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Brown recluse dapsone dosage.Spider Bites |
Brown recluse dapsone dosage. Dapsone treatment of a brown recluse bite
An estimatedspecies of spiders exist; 34, have been described. Both are capable of injecting venom into their victims. The spider injects its venom via hollow modified mouth parts called chelicerae that deliver the venom from modified salivary glands. At the end of their tails, scorpions have a hollow stinger connected to a poison gland that delivers venom when it pierces its victim with a very rapid forward thrust. According to Vetter and Visscher, 2 mechanisms located near the mouth such as chelicerae are primarily for food gathering — defense is a secondary function; mechanisms located in the rear of the animal stingers are considered primarily for defense but also are used in food gathering.
Print and television media horror stories have led to a marked exaggeration of the dangers and fear of spiders arachnophobia that exaggerate the real threat. The chelicerae of two types of spiders are large enough to penetrate skin and, although very rare, have resulted in deaths in infants and the elderly.
The black widow spider Latrodectus mactans produces a neurotoxin that causes systemic symptoms but no necrotic wound. The brown recluse spider is most prevalent and has the most potent venom. The lesion caused by the brown recluse spider follows a similar pattern as that caused by a Chilean brown spider Loxosceles laeta bite.
The brown recluse spider, including the legs, is about the size of a US quarter see Figure 1. The body is approximately 10 mm long and brownish, varying from a dull yellow to a tawny dark brown. The L. These spiders hibernate during the fall, winter, and early spring and become active in late March or early April.
The bites usually occur because clothing that has been hanging up or stored is donned without first shaking it out. Reaching into dark recesses is also a common source of injuries. The venom of the brown recluse spider is a complex substance. Various purification techniques have identified subcomponents, including proteases, alkaline phosphatase activity, lipase activity, sphingomyelinase-D, hyaluronidase activity, and others. The pathological sequence includes the aggregation of platelets, endothelial swelling, and destruction; these events plug capillaries with white cells, which, in turn, causes ischemia and necrosis.
Diagnosing a spider bite can be difficult. It may be days or weeks after the event before the patient is seen by a physician, usually without the spider. The clinical manifestations of the L. Bites of minimal envenomation result in wounds with lesser symptoms: slight erythema, localized urticaria, and discomfort that disappears in 3 to 5 days and requires little or no care. Slightly more venom increases the cutaneous reaction, although the bite might not be felt immediately.
A dull discomfort in the area may begin 4 to 6 hours after the bite. The area may be pale with a small blister in the center. Discomfort can be controlled with acetaminophen or ibuprofen. These wounds usually heal within 1 to 2 weeks with local wound care such as cleaning, topical applications, and a band aid.
A more significant wound may initially be perceived as a tiny pinprick or not at all. Six to 12 hours later the victim begins to develop pain. Two tiny puncture marks are visible and the area becomes erythematous. The center then forms a hemorrhagic bleb that grows to several centimeters depending on the host and the volume of venom.
The area under the bleb becomes necrotic, gradually expanding to 3 cm to 10 cm in diameter. In some fatty areas, the wound may be larger.
As the inflammatory advance slows, the gangrenous area desiccates and becomes an eschar. As the eschar matures, the body gradually sloughs the necrotic tissue and a granulation bed forms. Cicatrization and epithelialization take place and the wound may require 6 weeks to 4 months to heal. Frank devitalized tissue may be cautiously debrided. No marginal tissue or tissue of questionable viability should be removed. If a bioload is suspected, non-cytotoxic topical antimicrobials may be applied.
Routine principles for management of exudate and moist wound healing should be followed. The most severe envenomation results in a systemic reaction.
Speculation is that this might be due to a direct intracapillary injection of the venom at the time of the bite. Patients experiencing this type of reaction usually become very ill within 2 to 3 days.
The venom is a powerful hemolytic agent and can rapidly lyse red blood cells. Patients develop chills, joint pain, malaise, nausea, vomiting, punctate rash, and hemoglobinurea along with low-grade fever. One of the worst complications is disseminated intravascular coagulation. Generally, bites with severe systemic symptoms usually have fewer local wound problems. The wound should be cleaned and dressed; an ice pack should be applied. An IV should be started along with fluids by mouth to flush the kidneys in case of hemolysis.
Testing to determine a G6PD deficiency is necessary before prescribing Dapsone because the drug may cause hemolysis in these patients. Dapsone is dose-dependent and should be given with caution to patients with infections or diabetic ketosis capable of producing hemolysis. Patients with severe wounds should be admitted to the hospital; patients with systemic symptoms should be treated as an emergency. In addition to the treatment mentioned, patients should be blood-typed and have a Foley catheter for hourly checks on urine output.
Because of the usual significant hemolysis, adequate urine output must be maintained to prevent renal shutdown. Hemoglobin levels and platelet counts should be assessed every 4 hours for 24 hours. Efforts to provide serological confirmation of brown recluse envenomations and an antivenin against sphingomyelinase-D have been underway for more than 10 years. A recent study determined that venom specificity with an Enzyme-linked Immunosorbent Assay ELISA is possible and may eventually be available for clinical application in areas native to the Loxosceles species.
A passive hemagglutination test has been developed to aid in the diagnosis of brown recluse envenomation. This test is able to identify envenomation up to 2 weeks after the incident; however, results are not available for 6 to 24 hours, past the time to initiate treatment.
Additional concerns arise from the number of false-negative reports when the specimen contains bloody exudate. A number of different forms of therapy have been used over the years since the first case of the brown recluse spider bite was described in Neither of these techniques has been helpful except in cases of excessive hemolysis. In this instance, steroids should be administered systemically. Cold packs seem to slow the activity of sphyngomyelinase-D. Dapsone Alvosulfon, Jacobus Pharmaceuticals, Inc.
Dapsone has two absolute contraindications: a documented hypersensitivity reaction to the drug and the previously mentioned G6PD deficiency.
The primary risks are methemaglobinemia, agranulocytosis, and hypersensitivity reactions, although fatal reactions have been reported.
Antivenom is probably the best treatment for envenomation. If administered within the first 24 hours, it should significantly decrease the size of the lesions. However, antivenom is still not commercially available. Hyperbaric oxygen therapy has been used successfully in the management of necrotic wounds, but not in all cases. First, the hypoxic nature of nonhealing wounds suggests a strong relationship between healing and oxygen supply.
The second mechanism of action directly involves the venom, possibly inactivating its necrotizing component. Sphingomyelinase-D digests the intercellular matrix, allowing the venom to spread; hypothetically, hyperbaric oxygen therapy denatures the sphingomyelinase-D.
Controlled animal and human studies are still needed to conclusively demonstrate the efficacy of hyperbaric oxygen therapy. The absolute contraindications to hyperbaric therapy include chemotherapy, uncontrolled seizure disorders, a history of spontaneous pneumothorax, pregnancy, and anabuse. The average number of treatments is five; a series can range from two to 18 treatments. Hyperbaric oxygen therapy is recommended until the spread of the erythematous area stops. After this time, hyperbaric treatment is unnecessary unless indicated for wound healing, such as in the preservation of a skin graft.
B, a year-old Caucasian woman in excellent health, was bitten by a spider on the medial right thigh at am. The bite was not very painful so she dressed and attended school. As the day progressed, the pain gradually increased. By noon, the area of erythema was approximately 5 cm.
That afternoon she saw her local physician who provided no treatment. Throughout the evening, the pain — described as a burning scalding sensation — increased. She was unable to sleep and developed a fever of o F with shaking chills.
B saw her physician the next morning and was immediately referred to the Osteopathic Medical Center of Texas Hyperbaric Medicine Department. She brought in a carcass of a Loxosceles species, probably a reclusa. The patient appeared acutely ill. She had a fine macular rash extending over her trunk and extremities. On the medial aspect of her right thigh, a cm ecchymotic area was indurated and exquisitely tender see Figure 2. The patient noted a 3-mm shallow pit with very dark discoloration as the point of the bite.
Her initial laboratory values were normal with a hemoglobin of The patient was immediately cleared for hyperbaric oxygen therapy and treated at 2. On the second day, the patient developed tenderness along the superficial femoral vein and tender inguinal lymphadenopathy. Ultrasonography revealed no intraluminal clots and the symptoms gradually subsided. Her hemoglobin fell precipitously to 8. The antibiotic was held and vigorous hydration preserved renal function.
❿Brown recluse dapsone dosage -
Brown Recluse Spider Bites: A Complex Problem Wound. A Brief Review and Case Study.ID Q&A: Treating Spider Bites: Is Dapsone an Option? | Consultant
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Insect bites and stings are a relatively common occurrence with more than 50, exposures occurring per year in the United States. One of the most clinically significant spiders is the recluse spider, whose bite can progress to ulcerating dermonecrosis at the bite site. Brown recluse spiders are part of the genus Loxosceles. Recluse spiders are rarely aggressive and bites are uncommon.
Most bites occur when the spider gets pressed against the skin by clothing, towels, bedding or gloves. Bites most frequently occur at night and in the early morning during warmer months. Frequently, patients do not feel the recluse bite and it does not cause immediate pain. Brown recluse spiders have several toxins, the most clinically significant being the hemotoxic agent sphingomyelinase D.
Recluse spider bites can result in the clinical condition of loxoscelism, which is the only proven type of necrotic arachnidism in humans. A small number of bites produce dermonecrotic skin lesions and an even smaller number of bites produce systemic symptoms. A study by Leach and colleagues found that skin necrosis occurred in 37 percent of recluse spider bites and systemic illness occurred in 14 percent of cases.
In necrotic cutaneous loxoscelism, symptoms secondary to the recluse spider bite remain localized to the skin. Dermonecrotic skin lesions typically begin with pain and burning at the bite site that progress for two to eight hours after the initial bite occurred. Over the next 12 to 36 hours, symptoms progress with the bite area first becoming pale and the surrounding area becoming red and edematous.
The area then develops a bluish, hard, stellate center that becomes progressively more necrotic and eventually sloughs. In approximately 14 percent of cases, recluse bites result in a combination of local cutaneous and systemic symptoms known as viscerocutaneous loxoscelism.
In advanced cases, the recluse spider hemotoxin can cause destruction of red blood cells, resulting in hemolytic anemia. There are numerous infectious and non-infectious conditions that can produce necrotic wounds similar to the recluse spider bite and physicians misdiagnose an estimated 80 percent of recluse spider bites.
Despite being one of the most clinically significant spider bites, recluse spider bites have no established treatment protocols. The initial recommended treatments for recluse spider bites includes cleaning the bite site, cold compresses, elevation, immobilization, analgesics, antihistamines and tetanus prophylaxis. These treatments include antibiotics, glucocorticoids, hyperbaric oxygen, surgical intervention and nitroglycerin. Dapsone Aczone, Allergan has been in use for several decades in the treatment of recluse spider bites.
Physicians presumed that dapsone stopped dermonecrosis by inhibiting leukocyte migration, degranulation and cytokine release. Authors suspect that dapsone may be effective in treating recluse spider bites that physicians had misdiagnosed as infections. One may use both systemic and intralesional glucocorticoids to treat recluse spider bites.
Oral glucocorticoids may relieve many of the systemic symptoms that result from recluse spider bites, but intralesional injections have no benefit and can actually delay wound healing. Hyperbaric oxygen. Studies evaluating the effect of hyperbaric oxygen for the treatment of recluse spider have shown mixed treatment outcomes with some studies showing clinical benefits and other studies showing no effect Surgical intervention.
Studies have shown no clinical benefit and possible worse clinical outcomes with early surgical excision for the treatment of recluse spider bites. Nitroglycerin is a suggested treatment to counteract the vasoconstrictive effect of recluse spider bite venom, but animal studies show no benefit of nitroglycerin in decreasing necrosis and that nitroglycerin treatment can lead to increased inflammation and signs of systemic loxoscelism.
In conclusion, while recluse spider bites are relatively uncommon, they are clinically significant due to their potential to cause dermonecrosis at the bite site. While most recluse spider bites are minor and spontaneously resolve, they can lead to both necrotic cutaneous loxoscelism and viscerocutaneous loxoscelism. There are numerous infectious and noninfectious conditions that can produce necrotic wounds similar to the recluse spider bite.
Methicillin-resistant Staphylococcus aureus infection is one of the most common disorders misdiagnosed as a recluse spider bite. Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med. Vetter RS. Arachnids misidentified as brown recluse spiders by medical personnel and other authorities in North America.
An approach to spider bites. Erroneous attribution of dermonecrotic lesions to brown recluse or hobo spider bites in Canada. Can Fam Physician. Brown recluse spider bites to the head: three cases and a review. Ear Nose Throat J. Wasserman G, Anderson P. Loxoscelism and necrotic arachnidism.
J Toxicol Clin Toxicol. Rhabdomyolysis in presumed viscero-cutaneous loxoscelism: report of two cases. Vetter R, Bush S. The diagnosis of brown recluse spider bite is overused for dermonecrotic wounds of uncertain etiology. Ann Emerg Med. Dominguez TJ. J Am Board Fam Pract. Clinical presentation and outcome of brown recluse spider bite. The diagnosis and treatment of brown recluse spider bites.
Necrotic arachnidism. J Am Acad Dermatol. Comparison of colchicine, dapsone, triamcinolone, and diphenhydramine therapy for the treatment of brown recluse spider envenomation: a double-blind, controlled study in a rabbit model.
Arch Dermatol. The brown recluse spider bite: controlled evaluation of treatment using the white rabbit as an animal model. South Med J. The treatment of brown spider bite. Plast Reconstr Surg. Effect of hyperbaric oxygen on sphingomyelinase D activity of brown recluse spider Loxosceles reclusa venom as studied by 31P nuclear magnetic resonance spectroscopy.
Am J Trop Med Hyg. Brown recluse spider bites: beneficial effects of hyperbaric oxygen. J Hyperb Med. Svendsen FJ. Treatment of clinically diagnosed brown recluse spider bites with hyperbaric oxygen: a clinical observation.
J Ark Med Soc. Therapy of brown spider envenomation: a controlled trial of hyperbaric oxygen, dapsone, and cyproheptadine. Comparison of hyperbaric oxygen and dapsone therapy for Loxosceles envenomation.
Acad Emerg Med. Brown recluse spider bites. A comparison of early surgical excision versus dapsone and delayed surgical excision. Ann Surg. A controlled trial of topical nitroglycerin in a New Zealand white rabbit model of brown recluse spider envenomation. Learn More. Sign in.
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Q: Some studies suggest that orally administered dapsone is effective for infections caused by spider bites (eg, brown recluse spiders) in dosages of 4. Dapsone treatment of a brown recluse bite. Administration, Oral; Adult; Animals; Dapsone / administration & dosage; Dapsone / therapeutic use*. TREATMENT — For patients with ulceration or systemic complaints, the evidence supporting the use of Loxoscelism specific treatments (eg, dapsone. sumed eyelid brown recluse spider bite in which inflammation responded dramatically to treatment with oral Dapsone. Earlier treatment may. Dapsone treatment of brown recluse bite. JAMA. ; Wille RC, Morrow JD. Case report: Dapsone hypersensitivity syndrome associated with treatment. Related CE. Preventive measures are primarily aimed at putting physical barriers between the spider and a potential bite victim. Editorial Board. Bangasser R.These are the widow spiders Latrodectus and the recluse spiders Loxosceles. While these venomous exposures are rarely fatal, bites can often lead to extremely painful muscle spasms or even skin necrosis.
Nonpharmacologic and pharmacologic treatment options are available, including an antivenin for widow bites and opioids and benzodiazepines for symptom relief. Pharmacist involvement includes giving advice about prevention and treatment and providing appropriate patient counseling on prescribed or administered medications.
Spiders are found all around the world and are a great source of fear for many people, whether venomous or not. The United States has only two genera of spiders that are venomous enough to be considered medically relevant. Widow Spider: This spider, aptly named for the propensity of the female to eat the male after mating, is found worldwide, and five different species are present in the U.
This spider can often be identified by a characteristic red or orange hourglass mark on the ventral abdomen. Their bites usually result from a defensive action by the spider after it has been disturbed. Some differences between the male and female widow spiders include size and color.
Male widow spiders tend to be smaller and lighter in color than females. More important, it is the female widow spider that is venomous to humans; the male widow spider lacks the ability to envenomate humans. Recluse Spider: Thirteen different species of recluse spider are located in the U. Other species are less widespread and often are contained within one to several states.
The spiders in this genus are brown and contain no unique identifying features, with the exception of L reclusa , which has unique brown markings in the shape of a violin, fiddle, or cello on its dorsal thorax. Widow spider venom contains several different neurotoxins, known as latrotoxins , that act to impair or destroy nerve tissue.
Of particular note is that latrotoxins seem to target specific types of animals. For example, some latrotoxins exert their effects only on insects; another type affects only crustaceans; and yet another targets only vertebrates. For vertebrates, the selective latrotoxin in widow spider venom is alpha-latrotoxin, which exerts its effects by two different mechanisms.
Both mechanisms result in a sizable release of presynaptic neurotransmitters, including acetylcholine, dopamine, glutamate, and norepinephrine.
Recluse spider venom contains several toxic enzymes, the most damaging one being sphingomyelinase D. First, they can activate the complement system and the membrane attack complex by recruiting inflammatory cells to the site of the bite. The activation of the complement system from recluse spider venom induces dermonecrosis. Sphingomyelinase D also activates neutrophils, which can cause a breakdown of collagen fibers in the skin. There is an increase in the expression of gelatinase, which may lead to the development of skin breakdown.
A bite from a widow spider feels similar to a pinprick and may be moderately to severely painful. The initial bite of a recluse spider is often minimally painful or not painful at all.
Although bites from widows or recluses can be alarming and appear quite serious, they often resolve without causing serious injury or death.
Necrotic wounds caused by recluse bites take about 1 to 8 weeks to heal with proper wound care. Nonpharmacologic Therapies: Nonpharmacologic treatment options for widow spider bites are rather minimal. The first suggested treatment is to cleanse the wound at the site of the bite.
The next step is to apply an ice pack or other cold substance to the affected area to help reduce local pain and inflammation.
Nonpharmacologic treatment for recluse spider bites is similar to that for widow bites. The wound should first be cleansed to prevent infection. Then, a cold compress is applied to the affected area.
The bite site should be immobilized and elevated if the bite occurred on an extremity. Lastly, tetanus prophylaxis should be given in the form of a tetanus booster. Pharmacologic Therapies: Initial pharmacologic therapy for widow bites is aimed at relieving the associated muscle pain and cramping. Formerly, calcium gluconate was a first-line option to treat the symptoms associated with widow spider envenomation. However, reviews of widow spider exposure cases have shown that this treatment is not as effective as the use of IV benzodiazepines and opioids such as morphine mean dose 15 mg or meperidine mean dose 88 mg.
In the case of severe toxicity associated with widow spider envenomation, a Latrodectus antivenin is available. Indications for antivenin use include uncontrolled hypertension, seizures, and respiratory arrest following envenomation. The dosage for adults and children is the entire contents of the reconstituted vial, with administration either IM anterolateral thigh or via IV infusion in 10 to 50 mL of normal saline over a minute time span.
However, sometimes a second dose of antivenin may be necessary. Because the antivenin is made from horse serum, anaphylaxis precautions, such as the ready availability of a tourniquet and epinephrine, should be taken. The antivenin comes with a vial of horse serum to allow for sensitivity testing before administration.
Serum sickness has been reported up to 12 days after antivenin administration. Pharmacologic therapy for recluse bites is less clear owing to the scarcity of clinical trials on the subject. However, a randomized, controlled trial in rabbits, which display reactions similar to those of human beings, showed no additional benefit compared with the control group.
Wearing protective clothing such as gloves, long-sleeved shirts, and long pants tucked into socks when outdoors can help prevent widow bites. Applying insect repellent containing diethyltoluamide DEET to skin and clothing can provide extra protection. It is also a good idea to inspect and shake out gloves, shoes, or any other items that may come in contact with the body, in case widow spiders are residing in them. Since recluse bites commonly take place indoors, measures can be taken in the home to lessen the chance of an exposure.
First, the home should be adequately sealed to prevent spiders from entering. This includes adequate insulation and sealing around doors, windows, attics, and crawl spaces. Vacuuming under furniture and clearing spider webs with a broom or vacuum is also helpful.
Household insecticides may be used to kill and repel household spiders. Instead, the spider should be removed by a quick flick of the finger. Pharmacists who practice in areas where these types of spiders are found should become familiar with prevention and treatment recommendations.
Pharmacists can give advice about prevention and treatment and reassure patients that bites rarely result in serious injury. Pharmacists can also advise patients to check with their physicians as to the date of their last tetanus booster. Finally, if a patient is being treated after an exposure, pharmacists can provide appropriate counseling on prescribed or administered medications such as antihistamines e.
Despite being a source of fear for many people, the only clinically relevant spider bites in the U. While these bites are rarely fatal, both types contain venom that can lead to local and systemic effects. Widow spider venom acts on neurons to cause a sizable neurotransmitter release, resulting in powerful and painful muscle cramping.
Recluse spiders cause an increase in immune-system signaling, resulting in necrosis and ulceration of the skin. Early wound care, such as applying ice and cleansing the wound, can help relieve pain and prevent infection.
Pharmacologic therapy is aimed mainly at symptom relief. Oral and parenteral analgesics may be used to relieve severe pain, antihistamines may be used to relieve itching, and benzodiazepines may be used to relieve muscles spasms from widow bites. Currently, an antivenin is available for widow spider envenomation, but no such drug is approved for recluse spider envenomation.
Preventive measures are primarily aimed at putting physical barriers between the spider and a potential bite victim. Wearing long-sleeved clothing and clearing yard debris can help prevent widow bites, and properly insulating homes and sealing doors and windows can prevent household recluse spider bites. Chemical barriers such as insecticides and insect repellents containing DEET can also deter spider bites.
Ultimately, currently available prevention and treatment measures can render these potentially clinically significant spider bites insignificant. Juckett G. Anthropod bites. Am Fam Physician. Venomous spiders. Accessed June 10, First report of brown widow spider sightings in Peninsular Malaysia and notes on its global distribution.
The treatment of black widow spider envenomation with antivenin Latrodectus mactans : a case series. Perm J. Latrodectus envenomation in Greece. Gertsch WJ, Ennik F. Bull AMNH. Accessed June 26, Common spider bites. Diagnoses of brown recluse spider bites loxoscelism greatly outnumber actual verifications of the spider in four western American states.
The multiple actions of black widow spider toxins and their selective use in neurosecretion studies. Alpha-latrotoxin triggers transmitter release via direct insertion into the presynaptic plasma membrane. EMBO J. Sphingomyelinase D from Loxosceles laeta venom induces the expression of MMP7 in human keratinocytes: contribution to dermonecrosis.
PLoS One. Loxosceles sphingomyelinase induces complement-dependent dermonecrosis, neutrophil infiltration, and endogenous gelatinase expression. J Invest Dermatol. Cacy J, Mold JW. The clinical characteristics of brown recluse spider bites treated by family physicians: an OKPRN study. Oklahoma Physicians Research Network. J Fam Pract.
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