A 28 y.o. male arrives in the ED with a rash and a finding under his tongue. What problem does this represent?

Our patient had a brown recluse spider bite six days pta.  He developed severe pain over the area of the bite and hemolysis.  He presented with sublingual jaundice and a hct of 16.

Classic "violin" pictured above

The brown recluse venom contains spningomyelinase D, alkaline phosphatase, lipase, hyaluronidase, deoxyribonuclese and ribonuclease. Since Spingomyelinase D is temperature dependent,  application of cool compresses may limit necrosis. There are no other proven treatments other than supportive. The brown recluse is not an aggressive spider but will bite if it feels threatened.  The initial bite is painless but within several hours an intense pruritus and pain occur from local vasospasm.  Systemic symtoms include, fever, hemolysis, DIC, renal failure , seizures and coma.    The two poisonous spiders of North America are the brown recluse and the black widow. 

While the brown recluse  has predominately skin necrosis effects, the black widow possesses a neurotoxin.  Alpha-latrotoxin which stimulates motor endplates causing neurologicand autonomic dysfunction. Antivenom is available however there is a risk for allergic reaction to it with one reported case of death.

 black widow with hour glass marking

black widow with hour glass marking

While  the brown recluse and black widow are not aggressive, this is not the case with spiders in much of the world.  The wandering spiders, in the genus Phoneutria, are the most aggressive and venomous spiders in the world. They roam the jungle floorsin Central and South America at night looking for food. Their venom contains a neurotoxin that cases paralysis and asphyxiation, with intense pain and inflammation.  In males, priapism may result.  There is an antivenin. 

Funnel-web spiders ( genera Hadronyche and Atrax) are venomous spiders from Australia .  They create funnel-like burrows in which to trap prey. Their venom is a delta-atracotoxin(robustoxin ) which is neurotoxic. While the most common complication of a bite is pain; they have been know tocause fasciculations, pulmonary edema, and coma.  An antivenin is available.

Another common spider of North America is the yellow sac spider.  They are attracted to the smell of gasoline and weave webs inside the canister vents of Mazda vehicles resulting in blockages which may cause fuel leakage.  Because of these spiders Mazda 6 models built between 2010 and 2012 were recalled to fit them with software that alerts drivers of problems.

 

Our patient was admitted to the ICU and required 7 units of blood for ongoing hemolysis. He was found to have stress ulcers on endoscopy though they were not bleeding. He recovered and was discharged. 

 

Centers for Disease Control and Prevention Workplace safety & health topics;

http://reference.medscape.com/features/slideshow/venomous-spiders#page

Vetter RS, Isbister GK, Bush SP, Boutin LJ 2006 Verified bites by yellow sac spiders in the United States and Australia where is the necrosis?  Am J Trop Med Hyg 74(6) pp 1043-49.

Spider invasion prompts Mazda software fix.  BBC7 April 2014. 

Howell W, Jenkins M, Ronald L. 2004 Spiders of the US: a photographic guide.  ISBN 0-536-75853