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“I think something bit me.”. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases 4/16/08. CC: Arm pain.

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i think something bit me

“I think something bit me.”

Gretchen Shaughnessy, MD

Clinical Fellow

Dept of Infectious Diseases

4/16/08

cc arm pain
CC: Arm pain
  • 27 yo CM remote history of substance abuse presented to OSH with R arm swelling. 6 days PTA he had been helping his brother move a woodpile. After he carried the logs from one side of the yard to the other he noticed a sore spot on the inside of his right elbow.
  • He had seen spiders on the logs and recently killed some brown spiders in his house, so concluded he had been bit by a spider.
  • The sore spot became more swollen and red over the next few days. The area became more firm and tender then started to darken in color.
hpi cont
HPI (cont)
  • One day PTA the patient was seen at his primary care physician’s office for severe pain and swelling. He was prescribed levofloxacin and instructed to go to the ED if his symptoms got worse.
  • The patient went home from the doctor’s office planning to refill the prescription in the morning. That night at midnight he presented to his local ED for severe pain and redness in his arm.
  • He states his arm was “so swollen it felt like it was gonna pop open.” It was “so dark it looked like a hunk of meat.” He said the wound “smelled like rotting meat.”
hpi cont1
HPI (cont)
  • The ER MD called a surgical consult to assess for necrotizing fasciitis. The surgeons Recommended transfer to UNC. Called the UNC ID fellow and requested a transfer.
  • Per physician – redness was previously all below the elbow, since the patient had been in the ED (3 hours) it had extended superiorly towards his bicep.
hpi cont2
HPI (cont)
  • The patient was started on imipenum, clindamycin, and vancomycin and transported to UNC.
  • From departure of OSH to arrival at UNC ED the patient reports the redness has decreased. Prior marker line approximately 2cm from current errythematous border
slide6
PMH
  • Face and head trauma (2000) - the patient had been battered, experienced multiple facial lacerations but no LOC.
  • h/o Anxiety and depression - previously treated with lexapro
medications
Medications
  • Prior to hospitalization - None
  • Allergies - NKDA
history cont
History (cont)
  • Social History: tob 2 pacs a day for 10 years ETOH 2 drinks /week h/o cocaine, XTC, mj use in the distant past. The patient adamantly denies using any IV drugs recently, denies any HIV risk factors. His last HIV test was 2 years ago and was negative.
  • No pets
  • Lives near Fayetteville, NC
  • Family History: DM - uncles. HTN - father
physical exam
Physical Exam
  • 154/89 - 76 - 15 - 36.2
  • INAD, resting comfortably. EOMI, PERRLA, nonicteric
  • no e/e on OP. no JVDLymph Nodes no LAD appreciated in cervical, supraclavicular, or inguinal regions
  • RRR no murmurs CTAB no rash or lesions other than RUE
  • a&ox3, pleasant and cooperative
  • soft NT nabs, no HSM LUE and BLE have no c/c/e
  • RUE with approx 2cm area of dark discoloration, exquisite tenderness, and purulent drainage on the medial aspect of the R anticubital fossa. there is surrounding edema, minimal induration. The errythema is approximately 5cm receeded from the marker line labelled 4/11/04 0445am.
  • Neurological no focal defecits, sensation intact
operative report
Operative Report

a small cavity in the subcutaneous area of the antecubital fossa that did involve the defect into the fascia, but there was no deep collection of pus, dead muscle or deeper involvement. There was a small amount of necrotic skin and subcutaneous tissue, all of which was debrided away.

hospital course
Hospital Course
  • Diagnosed with streptococcus anginosus cellulitis with fascial defect s/p debriedment
  • Did well clinically, no further fevers, WBC remained normal. 4 days of IV therapy then d/ced on amoxicillin/clavulanate to follow up with ortho and ID
ddx of blackened eschar lesion
Cutaneous anthrax lesions

Brown recluse spider bite

Rickettsial pox

Cutaneous leishmaniasis

Varicella zoster

Herpes simplex

Staphylococcal or streptococcal cellulitis

Ecthyma gangrenosum

Ulceroglandular tularemia

Plague

Eczema

Typhus

Glanders

Rat-bite fever

Aspergillosis

Mucormycosis

Leprosy

Vaccinia

DDx of blackened eschar lesion
spider bite
Brown Recluse is often blamed for necrotic lesions

In North Carolina this is fairly unlikely

Literature looking at the falsely high incidence of “spider bites”

Spider Bite?

Brown Recluse photo: R. Bessin, University of Kentucky Entomology.

spider survey
Vetter et al. survey of a Kansas home using glue boards

Found 2055 confirmed Loxosceles reclusa from June-Nov 2001

No bites to family of four living in the home during that time

Spider Survey
brown recluse bite vs bacterial infection
Brown Recluse Bite vs Bacterial Infection

Images from University of Kentucky Dept of Entomology.

references
References
  • Uptodate.com 4/15/08
  • Mandell’s Principles and Practices of Infectious Disease, 5th Ed.
  • Majeski, J. Necrotizing fasciitis developing from a brown recluse spider bite. Am Surg 2001; 67:188.
  • Wright, SW, Wrenn, KD, Murray, L, et al. Clinical presentation and outcome of brown recluse spider bites. Ann Emerg Med 1997; 30:28.
  • Anderson, PC. Spider bites in the United States. Dermatol Clin 1997; 15:307.
  • Williams, ST, Khare, VK, Johnson, GA, et al. Severe intravascular hemolysis associated with brown recluse spider envenomation: A report of two cases and review of the literature. Am J Clin Pathol 1995; 104:463.
  • Vetter, R. Identifying and misidentifying the brown recluse spider. Dermatol Online J 1999; 5:7.
  • Vetter RS, Barger DK. An infestation of 2,055 brown recluse spiders (Araneae: Sicariidae) and no envenomations in a Kansas home: implications for bite diagnoses in non-endemic areas. J Med Entomol 2002; 39:948-951.
  • Vetter RS, Cushing PE, Crawford RL, Royce LA. Diagnoses of brown recluse spider bites (loxoscelism) greatly outnumber actual verifications of the spider in four western American states. Toxicon 2003; 42:413-418.