I recently described a case featuring a 17 year old boy in the Saint Louis area who was
afflicted with a brown recluse spider bite. Link to that video is in the description below. Despite
best efforts by the parents, the boy lived a lifestyle that perhaps allowed and encouraged
arachnids among others to thrive. He lived on the first floor of a house in a region where
Loxosceles reclusa is endemic. He would throw his clothes on the floor in a pile,
mixing clean and soiled clothes for weeks on end. What was shown on video was likely cleaner still
than the reality. He had a temporary wake up call when he one day woke up and found a spider
crawling around in his bed. But old habits die hard and he promptly reverted back to his ways,
and unluckily, he one day put on a sock that had a spider in it. It bit him, but he didnt know it at
first, he mistook it for a rock in the sock. Then it bit again. And he ignored it for a while until
he found a blistering bruise like lesion that he thought looked strange. Usually a stone in your
sock won’t mess up your foot like that. He went to look back in the sock and found the smashed spider
body inside. But he didnt come in to the emergency room until he noticed that his urine was red.
That video, and this one too, are not here to scare anyone about spiders. It’s to teach about
the medicine of one particular genus of venomous spider using a medical case. Its outcomes are not
even as catastrophic as some described in writing. When I lived in Chicago, I lived in a high rise,
and found out the hard way, that for some reason, the spiders kept getting
bigger the higher up you lived. Usually they were outside, and you could see them from the windows.
Somehow, grasshoppers could get up above the 40th floor. I dont know how they did that,
but the big spiders would catch and eat them. Occasionally, the spiders would somehow get
on the inside of the window and into your unit. When this happened to me, I would usually see a
newly spun web at the top corner of my window when the sun was shining in in the morning.
The scary part was that the there was no spider to be found by the web. Where was it? Was it hiding
in my bed?? Was it in my kitchen ready to take a bite out of my breakfast? At night when I got
home, I would find the spider after seeing a reflection of the ceiling light in the window.
There was no sleeping those nights. And by big, I mean those spiders were probably around the size of my palm.
Now with that said, whatever species of spider that was, it is not venomous in a way that a bite
could cause systemic illness because the United States has 2 known venomous spiders endemic to
the land. That’s it. You might find on websites that there are others, but the best evidence we
have at the time of this recording, June 2022, is that there’s Loxosceles and Latrodectus,
the recluse spiders and the black widow. And those big high rise Chicago spiders
are neither of those, especially not a recluse because brown recluse doesnt live in Chicago.
Loxosceles spiders live in this region, Central to South Midwest,
and along the US-Mexico border to Southern California. If you live North of I-80,
and remember even number interstates go East-West so this one goes from San Francisco to New Jersey,
you shouldn’t find brown recluses. That statement opens a can of worms.
That statement is the reason why I had to delay the video on the Chubbyemu channel,
so that this one could be released at the same time. It’s not going to just be the comments to
this video and the Chubbyemu video that will comment about where Brown Recluse spiders are, but
those same comments are in actual correspondence in medical literature, more on this in a bit.
There’s not just a brown recluse, but also a Desert recluse spider,
Loxosceles deserta that's all along the US-Mexico
border. Loxosceles spiders have 3 pairs of eyes, arranged in a non touching pattern, and the brown
recluse often has a fiddle shape on its back, the spider is brown, body can be up to half an inch,
almost 2 inches if you include the leg span. This is important to know, because sometimes,
a diagnosis of brown recluse spider bite is made in an area where these spiders dont live.
And they did recover the body of some spider, and they’ll claim it’s a brown recluse, when it’s not.
Lots of recluse spiders may not be big enough to be venomous. Females appear to produce more venom
than males. Female venom appears to cause more intense cutaneous and systemic signs and symptoms.
Among the spiders in Loxosceles genus, the bites appear to produce similar signs and
symptoms varying in severity, therefore the pathological condition arising from
a bite is called Loxoscelism. This also means that if we look globally,
there are different species in the Loxosceles reported on every continent except Asia. South
America appears to have the most reported cases of Loxoscelism. Brazil has the Gaucho spider,
which is Loxosceles gaucho, the reports published from these countries of Loxosceles envenomation
are similar to what we see in the United States for Brown and Desert recluse,
if the presentations aren’t greater in severity over there.
So what does a bite look like? Well, I said in the Chubbyemu video, there’s a cutaneous loxoscelism,
sometimes characterized by the “red white and blue” appearance at first, that is erythema,
ischemia, and necrosis. The venom is a mixture of toxins consisting of proteins, glycoproteins,
and low molecular weight peptides. There’s also enzymes, collagenases, alkaline phosphates,
phosphohydrolases, hyaluronidases and metalloproteinases. Sphingomyelinases
D are the enzymes that seem to be key from the venom in humans. They catalyze the hydrolysis of
sphingomyelin, which releases choline and ceramide 1-phosphate. They hydrolyze a wide range of
phospholipids, causing cellular necrosis. On the skin there’s a gravitational spreading pattern
that’s observed, likely from hyaluronidase. As cells necrose, indirect activation of
the complement system recruits polymorphonuclear leukocytes. In red blood cells, sphingomyelinase
D induces activation of membrane bound metalloproteinases, glycophorins are cleaved,
activating complement by the alternative pathway, ending in cell lysis. If there’s an alternative
pathway, there’s a classical complement pathway, and sphingomyelinase D activates
that in erythrocytes, changes conformation in the membrane, leading to exposure of phosphatidyl
serine on the external lipid monolayer, allows for C1q binding, the first part of the classical
complement pathway, ending in hemolysis. Hemolysis leads to free hemoglobin, causing oxidative damage
because of the iron moiety, depositing pigment in the nephrons and leading to kidney damage.
The hemolytic anemia is suggested by a low hemoglobin, low haptoglobin because that’s
what the body tries to use to protect against free hemoglobin and lactate dehydrogenase. So
in the systemic case of loxoscelism, which is rare, these patients can become really sick.
And the cutaneous manifestations of loxoscelism dont appear to have any
correlation to the severity of systemic illness. In the United States, we dont have anything more
than supportive care for loxoscelism. For wounds, there can be debridement if needed, but there’s no
antivenoms in the United States for systemic bites. The venom is temperature sensitive,
so cold compress and elevate the bite, if you know for sure it’s loxosceles and see your physician.
So, how rare exactly is all of this? The short answer is, based on the data we have,
systemic illness is very rare. At least for Brown Recluse, it’s in the name Recluse. In general we
know spiders are synanthropic, meaning the more people there are, the more spiders there are,
they happen to live among us, but it’s not like they want to cuddle up with us at night time.
There’s people who have practiced emergency medicine, who are the doctors who would see
these cases, for more than 25 years in Memphis Tennessee, Oklahoma, Kansas, northern Texas, where
the spider is endemic and they haven’t ever seen really severe cases. If your first reaction is “Oh but
that’s anecdotal,” I don’t disagree with you, but don’t forget the effects of the events of 2020.
In light of the many worlds I have been a part of in my past lives, this quote perfectly describes
what I’m about to show you, “You want science and studies? you. I’ve got scars and blood and vomit.”
At least 20 years ago, doctors and entomologists put in writing in medical literature that Brown
Recluse spider bites in the United States are overdiagnosed. There’s hundreds of those cases
being reported in California, and ya there’s lots of people in that state, and Loxosceles are there,
but reported from San Francisco? Didn’t we just say I-80 is in San Francisco? And if you live
I-80 and north Brown Recluse doesn’t live there? So if they they’re not endemic there, where did
the bite come from?
A staphylococcus infection causes necrotic skin wound. So does strep. So does Lyme
disease. So does fungus, and poison ivy, and vasculitis, and many others. Are we sure?
There’s recent case reports published in literature in 2021 saying that in Michigan,
due to the shift in climate, that brown recluse is there now. “Well maybe it wasn’t a spider bite.”
What’s a response you might get to that statement? “You want science and studies?
F you. I’ve got scars and blood and vomit.”
So we have our inputs of information here. Non-endemic area of spider,
for bites that appear to be overdiagnosed, patient had significant risk factors for other
dermonecrotic wounds, no spider was recovered and based on patient claim that an insect
bit her leg while she was sleeping outside. I’ll let you do more digging if you’d like.
There’s correspondence from 2005 in the New England Journal, talking about Brown
Recluse spider bites. Physicians based out in Connecticut, north of I-80,
saying that they’ve seen some brown recluse bites over several decades of practice.
And they were told in writing, those were not brown recluse bites.
Ok so in professional correspondence, this is only a small handful of what’s out there.
The main point is that if the spiders dont live in the area, the dermonecrotic wound you’re
seeing is likely not cutaneous loxoscelism, and you want to rule out other causes before
landing on just “spider bite” arachnidism because you could be wasting precious time on treatment.
This is the extreme case of “everything that looks like it, is a brown recluse spider bite”
Now, swing the pendulum to the other extreme. That nothing is ever a brown recluse bite. Well
that’s appeared in documentation, where a patient was thought to have a soft tissue infection,
community acquired methicillin resistant staph aureus, even had exploratory surgery,
but instead it turned out to be, systemic loxoscelism, and so the patient had a surgery that
they didnt need to have, and this happened in a place where brown recluse are endemic to the area.
None of this is “dunking” on my colleagues. This action and reaction sequence isn’t
unique. Patients do the arguing about spider bites too, it’s going to be prominent anywhere
where people can comment, especially given the frightening nature of spiders.
Alright main point of this and the Chubbyemu video, there’s 2 known venomous spiders in the
United States, the Brown recluse and the Black Widow. Their bites can cause systemic illness, although they're rare in both cases. The brown recluse lives here.
The black widow lives all across the lower 48 states. If you don’t
live in this area of the country, more likely than not, it’s not a brown recluse bite, if it’s even a
spider bite in the first place. If you don’t leave your clothes all over the floor like the patient in the Chubbyemu
video did, that may help prevent you putting on clothes that has a spider hiding in it.