Two Letters Re: The Rude Awakening of a Spider Bite
Dear Mr Rawles:
Fitzy describes a classic presentation for a staphylococcal furuncle, which in this day and age is often caused by cMRSA (community acquired Methicillin Resistant Staphylococcus Aureus) colonizing a patient’s skin. These typically start as small “pimples” or “bites” on the skin surface, usually in areas of warmth and dampness, but any area of the body can be affected. Most cases start as infected hair follicles or in areas of micro-abrasion or injury, not due to bites.
It sounds like his doctor started him on doxycycline when bactrim or clindamycin might have been more appropriate. Size of the lesion can be variable, but they can easily become as large as a hands-width, are tender, red, and warm to touch. A central “pimple” may appear and spontaneous drainage can result, especially if hot compresses are applied. While oral antibiotics such as clindamycin or bactrim are usually used given resistance patterns of the organism, doxycycline or minocycline can also be used, while serious cases may require hospitalization and administration of intravenous antibiotics, including “big guns” like vancomycin or daptomycin. Fluoroquinolones such as ciprofloxacin are not as useful than they were years ago because resistance is common, and cMRSA is usually resistant to other common anti-staphylococcal antibiotics such as keflex. Most patients are surprised that antibiotics are actually adjunctive therapy to surgical drainage, which should only be performed by trained medical personnel or someone very familiar with anatomy.
This problem is often seen amongst household contacts, and attempts at control included frequent washing of sheets, avoidance of use of common towels, and basic hand hygiene. Attempts at elimination of colonization in a households utilizing strict hygiene practices, oral antibiotics, chlorhexidine or equivalent washes, and nasal antibiotics are at best 50% successful.
As for bites, most reactions are localized and do not require treatment. Utilization of anti-histamines or topical steroids may be beneficial in more involved reactions. Anaphylaxis to spider bites is rare and such cases require immediate treatment with epinephrine, and then perhaps intravenous anti-histamines and steroids.
I have never treated a brown recluse spider bite. However, in my limited understanding, the bite of the brown recluse spider, fortunately rare, can result in severe manifestations of tissue death around the bite, and may require extensive surgical debridement and long-term wound care with physical therapy if limbs are affected. Prevention stems from control of insects in and around habitations and outside structures where you are likely to be working. Sincerely, – G.S., MD
James Wesley:
Fitzy raises several issues in your letter that I would like to address. I have also attached links to a few articles regarding Brown Recluse Spiders that might be helpful. Without intending to second-guess your physician or trying to make a diagnosis in a patient that I have not seen and examined it sounds as if you had an episode of cellulitis, likely due to Staphylococcus (Staph) or Streptococcus (Strep) and not a spider bite at all.
The type of spider that is known to cause necrotic (dead tissue) lesions in the Western Hemisphere is the Recluse Spider, most commonly the Brown Recluse Spider. The main direct effect of a Brown Recluse Spider bite is not cellulitis with redness and swelling but death of the tissue or necrosis. Cellulitis can occur as a secondary complication of a Brown Recluse Spider bite but an ulceration or open sore should be a definite part of the clinical picture. Black widow spiders are the other most common type of poisonous spider but their bites cause muscle and abdominal cramps and are unlikely to cause necrosis and cellulitis. If you had no ulceration and sloughing of the skin and underlying tissue I would question whether you had a Brown Recluse Spider bite or a different cause of your cellulitis.
Additionally if you were in Pennsylvania at the time of your presumed envenomation, you were almost certainly not likely bitten by a Brown Recluse Spider. The range for the Brown Recluse is the Midwest and Lower Great Plains; Brown Recluse Spiders are rarely found outside this area. You may have been bitten by some type of arthropod (insect) which caused the cellulitis you had but it is hard to attribute the infection to a Brown Recluse.
The issue of using steroids, either by direct local injection or systemically (oral or intramuscular or intravenous injection) is one that has been kicking around the medical profession for a long time. Although in theory it makes sense, unfortunately steroids have never been proven to be effective in the treatment of Brown Recluse Spider bites. The method that you describe of very small dose local injections is unlikely to provide any significant treatment to a Brown Recluse Spider bite for one major reason: the amount of steroid that is injected is far too small to penetrate as deep as the venom does (and very quickly) and so will not spread into all of the affected tissue. Injecting larger doses of steroids can cause serious side effects, including destruction of the tissues especially if injected on the face or neck and all of the systemic adverse effects of steroids.
The other drawback to steroid injection into the area of envenomation is timing. By the time the decision is made to inject the site usually several hours have passed and the enzymes from the spider venom are already well on their way in causing damage to the tissue. The breakdown of the tissue and ulcer formation is the end-result of the venom and by the time this is seen it is far too late for steroids to help. Using steroid injections any time a person has a small area of redness and swelling that MIGHT be a Brown Recluse Spider bite will overuse the steroids greatly.
Situations like yours in a long-term TEOTWAWKI situation are certainly going to be a challenge. It will be difficult to store enough antibiotics, even for medical professionals, to manage many episodes of cellulitis. As has been reported in the press recently there has also been an explosion of drug-resistant Staph. The reasons for the development of drug-resistance are many but in large part resistance is due to the abuse of antibiotics for illnesses that do not require or respond to antibiotics and using antibiotics for a bacterial infection for too short a time to get rid of the infection completely. Viral illnesses, such as the common cold, influenza and most cases of bronchitis, do not need antibiotics which will not treat the virus in any way. I cannot tell you how much time I waste trying to convince patients of this fact and they are always unhappy when they don’t get their antibiotic prescription for their viral illness. (This is one of the main reasons your physician will be hesitant to give you a prescription for antibiotics to store in your preparations even if they understand your concerns about the upcoming hard times—we have concerns regarding the inappropriate use of antibiotics causing those antibiotics to quickly become ineffective as well as potential allergic and adverse reactions. If you ask your physician for antibiotic prescriptions, also ask for some very specific guidelines for when those antibiotics are to be used.)
Good hygiene, both of the body and the home environment whatever that may be, to decrease the risk of infections is a good practice now and will be a critical task in times when medical care will be more limited. – Ladydoc
Some Useful References:
Causes of Necrotic Wounds other than Brown Recluse Spider Bites