Loxoscelism (Loxosceles reclusa) Envenomation Causing Acute Hemolytic Anemia: Case Report

Loxoscelism (Loxosceles reclusa) Envenomation Causing Acute Hemolytic Anemia: Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Loxoscelism (Loxosceles reclusa) Envenomation Causing Acute Hemolytic Anemia: Case Report Steven Laxton, David Whetstone This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4378804/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This case report has the main objective of providing education surrounding the presentation, evaluation, diagnosis, and treatment of Loxosceles reclusa envenomation and presenting a case of loxoscelism that occurred in an adult that subsequently presented to the emergency department. A secondary objective of this case report is to add to the library of images bite wound associated with loxoscelism that resulted in inpatient admission and treatment for acute hemolytic anemia. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction Brown recluse spiders ( Loxosceles reclusa ): Brown recluse spiders ( Loxosceles reclusa ) are native spiders to North America (Figure 1) and are found in the mid-southern United States. Recluse spiders are commonly found in homes and basements (1) and are considered synanthropic spiders (i.e., their population numbers increase in association with humans). Within their endemic habitats, these spiders are commonly encountered within locations of homes not commonly used such as behind furniture, closets, basements, etc. (2) Figure 1: Distribution of Recluse spiders in the United States (Red area); Figure 1 shows the distribution of recluse spiders in the United States showing multiple species. In red is the dominant recluse species in the southeastern area of the United States. There are many methods for identification, however, the most accurate method of identifying a recluse spider involves counting the eyes if one is able to safely identify them by up close examination. 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. With the naked eye or low magnification, the eye pairs (dyads) may appear as individual eyespots. (Figure 2) A less reliable method for identification is via body markings. The brown recluse has a violin pattern on its anterior cephalothorax, but this method is not as reliable as the “violin pattern” varies with spider age. (3) Figure 2: Identification of Recluse Spider; Figure 2 shows an example of the two main methods for identification. The most accurate method of identifying a recluse spider involves counting the eyes if one can safely identify them by up close examination. Recluse spiders have six eyes, with a pair in front, a pair on both sides, and a gap between the pairs. With the naked eye or low magnification, the eye pairs (dyads) may appear as individual eyespots. (Figure 2) A less reliable method for identification is via body markings. The brown recluse has a violin pattern on its anterior cephalothorax, but this method is not as reliable. Envenomation/Bite presentation: Loxoscelism is the term for the medical manifestations of bites by recluse spiders which can include both local and systemic affects. The venom produced includes many enzymes that can cause injury but most notably, the phospholipases D (formerly designated as sphingomyelinases) are the culprit for causing most of the clinical entity of loxoscelism. This enzyme is the major culprit in causing necrotic loxoscelism, platelet disorders, hemolysis, and acute renal failure. (4) Local Effects Local effects can vary from two small puncture wounds that do not draw attention to dermal and myodermal necrosis. Usually, the local effects are the development of a red plaque that later progresses to central pallor. The pain typically increases over the next two to eight hours and may become severe. It may develop a vasculitic appearance. In most cases, however, this lesion is self-limited and resolves without further complications in approximately one week. However, in some patients, the lesion can develop a dark, depressed center over the ensuing 24 to 48 hours (about 2 days), culminating in a dry eschar that subsequently ulcerates. (5) Complications/ Systemic Illness Systemic symptoms are an infrequent complication (6) of recluse bites that do not correlate with local findings. The main systemic symptoms include malaise, nausea and vomiting, fever, myalgias with dark urine (rhabdomyolysis), pallor, jaundice, icterus, and painless dark urine (acute hemolytic anemia). (5) Rare and uncommon life-threatening complications following a recluse spider bite include angioedema, acute hemolytic anemia, disseminated intravascular coagulopathy, rhabdomyolysis, myonecrosis, renal failure, coma, and death which occurs in approximately 1 percent of confirmed bites. (6) Treatment: As the presentation varies from local effects to severe life-threatening complications so does the treatment for recluse envenomation. For patients with local effects the mainstay of treatment is wound care and pain management which can be as simple as wound observation, NSAIDs, and possibly updating tetanus immunization. For recluse bites that have signs of developing necrosis, no proven therapy aside from administration of antivenom exists, however, antivenom therapy is not currently available in the United States (9) therefore in patients with dermal necrosis the mainstay of treatment remains with local wound care and pain management. For patients with systemic effects the treatment remains in providing supportive care such as transfusing red blood cells in patients that develop hemolytic anemia and trending hemoglobin/hematocrit. (7) In patients with rhabdomyolysis, rapid infusion of isotonic saline to establish urine output of 200 to 300 mL/hour (4 mL/kg per hour in children) with a goal of preventing renal failure. As patient illness severity increases or progresses, patients must be monitored for further and more invasive supportive therapy such as intubation and ventilation in patients that need respiratory support. What is special in this case: As previously mentioned, approximately 1% of confirmed recluse bites have systemic effects. (6) This case is among the 1% as this patient developed acute hemolytic anemia necessitating transfusion. This case report also adds to the literature of loxoscelism with systemic effects as well as another image of a bite with both local and systemic symptoms including dermal necrosis and systemic effects of acute hemolytic anemia requiring inpatient admission for monitoring and transfusion. Case This patient is a 41-year-old female with no significant past medical history who presented to the emergency department with concerns for spider bite on her left upper extremity that occurred 5 days prior to presentation. She states she witnessed a spider crawling on her and the sensation of a “bite” in the area that then developed the finding of erythema surrounding an area of necrosis. (Figure 3) She stated that she had seen brown recluses in her house. Other symptoms reported were diffuse itchiness and associated vomiting since being bitten. She demonstrated a wound from the bite on her left upper extremity, which gradually worsened, having started with a little blister at the bite wound that developed to an area of erythema with a necrotic core. Upon presentation, the patient had vital signs most concerning for a tachycardia of 128 beats per minute and physical exam findings of an erythematous circular spot on left lateral mid arm with necrotic core. A small area of surrounding induration without fluctuance. It is important to remember that wound appearance and severity of envenomation do not correlate. (5) She also had mild jaundice and scleral icterus on examination. Figure 3: Wound on left lateral mid arm with necrotic core and surrounding erythema Laboratory examination was performed and found to have significant abnormalities in serum electrolytes, hepatic function, and blood count. The electrolyte abnormality was hypokalemia that was measured at 2.6 mmol/L. The hepatic function panel showed a mild elevation in liver enzymes (AST 55 U/L) and total bilirubin of 2.2 mg/dL. The blood counts showed an elevated white count (22.3x10 3 /mm 3 ) and depressed red blood count (3.93 x10 6 /mm 3 ) with an associated depressed hemoglobin (7.8 g/dL). Other laboratory measurements returned reassuring without elevation in creatinine kinase, international normalized ratio, prothrombin time, or partial thromboplastin time. The patient was treated with electrolyte replacement, IV fluids, and started on vancomycin and ceftriaxone for concern of possible secondary bacterial infection. The decision was then made to admit the patient given the concern for Loxosceles reclusa envenomation and anemia that will likely necessitate transfusion. During inpatient admission, the patient’s hemoglobin continued to downtrend to 5.8 g/dL requiring 1 unit packed red blood cell transfusion to which patient responded and did not need further transfusions. Patient’s hyperbilirubinemia resolved as well as electrolyte abnormalities. Two blood cultures grew no organisms. Antibiotic therapy of vancomycin and ceftriaxone was continued for three days until the decision was then made that patient was stable for discharge home with amoxicillin-clavulanic acid and doxycycline for cellulitis on arm surrounding area of spider bite. The area of dermal necrosis also healed without need for further intervention but did develop a notable scar. (Figure 4) Figure 4: Healed dermal necrosis following recluse bite as of March 13, 2024 The patient also graciously provided further images of the bite wound that ranges from prior to presentation (Figure 5), while in the hospital (Figure 6) and evolution of dermal necrosis following discharge to home. (Figures 7-9) These images following discharge home provide a good example of the evolution of dermal necrosis from start of central pallor to necrotic core and development of liquefactive necrosis. Figure 5: Area of recluse bite prior to presentation with start of necrosis Figure 6: Area of recluse bite while hospitalized with continued necrosis and reactive skin changes vs secondary bacterial infection surrounding bite Figure 7: Image following discharge from hospital with further development of central necrosis and improvement of surrounding erythema Figure 8: Further development of central necrosis with sloughing of necrotic skin Figure 9: Development of liquefactive necrosis and sharp demarcation of normal skin at wound edge Discussion Loxoscelism is a medical condition resulting from recluse spider envenomation. This condition can vary in presentation from simple wound and pain management to severe life-threatening conditions which occur in approximately 1% of recluse bites. When evaluating a patient with an isolated wound with unknown etiology loxoscelism remains on the differential diagnosis even though in the cases of simple wound management or pain control no specific therapy is being implemented that is unique to loxoscelism. However, in severe life-threatening cases of loxoscelism the treatment can be much more intensive from infusion of isotonic saline, packed red blood cell transfusion, correcting or treating electrolyte abnormalities, to much more intensive therapy if renal failure, encephalopathy, or respiratory failure progresses or persists. If loxoscelism is suspected, then further evaluation should be pursued. Recommended further laboratory evaluation includes complete blood count with peripheral smear, reticulocyte count, type and screen with Coombs, liver function panel, serum lactate dehydrogenase, serum haptoglobin, serum electrolytes, serum calcium and phosphate, serum uric acid if signs of rhabdomyolysis, blood urea nitrogen and creatinine, creatine kinase, rapid urine dipstick for blood and for urobilinogen with reflex to urinalysis if positive, prothrombin time (PT) with international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen and D-dimer if INR or aPTT is prolonged, electrocardiogram if rhabdomyolysis and electrolyte abnormalities are present. (8) The patient case presented the unique complication of loxoscelism of acute hemolytic anemia that required transfusion. Fortunately, the patient returned to her baseline health and required no further intervention and was stable for discharge to home. Conclusion When practicing medicine in the southern and mid-western United States and evaluating a patient with a single, isolated skin wound loxoscelism should remain on the differential diagnosis and prompt further investigation if suspected. Treatment varies from “nothing” to “everything” but is all supportive as there is no immediate and specific directed therapy that changes disease course aside from management of complications of loxoscelism. The patient case that we presented is included in the 1% of envenomation causing life threatening conditions. She suffered from an envenomation complication of acute hemolytic anemia that necessitated transfusion of blood after which she subsequently improved and was discharged home. Declarations Consent to participate written informed consent was obtained from all participants. Consent for publication Written informed consent was obtained from the patient for publication of this study and accompanying images. Funding No funding was obtained or used for this article Availability of data and materials No dataset was used. Any data used is included in the article. Ethical approval This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. UTHSC Internal Review Board (IRB) waived the need for approval of this studyi. Competing Interests The authors declare that they have no competing interests. References Spiders Map. Spider Research, 17. Sept. 2020, spiders.ucr.edu/spiders-map . Vetter RS, Diane K, Barger. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in nonendemic areas. J Med Entomol vol. 2002;39(6):948–51. 10.1603/0022-2585-39.6.948 . How to Identify and Misidentify a Brown Recluse Spider. Spider Research, 17. Sept. 2020, spiders.ucr.edu/how-identify-and-misidentify-brown-recluse-spider . Anderson PC. Loxoscelism threatening pregnancy: five cases. American journal of obstetrics and gynecology vol. 165,5 Pt 1 (1991): 1454-6. 10.1016/0002-9378(91)90389-9 . Isbister GK, Wen H. Fan. Spider bite. Lancet (London, England) vol. 378,9808 (2011): 2039–2047. 10.1016/S0140-6736(10)62230-1 . Anderson PC. Spider bites in the United States. Dermatol Clin vol. 1997;15(2):307–11. 10.1016/s0733-8635(05)70438-1 . Jacobs JW, et al. Laboratory Predictors of Hemolytic Anemia in Patients With Systemic Loxoscelism. Am J Clin Pathol vol. 2022;157(4):566–72. 10.1093/ajcp/aqab169 . Stahl WM. Acute phase protein response to tissue injury. Crit care Med vol. 1987;15(6):545–50. 10.1097/00003246-198706000-00001 . Streeper RT, Izbicka E. Diethyl Azelate for the Treatment of Brown Recluse Spider Bite, a Neglected Orphan Indication. In vivo (Athens, Greece) vol. 36,1 (2022): 86–93. 10.21873/invivo.12679 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4378804","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":311037841,"identity":"35f90a04-8624-4cc8-8622-97bc0175217f","order_by":0,"name":"Steven Laxton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYDACdghlx8/AwAZhHiCkhRmiKFmygZlELYwbDhCrRb6Z+Zn0h4o7zMY38o89/FHDIMd3IwG/FoPDbMYGB8484zO7kcxuzHOMwViSoBZmBsMHB9sOMwO1sEkzNjAkbiCkRb6Z/cMBoBbGzTOS2SR/NjDUE9TCcJgHbAvjBolkNgneBoYEA8J+4Sk2OHPmcLLEmcdm0jzHJAxnnnlAwGHt7dskKioO2/G3Jz6T/FFjI893nJDD0IAEacpHwSgYBaNgFGAHANtwRICBZ5cnAAAAAElFTkSuQmCC","orcid":"","institution":"University of Tennessee Health Science Center","correspondingAuthor":true,"prefix":"","firstName":"Steven","middleName":"","lastName":"Laxton","suffix":""},{"id":311037842,"identity":"b8f40f01-5f65-402f-a4b6-df219c05c3fa","order_by":1,"name":"David Whetstone","email":"","orcid":"","institution":"University of Tennessee Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Whetstone","suffix":""}],"badges":[],"createdAt":"2024-05-06 19:24:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4378804/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4378804/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58153761,"identity":"55dee335-a4d1-46ca-a536-912f3ca51fad","added_by":"auto","created_at":"2024-06-11 20:33:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45862,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Recluse spiders in the United States (Red area); Figure 1 shows the distribution of recluse spiders in the United States showing multiple species. In red is the dominant recluse species in the southeastern area of the United States.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/a7e8505144c3aa1f6afa28a1.jpg"},{"id":58153008,"identity":"1ae94179-2a36-4749-ac9e-daee56a5dcf6","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":537808,"visible":true,"origin":"","legend":"\u003cp\u003eIdentification of Recluse Spider; Figure 2 shows an example of the two main methods for identification. The most accurate method of identifying a recluse spider involves counting the eyes if one can safely identify them by up close examination. Recluse spiders have six eyes, with a pair in front, a pair on both sides, and a gap between the pairs. With the naked eye or low magnification, the eye pairs (dyads) may appear as individual eyespots. (Figure 2) A less reliable method for identification is via body markings. The brown recluse has a violin pattern on its anterior cephalothorax, but this method is not as reliable.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/d7d4d92786fbf4342aa36746.jpeg"},{"id":58153001,"identity":"d91bda59-c4d3-471b-b1e1-bab1e2a48fa0","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":6344,"visible":true,"origin":"","legend":"\u003cp\u003eWound on left lateral mid arm with necrotic core and surrounding erythema\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/986a9d6d78356164d55d5a91.jpg"},{"id":58153760,"identity":"71dad893-4820-4270-935f-9ee78e106a81","added_by":"auto","created_at":"2024-06-11 20:33:16","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":12767,"visible":true,"origin":"","legend":"\u003cp\u003eHealed dermal necrosis following recluse bite as of March 13, 2024\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/95f5337bf150a34ff2dda856.jpg"},{"id":58153003,"identity":"25a16c98-1e5f-4a9c-bb70-82778cd2adb6","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":7904,"visible":true,"origin":"","legend":"\u003cp\u003eArea of recluse bite prior to presentation with start of necrosis\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/df46ea7aa0f4094894c18850.jpg"},{"id":58153004,"identity":"4e1e8b96-0840-4dc1-8f03-5a2cdd144740","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":5844,"visible":true,"origin":"","legend":"\u003cp\u003eArea of recluse bite while hospitalized with continued necrosis and reactive skin changes vs secondary bacterial infection surrounding bite\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/9faa4850db97889eeadb7ebe.jpg"},{"id":58153007,"identity":"4c459a58-d2d9-4fe6-84aa-7089d32b4888","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":10626,"visible":true,"origin":"","legend":"\u003cp\u003eImage following discharge from hospital with further development of central necrosis and improvement of surrounding erythema\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/34cdad5b962930a6f8a819ce.jpg"},{"id":58153005,"identity":"d0507942-2325-4959-baa7-78df18adc734","added_by":"auto","created_at":"2024-06-11 20:25:16","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":8244,"visible":true,"origin":"","legend":"\u003cp\u003eFurther development of central necrosis with sloughing of necrotic skin\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/a0efa2e885bd1db782b8bfb5.jpg"},{"id":58153762,"identity":"dd8fc2cb-9790-4619-896a-66d2b9248b30","added_by":"auto","created_at":"2024-06-11 20:33:16","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":10341,"visible":true,"origin":"","legend":"\u003cp\u003eDevelopment of liquefactive necrosis and sharp demarcation of normal skin at wound edge\u003c/p\u003e","description":"","filename":"Picture9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/9f77c2a6d7b9c7361975b001.jpg"},{"id":72180363,"identity":"af435b5f-1c82-42c9-84f1-668e8c8d10b9","added_by":"auto","created_at":"2024-12-23 12:32:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":924397,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4378804/v1/394f8d89-42c0-4269-a4e8-5c77976254b8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Loxoscelism (Loxosceles reclusa) Envenomation Causing Acute Hemolytic Anemia: Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cstrong\u003eBrown recluse spiders (\u003cem\u003eLoxosceles reclusa\u003c/em\u003e):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBrown recluse spiders (\u003cem\u003eLoxosceles reclusa\u003c/em\u003e) are native spiders to North America (Figure 1) and are found in the mid-southern United States. Recluse spiders are commonly found in homes and basements (1) and are considered synanthropic spiders (i.e., their population numbers increase in association with humans). Within their endemic habitats, these spiders are commonly encountered within locations of homes not commonly used such as behind furniture, closets, basements, etc. (2)\u003c/p\u003e\n\u003cp\u003eFigure 1: Distribution of Recluse spiders in the United States (Red area); Figure 1 shows the distribution of recluse spiders in the United States showing multiple species. In red is the dominant recluse species in the southeastern area of the United States. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are many methods for identification, however, the most accurate method of identifying a recluse spider involves counting the eyes if one is able to safely identify them by up close examination. 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. With the naked eye or low magnification, the eye pairs (dyads) may appear as individual eyespots. (Figure 2) A less reliable method for identification is via body markings. \u0026nbsp;The brown recluse has a violin pattern on its anterior cephalothorax, but this method is not as reliable as the \u0026ldquo;violin pattern\u0026rdquo; varies with spider age. (3)\u003c/p\u003e\n\u003cp\u003eFigure 2: Identification of Recluse Spider; Figure 2 shows an example of the two main methods for identification. The most accurate method of identifying a recluse spider involves counting the eyes if one can safely identify them by up close examination. Recluse spiders have six eyes, with a pair in front, a pair on both sides, and a gap between the pairs. With the naked eye or low magnification, the eye pairs (dyads) may appear as individual eyespots. (Figure 2) A less reliable method for identification is via body markings. \u0026nbsp;The brown recluse has a violin pattern on its anterior cephalothorax, but this method is not as reliable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvenomation/Bite presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLoxoscelism is the term for the medical manifestations of bites by recluse spiders which can include both local and systemic affects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe venom produced includes many enzymes that can cause injury but most notably, the phospholipases D (formerly designated as sphingomyelinases) are the culprit for causing most of the clinical entity of loxoscelism. This enzyme is the major culprit in causing necrotic loxoscelism, platelet disorders, hemolysis, and acute renal failure. (4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLocal Effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLocal effects can vary from two small puncture wounds that do not draw attention to dermal and myodermal necrosis. Usually, the local effects are the development of a red plaque that later progresses to central pallor. The pain typically increases over the next two to eight hours and may become severe. It may develop a vasculitic appearance. In most cases, however, this lesion is self-limited and resolves without further complications in approximately one week. However, in some patients, the lesion can develop a dark, depressed center over the ensuing 24 to 48 hours (about 2 days), culminating in a dry eschar that subsequently ulcerates. (5)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications/ Systemic Illness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSystemic symptoms are an infrequent complication (6) of recluse bites that do not correlate with local findings. The main systemic symptoms include malaise, nausea and vomiting, fever, myalgias with dark urine (rhabdomyolysis), pallor, jaundice, icterus, and painless dark urine (acute hemolytic anemia). (5)\u003c/p\u003e\n\u003cp\u003eRare and uncommon life-threatening complications following a recluse spider bite include angioedema, acute hemolytic anemia, disseminated intravascular coagulopathy, rhabdomyolysis, myonecrosis, renal failure, coma, and death which occurs in approximately 1 percent of confirmed bites. (6)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the presentation varies from local effects to severe life-threatening complications so does the treatment for recluse envenomation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor patients with local effects the mainstay of treatment is wound care and pain management which can be as simple as wound observation, NSAIDs, and possibly updating tetanus immunization. For recluse bites that have signs of developing necrosis, no proven therapy aside from administration of antivenom exists, however, antivenom therapy is not currently available in the United States (9) therefore in patients with dermal necrosis the mainstay of treatment remains with local wound care and pain management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor patients with systemic effects the treatment remains in providing supportive care such as transfusing red blood cells in patients that develop hemolytic anemia and trending hemoglobin/hematocrit. (7) In patients with rhabdomyolysis, rapid infusion of isotonic saline to establish urine output of 200 to 300 mL/hour (4 mL/kg per hour in children) with a goal of preventing renal failure. As patient illness severity increases or progresses, patients must be monitored for further and more invasive supportive therapy such as intubation and ventilation in patients that need respiratory support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is special in this case:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs previously mentioned, approximately 1% of confirmed recluse bites have systemic effects. (6) This case is among the 1% as this patient developed acute hemolytic anemia necessitating transfusion. This case report also adds to the literature of loxoscelism with systemic effects as well as another image of a bite with both local and systemic symptoms including dermal necrosis and systemic effects of acute hemolytic anemia requiring inpatient admission for monitoring and transfusion.\u0026nbsp;\u003c/p\u003e"},{"header":"Case","content":"\u003cp\u003eThis patient is a 41-year-old female with no significant past medical history who presented to the emergency department with concerns for spider bite on her left upper extremity that occurred 5 days prior to presentation. She states she witnessed a spider crawling on her and the sensation of a \u0026ldquo;bite\u0026rdquo; in the area that then developed the finding of erythema surrounding an area of necrosis. (Figure 3) She stated that she had seen brown recluses in her house. Other symptoms reported were diffuse itchiness and associated vomiting since being bitten. She demonstrated a wound from the bite on her left upper extremity, which gradually worsened, having started with a little blister at the bite wound that developed to an area of erythema with a necrotic core.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUpon presentation, the patient had vital signs most concerning for a tachycardia of 128 beats per minute and physical exam findings of an erythematous circular spot on left lateral mid arm with necrotic core. A small area of surrounding induration without fluctuance. It is important to remember that wound appearance and severity of envenomation do not correlate. (5) She also had mild jaundice and scleral icterus on examination.\u003c/p\u003e\n\u003cp\u003eFigure 3: Wound on left lateral mid arm with necrotic core and surrounding erythema\u003c/p\u003e\n\u003cp\u003eLaboratory examination was performed and found to have significant abnormalities in serum electrolytes, hepatic function, and blood count. The electrolyte abnormality was hypokalemia that was measured at 2.6 mmol/L. The hepatic function panel showed a mild elevation in liver enzymes (AST 55 U/L) and total bilirubin of 2.2 mg/dL. The blood counts showed an elevated white count (22.3x10\u003csup\u003e3\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e) and depressed red blood count (3.93 x10\u003csup\u003e6\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e) with an associated depressed hemoglobin (7.8 g/dL). Other laboratory measurements returned reassuring without elevation in creatinine kinase, international normalized ratio, prothrombin time, or partial thromboplastin time.\u003c/p\u003e\n\u003cp\u003eThe patient was treated with electrolyte replacement, IV fluids, and started on vancomycin and ceftriaxone for concern of possible secondary bacterial infection. The decision was then made to admit the patient given the concern for \u003cem\u003eLoxosceles reclusa \u003c/em\u003eenvenomation and anemia that will likely necessitate transfusion.\u003c/p\u003e\n\u003cp\u003eDuring inpatient admission, the patient\u0026rsquo;s hemoglobin continued to downtrend to 5.8 g/dL requiring 1 unit packed red blood cell transfusion to which patient responded and did not need further transfusions. Patient\u0026rsquo;s hyperbilirubinemia resolved as well as electrolyte abnormalities. Two blood cultures grew no organisms. Antibiotic therapy of vancomycin and ceftriaxone was continued for three days until the decision was then made that patient was stable for discharge home with amoxicillin-clavulanic acid and doxycycline for cellulitis on arm surrounding area of spider bite. The area of dermal necrosis also healed without need for further intervention but did develop a notable scar. (Figure 4)\u003c/p\u003e\n\u003cp\u003eFigure 4: Healed dermal necrosis following recluse bite as of March 13, 2024\u003c/p\u003e\n\u003cp\u003eThe patient also graciously provided further images of the bite wound that ranges from prior to presentation (Figure 5), while in the hospital (Figure 6) and evolution of dermal necrosis following discharge to home. (Figures 7-9) These images following discharge home provide a good example of the evolution of dermal necrosis from start of central pallor to necrotic core and development of liquefactive necrosis.\u003c/p\u003e\n\u003cp\u003eFigure 5: Area of recluse bite prior to presentation with start of necrosis\u003c/p\u003e\n\u003cp\u003eFigure 6: Area of recluse bite while hospitalized with continued necrosis and reactive skin changes vs secondary bacterial infection surrounding bite\u003c/p\u003e\n\u003cp\u003eFigure 7: Image following discharge from hospital with further development of central necrosis and improvement of surrounding erythema\u003c/p\u003e\n\u003cp\u003eFigure 8: Further development of central necrosis with sloughing of necrotic skin\u003c/p\u003e\n\u003cp\u003eFigure 9: Development of liquefactive necrosis and sharp demarcation of normal skin at wound edge\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLoxoscelism is a medical condition resulting from recluse spider envenomation. This condition can vary in presentation from simple wound and pain management to severe life-threatening conditions which occur in approximately 1% of recluse bites.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;When evaluating a patient with an isolated wound with unknown etiology loxoscelism remains on the differential diagnosis even though in the cases of simple wound management or pain control no specific therapy is being implemented that is unique to loxoscelism. However, in severe life-threatening cases of loxoscelism the treatment can be much more intensive from infusion of isotonic saline, packed red blood cell transfusion, correcting or treating electrolyte abnormalities, to much more intensive therapy if renal failure, encephalopathy, or respiratory failure progresses or persists.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIf loxoscelism is suspected, then further evaluation should be pursued. Recommended further laboratory evaluation includes complete blood count with peripheral smear, reticulocyte count, type and screen with Coombs, liver function panel, serum lactate dehydrogenase, serum haptoglobin, serum electrolytes, serum calcium and phosphate, serum uric acid if signs of rhabdomyolysis, blood urea nitrogen and creatinine, creatine kinase, rapid urine dipstick for blood and for urobilinogen with reflex to urinalysis if positive, prothrombin time (PT) with international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen and D-dimer if INR or aPTT is prolonged, electrocardiogram if rhabdomyolysis and electrolyte abnormalities are present. (8)\u003c/p\u003e\n\u003cp\u003eThe patient case presented the unique complication of loxoscelism of acute hemolytic anemia that required transfusion. Fortunately, the patient returned to her baseline health and required no further intervention and was stable for discharge to home.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhen practicing medicine in the southern and mid-western United States and evaluating a patient with a single, isolated skin wound loxoscelism should remain on the differential diagnosis and prompt further investigation if suspected. Treatment varies from \u0026ldquo;nothing\u0026rdquo; to \u0026ldquo;everything\u0026rdquo; but is all supportive as there is no immediate and specific directed therapy that changes disease course aside from management of complications of loxoscelism.\u003c/p\u003e\n\u003cp\u003eThe patient case that we presented is included in the 1% of envenomation causing life threatening conditions. She suffered from an envenomation complication of acute hemolytic anemia that necessitated transfusion of blood after which she subsequently improved and was discharged home.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ewritten informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this study and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained or used for this article\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo dataset was used. Any data used is included in the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eUTHSC\u0026nbsp;Internal Review Board (IRB) waived the need for approval of this studyi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSpiders Map. Spider Research, 17. Sept. 2020, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003espiders.ucr.edu/spiders-map\u003c/span\u003e\u003cspan address=\"http://spiders.ucr.edu/spiders-map\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVetter RS, Diane K, Barger. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in nonendemic areas. J Med Entomol vol. 2002;39(6):948\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1603/0022-2585-39.6.948\u003c/span\u003e\u003cspan address=\"10.1603/0022-2585-39.6.948\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHow to Identify and Misidentify a Brown Recluse Spider. Spider Research, 17. 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In vivo (Athens, Greece) vol. 36,1 (2022): 86\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21873/invivo.12679\u003c/span\u003e\u003cspan address=\"10.21873/invivo.12679\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4378804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4378804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis case report\u003c/span\u003e has the main objective of providing education surrounding the presentation, evaluation, diagnosis, and treatment of \u003cem\u003eLoxosceles reclusa\u003c/em\u003e envenomation and presenting a case of loxoscelism that occurred in an adult that subsequently presented to the emergency department. A secondary objective of this case report is to add to the library of images bite wound associated with loxoscelism that resulted in inpatient admission and treatment for acute hemolytic anemia.\u003c/p\u003e","manuscriptTitle":"Loxoscelism (Loxosceles reclusa) Envenomation Causing Acute Hemolytic Anemia: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 20:25:11","doi":"10.21203/rs.3.rs-4378804/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53bbac10-866b-4005-be14-5745f3dbe2ed","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T12:24:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-11 20:25:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4378804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4378804","identity":"rs-4378804","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}