eMJA: Pincus et al, Acute and recurrent skin ulceration after spider bite
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Notable Case
Acute and recurrent skin ulceration after spider bite
We reviewed the records of the Australian Venom Research Unit and The Alfred Hospital
Department of Hyperbaric Medicine from January 1992 to July 1998 and found 15 cases of
skin ulceration after spider bite that could be followed up with the patient and the treating
physician. Fourteen patients had skin ulceration attributed to white-tailed spider bites but in
only three was this confirmed. One patient had skin necrosis after a confirmed black house
spider bite. Recurrent skin ulceration occurred in nine of the 15 patients.
Steven J Pincus, Kenneth D Winkel,
Gabrielle M Hawdon and Struan K Sutherland
MJA 1999; 171: 99-102
See also White
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Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details
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Introduction Spider bite is the single commonest reason for inquiries to the Victorian Poisons
Information Centre, with over 1300 calls recorded in 1997.1 Most people with spider
bite require no specific treatment and suffer only minor symptoms, but a small number
develop necrotic skin lesions associated with significant morbidity. 2-4 One series
reported no significant illnesses in 36 bites, 5 and only seven definite cases of skin
necrosis after spider bite have been published in Australia.3,4,6,7 This paucity of
reports has led to debate as to the ability of Australian spiders to cause skin necrosis
(necrotising arachnidism).
We performed a retrospective analysis of case records of suspected necrotising
arachnidism in Australia to better define its clinical features and to compare it with
loxoscelism, a well-recognised cause of skin ulceration in the Americas.
Methods
Patients were identified from records of inquiries from clinicians between January
1992 and July 1998 held by the Australian Venom Research Unit and cases referred to
the Hyperbaric Unit of the Alfred Hospital, Melbourne. Initial case-finding criteria
were a history of spider bite with subsequent ulceration or necrosis at the bite site.
Only cases in which both the patient and primary treating doctor were contactable by
telephone were included (with the informed consent of both patient and doctor).
In the patient interview we asked for demographic details, the method of identification
of the spider, details of ulcerative or necrotic lesions and any other related problems,
treatment, outcome details and relevant past medical history. This information was
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confirmed with the patient's doctor, who was also asked about details of investigations,
treatments and outcomes.
Results
Fifteen cases were identified from more than 600 patients with skin lesions but
without confirmed spider bite. In 14 cases (Box 1) the spider was said to be a whitetailed spider (Lampona species) but in only three cases was this identification
confirmed. One case involved two black house or black window spiders (Badumna
species; see Box 2).
All of the spider bites were to the limbs, and involved blistering, ulceration or necrosis
of the skin. Thirteen were described as painful. Five patients experienced ongoing
disability, and one required amputation of the hand and distal forearm. Four of the 15
patients experienced systemic symptoms (fever), and three had ulcers that were
culture-positive for Staphylococcus species (one positive for Streptococcus species
also). Nine patients had recurrent lesions, involving recurrent breakdown or blistering
of the skin after healing, or breakdown of skin grafts used to treat non-healing ulcers.
Oral or intravenous antibiotics (including doxycycline, penicillin or flucloxacillin)
were given to 14 patients. Other treatments included dressings, antihistamines, topical
and oral corticosteroids, hyperbaric oxygen therapy and skin grafting.
Discussion A major difficulty in the clinical study of spider bite is accurately identifying the
spiders involved. Our series included 11 cases in which a spider was witnessed to bite
the patient but was not captured for identification, one case where the spider was
captured and identified by a clinician, and three cases where the spider was captured
and identified by an expert arachnologist. White-tailed spiders are distinctive, but in
most of these cases absolute attribution to Lampona is not possible. Window spiders
are relatively nondescript, and therefore less likely to be correctly identified unless
captured and formally identified by an arachnologist.
Four cases of skin loss attributed to bites from Lampona have been previously
reported. 3,4,7 Two of these (Cases 54 and 137 ) are included in this study, as both
patients were reported to the AustralianVenom Research Unit independently.
Several cases of bites from Badumna species have been published. These patients
mostly experienced significant sickness, without skin loss.2,8 Some skin loss was
reported in the case of a male black house spider bite.6 The case presented here (Box
2) is the first to link the female spider to skin necrosis.
It has been suggested that many cases of suspected necrotising arachnidism in
Australia may be the result of bites from spiders of the genus Loxosceles, a group
associated with necrotising arachnidism on several continents.9 While it is probable
that some Australian cases of necrotising arachnidism might be attributed to this
spider, it would be difficult to implicate Loxosceles in the cases reported here.
The lesions reported in this series show similarities but also significant differences
from those caused by Loxosceles. As with Loxosceles, the initial bite appears to be
relatively painless, with pain developing over the next 12-24 hours, accompanied by
local erythema and oedema, then blister formation and ulceration.10 However,
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Loxosceles produces a deep ulcer, with a rolled edge and necrotic base, extending into
and sometimes through subcutaneous fat to expose underlying muscle. 10,11 By
contrast, most ulcers reported here were superficial, being confined to the epidermis
and dermis. Another important difference appears to be the site of bites that progress
to significant ulceration. Significant Loxosceles lesions occur in areas of abundant
subcutaneous fat, with involvement extending beyond the margins of the skin
necrosis. 11 The lesions reported here occurred in areas of little or no subcutaneous fat.
An infectious aetiology has been proposed for necrotising arachnidism in Australia,12
but the concept that Mycobacterium ulcerans might be such an agent13 was
subsequently challenged. 14 Bacillus, Staphylococcus and Penicillium species have
been cultured from several spider venoms, including that of a Lampona species. 14
Only three of the 15 patients in our series had ulcers which grew any microorganisms,
but, as 14 patients had been treated with antibiotics, infective organisms may have
been cleared before cultures were prepared. However, the absence of cultured
organisms and poor clinical response to antibiotic therapy seen in many patients
suggests that this condition is more complex than simple skin infection.
Nine of the 15 patients in our case series had recurrent ulceration. This problem had
not been reported in Australia until very recently.7 There are several American reports
of lesions attributed to Loxosceles that have resulted in chronic non-healing ulcers and
recurrent ulceration. These were felt to be secondary to induction of a pyoderma
gangrenosum-like disease process.15 Pyoderma may follow a minor injury and may be
aggravated by surgery.16 It is typically associated with systemic immune
abnormalities, but up to 50% of cases are described as "idiopathic". Spider bite may
act as a trigger to precipitate this condition in susceptible individuals.
Several patients in our case series had histological findings consistent with pyoderma,
and surgical intervention may have been associated with a poorer outcome. Although
no patient in this series received corticosteroids at the doses recommended for
pyoderma, long term topical corticosteroids may have slowed progression of the lesion
in case 14. Prospective study of the value of this treatment in cases of necrotising
arachnidism should be considered.
Management of necrotising arachnidism remains an area of debate, and there is
limited information upon which to make recommendations for the Australian situation.
At least for Loxosceles envenomations, conservative management appears to be the
best primary treatment. This should include tetanus prophylaxis and routine wound
care. Early ice water application to bites is recommended to counter inflammation.
Initial studies proposed early excision and grafting of ulcers, 11 but more recent
experience suggests that this may worsen the lesion and delay healing. 17
Hyperbaric oxygen therapy is gaining popularity in general wound management.
Animal models have produced conflicting results on the value of this type of treatment
for Loxosceles lesions. 18,19 Treating ulcers attributed to Lampona bites with
hyperbaric oxygen therapy appears to have a marked clinical benefit. 4
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Acknowledgements
We thank Mr Albert Ong, of the Pathology Department, Gladstone Base Hospital, for
permission to reproduce his photograph of a patient, Dr Robert Raven and Mr Phil
Lawless of the Arachnology Department of the Queensland Museum, and Ms Catriona
McPhee and Dr Ken Walker of the Museum of Victoria for spider identification and
photographs, and Dr Ian Miller, Director of the Hyperbaric Unit at the Alfred Hospital
in Melbourne, for assistance in collecting patient information. This study would not
have been possible without the assistance of the many other clinicians and patients
involved. We thank the Victorian Department of Human Services, CSL Limited, BHP
Community Trust and Snowy Nominees for financial support, and Dr Anna Young
and Dr Tony Pennington for helpful discussion.
Call NASTY!
To address the paucity of clinical data on necrotising arachnidism the Australian
Venom Research Unit, together with the Monash Medical Centre's Department of
Emergency Medicine, is conducting a long term prospective study of the outcome
of spider bite. Clinicians and the public are encouraged to report definite spider
bites (with spider captured) immediately after the bite. The on-call investigator can
be contacted via the Monash Medical Centre switch (telephone: 03 9550 1111) as
the NASTY Study (Necrotising Arachnidism Study). Definitive identification of the
spider involved by an arachnologist is essential to advance our understanding of this
condition.
References
1. Victorian Poisons Information Centre Annual Report 1997. Melbourne: Royal
Children's Hospital, 1998.
2. Sutherland SK. Australian animal toxins. The creatures, their toxins and care of
the poisoned patient. Melbourne: Oxford University Press, 1983.
3. Gray M. A significant illness that was produced by the white-tailed spider,
Lampona cylindrata. Med J Aust 1989; 151: 114-116.
4. Skinner MW, Butler CS. Necrotising arachnidism treated with hyperbaric
oxygen. Med J Aust 1995; 162: 372-373.
5. White J, Hirst D, Hender E. 36 cases of bites by spiders, including the whitetailed spider, Lampona cylindrata. Med J Aust 1989; 150: 401-403.
6. Macmillan DL. Envenomation by a window spider [letter]. Med J Aust 1989;
150: 16.
7. Chan S. Recurrent necrotising arachnidism [letter]. Med J Aust 1998; 169: 642643.
8. Tingate TR. Envenomation by the common black window spider [letter]. Med J
Aust 1991; 154: 291.
9. White J, Cardoso J, Fan H. Clinical toxicology of spider bites. In: Meier J,
White J, editors. Clinical toxicology of animal venoms and poisons. Boca
Raton: CRC Press, 1995.
10. Atkins JA, Wingo CW, Sodeman WA, Flynn JE. Necrotic arachnidism. Am J
Trop Med Hyg 1957; 7: 165-184.
11. Auer AI, Hershey FB. Proceedings: Surgery for necrotic bites of the brown
spider. Arch Surg 1974; 108: 612-618.
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eMJA: Pincus et al, Acute and recurrent skin ulceration after spider bite
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12. Harvey MS, Raven RJ. Necrotising arachnidism in Australia: a simple case of
misidentification [letter]. Med J Aust 1991; 154: 856.
13. Oppenheim B, Taggart I. More in spider venom than venom? Lancet 1990; 335:
228.
14. Atkinson RK, Farrell DJ, Leis AP. Evidence against the involvement of
Mycobacterium ulcerans in most cases of necrotic arachnidism. Pathology
1995; 27: 53-57.
15. Rees RS, Fields JP, King LE. Do brown recluse spider bites induce pyoderma
gangrenosum? South Med J 1985; 78: 283-287.
16. Callen JP. Pyoderma gangrenosum. Lancet 1998; 351: 581-585.
17. Rees RS, Altenbern DP, Lynch JB, King LE, Jr. Brown recluse spider bites. A
comparison of early surgical excision versus dapsone and delayed surgical
excision. Ann Surg 1985; 202: 659-663.
18. Strain GM, Snider TG, Tedford BL, Cohn GH. Hyperbaric oxygen effects on
brown recluse spider (Loxosceles reclusa) envenomation in rabbits. Toxicon
1991; 29: 989-996.
19. Maynor ML, Moon RE, Klitzman B, et al. Brown recluse spider envenomation:
a prospective trial of hyperbaric oxygen therapy. Acad Emerg Med 1997; 4:
184-192.
(Received 19 Oct 1998, accepted 1 Jun 1999)
Authors'
details
Australian Venom Research Unit, Department of Pharmacology, The University of Melbourne, VIC.
Steven J Pincus, MB BS, BSc(Hons), Research Registrar.
Kenneth D Winkel, MB BS, FACTM, Director.
Gabrielle M Hawdon, MB BS, MPH, Deputy Director.
Struan K Sutherland, MD DSc, Honorary Principal Fellow.
Reprints: Dr K D Winkel, Australian Venom Research Unit, Department of Pharmacology, The
University of Melbourne, Parkville, VIC 3052.
Email: k.winkelATpharmacology.unimelb.edu.au
©MJA 1999
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of 130 definite bites by Lampona species Med J Aust 2003; 179 (4): 199-202. [Bites
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<http://www.mja.com.au/public/issues/179_04_180803/isb10785_fm.html>
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1: Fourteen cases of acute and recurrent skin ulceration after suspected or
confirmed white-tailed spider bite*
Spider identity confirmed
1. A 27-year-old woman in Queensland was bitten on the leg by a female whitetailed spider (positively identified by one of the authors, SKS). She developed a
pimple-like lesion that blistered and broke down to form a 2x2cm ulcer. She was
treated with doxycycline, and healed over 1 month.
2. A 38-year-old man in Victoria was bitten on the calf by a female white-tailed
spider (positively identified by the Victorian Museum). The bite was painful, itchy,
erythematous and blistered, and progressed to shallow ulcers, while he became
feverish. He was treated with doxycycline and antihistamines, and the original
lesion healed over 10 days. He has since had multiple episodes of similar lesions,
with a gradual decrease in frequency.
3. A 33-year-old man in New South Wales was bitten on the leg by a white-tailed
spider (also sighted by the local medical officer). Initially the bite produced a small,
red, painful lesion. Culture produced a scant growth of S. aureus. The patient was
treated with doxycycline, and the lesion healed, then broke down at one month into
a 6x6cm ulcer that healed over four months. Spider identity not confirmed (patient
reported white-tailed spider bite, but no formal identification)
4. A 39-year-old man in Queensland was bitten on the shin. The bite was painful
and progressed rapidly to a 20x10cm ulcer. He presented at one week, febrile with
secondary infection. Staphylococcus and Streptococcus were cultured from the
wound. He was treated with intravenous and oral antibiotics, but presented again
three weeks later requiring further antibiotic treatment. The ulcer healed over the
next month. 5.·A 38-year-old man in Tasmania was bitten at the base of the little
finger. The lesion developed initially as a reddened disc with central darkening,
progressing to a painful ulcer (1x2cm). S. aureus was cultured from the lesion. He
was treated with intravenous and oral antibiotics without response. Hyperbaric
oxygen therapy was applied five times, until the lesion developed a granulating
base.
6. A 46-year-old man in New South Wales was bitten on the back of the hand by a
white-tailed spider. The bite resulted in a painful, erythematous 5x5cm area of
blisters that progressed to a chronic ulcer. He was unsuccessfully treated with
routine wound dressings, oral and intravenous antibiotics, developed a claw hand
and underwent amputation at the wrist.
7. A 46-year-old man in New South Wales was bitten on the shin. The bite resulted
in an itchy, painful swelling with a 1cm necrotic area, and the patient became
febrile. He was treated with flucloxacillin and penicillin, but the ulcer slowly
increased in size with central necrosis, before eventually healing over one month.
8. A 51-year-old man in Queensland was bitten on the back of the hand. Blisters at
the bite site progressed to a painful ulcer that had not healed two months after the
bite, when the wound was debrided and repaired with a split skin graft. Two weeks
later there was blistering and loss of the graft. Regrafting was also unsuccessful,
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leaving a persistent 15x8cm ulcer that took six months to heal. The lesion recurred
once three years later.
9. A 35-year-old man in Victoria was bitten on the palm of the hand. The bite
resulted in a painful lesion with central blistering. He was treated with antibiotics.
The blister broke down to a shallow ulcer that resolved slowly over a month. The
patient experienced several episodes of superficial blisters over the next year.
A white-tailed spider (Lampona cylindrata, actual length 1-2 cm) -- the likely
suspect in most of these cases of serious injury after spider bite. "Lampona group
spiders are found throughout Australia; L. cylindrata is particularly common in
disturbed and urban areas. These spiders live in crevices, under bark, rocks and leaf
litter and often in houses. They attack and eat other spiders including black house
spiders."
-- Australian Museum online
<http://www.austmus.gov.au/is/sand/whitspi.htm>
Accessed 11 June 1999.
10. A 33-year-old woman in Victoria was bitten on the medial malleolus. Initially a
red spot, the bite site blistered on Day 1, progressing to increasing inflammation and
spreading ulceration resulting in multiple ulcers on the lower leg. A biopsy showed
perivascular infiltration with polymorphic neutrophils and lymphocytes. The patient
was unsuccessfully treated with antibiotics and routine dressings for four months
before being referred for hyperbaric oxygen therapy. Twelve sessions of hyperbaric
oxygen therapy led to resolution of the ulcer, but the patient experienced several
recurrences of ulcers (1-2cm self-healing) per year thereafter.
11. A 69-year-old woman in Victoria was bitten on the medial malleolus. The bite
resulted in pain, erythema, oedema, multiple blisters, progressing to dry shallow
ulcers, with fever. The patient was treated with intravenous antibiotics and routine
wound dressings without response. Blisters and swelling increased for 10 days, then
healed over three weeks. Three months after the bite the patient experienced
multiple episodes of small blisters that healed in 5-7 days.
12. A 25-year-old woman in Victoria was bitten on the foot. The bite resulted in an
ulcer and erythema in the first web space and swelling to the ankle. The patient was
treated with oral antibiotics. The lesion healed over one month, but recurred four
times in the next six months, after which the patient had 10 sessions of hyperbaric
oxygen therapy. There was a minor recurrence one year after the bite.
13. A 35-year-old man in Victoria was bitten on the shin. The bite resulted in
painful, erythematous, swollen, multiple superficial ulcers. A biopsy showed dermal
necrosis and vasculitis infiltrated by polymorphic neutrophils. The patient was
treated with intravenous flucloxacillin and penicillin, oral augmentin,
immobilisation and (after two months) with a split skin graft. The graft healed over
one month, but the patient presented again a year after the bite with rapid
breakdown of the graft. A regraft gave a poor result and recovery was slow. 7
14. A 40-year-old woman in New South Wales was bitten on the arm. The bite
resulted in a red spot that grew to 2cm and developed a necrotic centre at seven
days, progressing to shallow ulcers in the mid-forearm (6x3cm). Biopsy showed
dermal necrosis and mixed perivascular infiltrate. Treatment with tetracycline was
ineffective, but topical and oral prednisolone appeared to slow the progression of
the ulcer. The patient underwent hyperbaric oxygen therapy, with resolution of the
ulcer, but she has experienced subsequent recurrences.
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*Identified from the Australian Venom Research Unit medical advisory service records and from the
Alfred Hospital Department of Hyperbaric Medicine records.
Back to text
2: Skin necrosis following bites from two Badumna spiders
This is the first report of skin necrosis after the bite
of a female black house spider. A previously well
55-year-old woman was bitten four times by two
spiders that fell onto her forearm after she had
sprayed them with insecticide. She felt an immediate
stinging pain after the bite. The spiders were
captured and later identified as female Badumna
spiders (species indeterminate) (Dr Robert Raven,
Museum Scientist, Arachnology, Queensland
Museum, personal communication). She presented to
hospital four days later with a painful, swollen
forearm, was admitted and, although systemically
well, was treated with intravenous flucloxacillin.
Over the next three days, several ragged ulcers with necrotic bases developed within
the swollen area. Microscopy of a swab of the ulcer showed numerous leukocytes,
but no organisms were seen on gram stain nor subsequently cultured. After
debridement, the ulcers were allowed to heal by secondary intention. The wounds
healed slowly over the next few months and have not recurred.
A black house or black window spider (Badumna insignis, actual length 1-1.5 cm).
"Black house spiders are widely distributed in southern and eastern Australia. They
are common in urban areas. Other Badumna group spiders are found throughout
Australia. Black house spider webs form untidy, lacy silk sheets with funnel-like
entrances. They are found on tree trunks, logs, rock walls and buildings (in window
frames, wall crevices, etc.). Badumna longinquus often builds webs on foliage."
-- Australian Museum online
<http://www.austmus.gov.au/is/sand/widspi.htm>
Accessed 11 June 1999.
Back to text
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