is not life saving. However, without antivenom, the patient will likely have a prolonged period of distressing symptoms and that of all available treatments, current evidence indicates antivenom is the most likely to be effective and may significantly reduce the duration of suffering and hospitalization. Prior to the administrations of widow antivenom, medications and equipment for the treatment of anaphylaxis should be immediately available, including IV fluids, epinephrine, and intubation equipment. (See 'Dosing and administration' below.) Allergic reactions should be managed by immediately stopping intravenous infusion of the antivenom (if applicable) and treating symptoms appropriately (table 4 and table 5). (See "Anaphylaxis: Rapid recognition and treatment".) Delayed serum sickness-like reactions are reported in 1 to 2 percent of patients receiving widow antivenoms [14,45]. All patients receiving antivenom should be informed of the possibility of serum sickness, the symptoms suggestive of serum sickness and advised to seek medical care if such symptoms occur. (See "Serum sickness and serum sickness-like reactions".) Dosing and administration Widow antivenoms should be given as soon as possible after the onset of significant symptoms warranting antivenom therapy, although patients with ongoing symptoms may benefit from treatment even days after the bite [46-49]. (See 'Indications' above.) Consultation with a medical toxicologist or other physician with expertise and prior experience treating spider bites is strongly recommended before initiating antivenom therapy. For emergency consultation with a medical toxicologist, the clinician may call 1-800-222-1222 in the USA. Outside of the USA, The World Health Organization provides a listing

of international poison centers at its website: (www.who.int/ipcs/poisons/centre/directory/en).Antivenom administration has a significant risk of allergic complications and should only occur in a continuously monitored emergency or intensive care unit setting. Airway equipment, epinephrine, antihistamine medication, and isotonic IV fluids should be available for immediate treatment of anaphylaxis (table 4 and table 5). (See 'Precautions concerning allergic reactions' above.)Premedication prior to antivenom use is controversial, with most evidence indicating it is without merit or of doubtful efficacy versus safety [37]. Therefore, unless there are clear, patient specific reasons for considering premedication, its use is not advised. There is no place for preadministration sensitivity testing of any antivenom; this procedure is non-predictive and hazardous and should never be undertaken.Widow spider antivenoms may be administered intravenously or intramuscularly (eg, in the lateral thigh). The initial dose of antivenom will vary depending on the product used. Clinicians should be guided by a poison control center, medical toxicologist, and/or information provided by the manufacturer. As with all other antivenoms, if used intravenously, secure IV access must first be established, the antivenom should be diluted and given either by slow "push" or continuous infusion, with the clinician present throughout administration: The initial dose of Black widow spider antivenom (Antivenin Latrodectus mactans equine) is 6000 antivenom units (equal to the entire contents of one reconstituted vial). The black widow (Latrodectus mactans) antivenom available in the United States is freeze dried and should be reconstituted in the 2.5 mL sterile diluent that is supplied. For intravenous administration in adults and children, we suggest further diluting the solution by adding it to 250 mL of normal saline. We administer this initially at 1 mL per minute for 15 minutes, with careful observation for signs of an allergic reaction (flushing, hives, itching, bronchospasm, etc.). If this initial administration is tolerated, we complete the infusion over one hour [44,50]. If there is no improvement, a second and third vial can be given at hourly intervals.The Red Back spider antivenom available in Australia comes in vials containing 500 units of antivenom in 1 to 1.5 mL solutions. Two vials are usually administered either undiluted, by intramuscular injection into the anterolateral thigh, or intravenously after the two vials are diluted into 200 mL of normal saline or 5 percent dextrose [51]. If response is not complete or symptoms begin to return, then a second dose of two vials may be given one hour after the first. A third dose of two vials may be given, although the diagnosis of widow spider bite should be reconsidered if there has been no response by the second or third dose [52].

In an Australian series, 76 percent of patients required only one vial, while two and three vials were needed in 18 and 6 percent, respectively [38]. However, the Australian National Poisons Information Center Network recommends that all cases receive two vial increments [51]. DISCHARGE INSTRUCTIONS AND AFTER CARE All patients should be counseled about how to care for the bite site and advised to watch the site for signs of secondary bacterial infection (eg, fever, spreading redness, pus formation or drainage).Patients who received antivenom should be informed of the symptoms of serum sickness, which may develop within the subsequent two to three weeks. They should seek medical care promptly for suggestive symptoms, including fever, rash, joint pain, and malaise. Serum sickness reactions may require treatment with systemic glucocorticoids. (See "Serum sickness and serum sickness-like reactions".) SUMMARY AND RECOMMENDATIONS Widow spiders (Genus Latrodectus) are found in warm climates worldwide and are capable of inflicting bites in humans. These spiders vary in appearance, although the American black widow (picture 1 and picture 2) and the Australian redback (picture 3 and picture 4) are distinctive in appearance. Clinical findings Patients presenting with widow bites typically have a recent (<8 hours) history of some outdoor activity such as gardening or cleaning out a garage. Three quarters of bites are on the extremities. (See 'Clinical history' above.)Patients presenting with possible spider bites should always be questioned carefully regarding the circumstances surrounding the bite. Other disorders are responsible for most skin lesions attributed to spider bites, unless the patient witnessed the spider inflicting the bite and can retrieve the spider for identification by an entomologist. (See 'Lesion and local symptoms' above.)Patients with regional or systemic findings of latrodectism may be diagnosed and treated in the absence of an identified widow spider bite. (See "Approach to the patient with a suspected spider bite: An overview".)Latrodectism is the medical term for the manifestations (both local and systemic) of bites of widow spiders. The typical black widow bite is a mild lesion consisting of a blanched circular patch with a surrounding red perimeter and a central punctum. Most bites are either asymptomatic or cause local pain. Significant envenomation causes prominent muscle pain and localized diaphoresis in the affected limb. Pain may spread to the abdomen, chest, or back. With severe envenomations, tachypnea, diaphoresis, hypertension, nausea, and painful muscle spasms may be seen. (See 'Clinical manifestations

of bites' above.)The symptoms of systemic latrodectism can mimic a surgical abdomen, myocardial infarction, rabies, or tetanus. (See 'Differential diagnosis' above.) Management Initial treatment measures following a spider bite include local wound care, elevation of the affected body part (if possible) and application of cold packs. Pain medication may be needed and tetanus prophylaxis should be administered if indicated. Most bites do not require additional intervention. (See 'Treatment' above.)For patients with symptoms of moderate to severe envenomation that persist despite the measures above, we suggest the administration of widow antivenom (Grade 2B). (See 'Widow antivenoms' above.)Allergic reactions are a possible with antivenoms. Patients should be informed of this, and medications and equipment for the treatment of anaphylaxis should be immediately available, including IV fluids, epinephrine, and intubation equipment. (See 'Precautions concerning allergic reactions' above.) DISCLOSURE Dr. White is the clinical toxinology consultant for CSL, Ltd., the sole producer of spider antivenoms for Australia. In this role, he provides assistance to clinicians managing patients with spider bites, regardless of their need for antivenom. Use of UpToDate is subject to the Subscription and License Agreement REFERENCES 1. Maretic, Z, Lebez D. Araneism with special reference to Europe, Polit, Pula, Yugoslavia 1979. 2. Vetter RS, Isbister GK. Medical aspects of spider bites. Annu Rev Entomol 2008; 53:409. 3. Garb JE, Gonzlez A, Gillespie RG. The black widow spider genus Latrodectus (Araneae: Theridiidae): phylogeny, biogeography, and invasion history. Mol Phylogenet Evol 2004; 31:1127. 4. Brown KS, Necaise JS, Goddard J. Additions to the known U.S. distribution of Latrodectus geometricus (Araneae: Theridiidae). J Med Entomol 2008; 45:959. 5. Mller GJ. Black and brown widow spider bites in South Africa. A series of 45 cases. S Afr Med J 1993; 83:399. 6. Saibil HR. The black widow's versatile venom. Nat Struct Biol 2000; 7:3. 7. Peterson ME. Black widow spider envenomation. Clin Tech Small Anim Pract 2006; 21:187. 8. Kiriakos D, Nez P, Parababire Y, et al. First case of human latrodectism in Venezuela. Rev Soc Bras Med Trop 2008; 41:202.