Case Presentation: A 17-year-old African American male with a past medical history of pulmonary embolism (PE) and morbid obesity presented to the hospital for right shoulder pain and dyspnea. On admission, his physical exam findings were most consistent with cellulitis, and he was started on IV vancomycin and PO clindamycin for MRSA and MSSA coverage while his blood cultures were pending. His D-dimer was 1182, ESR was 50, CRP was 18.9, hemoglobin was 12.4, and white blood cell count was 16.77. Further work-up was negative for PE and no soft tissue abscess or blood clot was found via ultrasound. On hospital day 3, his antibiotics were narrowed to PO bactrim and keflex after 48 hours of negative blood culture growth. However, after this change, a diffuse rash and a hemoglobin of 9.0 were apparent. This was thought to be an adverse drug reaction, but after changing his antibiotics to his original regimen, his status did not improve. Urinalysis was notable for urobilinogen, 3+ protein, and 3+ blood. Repeat lab work the following day showed a hemoglobin of 6.7, total bilirubin of 6.7, and the patient declined clinically. At this time, he was transferred to the PICU where he was diagnosed with systemic loxoscelism secondary to a brown recluse spider bite. Ultimately, the patient required five blood transfusions, IV cefepime and vancomycin, and was discharged on hospital day 13.
Discussion: This case demonstrates how easily brown recluse bites can be misdiagnosed and the rare complication that can occur. As such, close monitoring for the development of hemolytic anemia when brown recluse bites are suspected is of utmost importance. Given that there is no antivenom for Loxosceles reclusa bites, supportive care is the standard of care. This patient received supportive clinical treatment with aggressive IV resuscitation, transfusion of red blood cells, and systemic antibiotic therapy in hopes of preventing further decline or complications from infection of the bite itself. This patient’s case was complicated by a multitude of factors including a history of pulmonary emboli which may have served as a red herring when his d-dimer was elevated at presentation, morbid obesity which limited our ability to obtain additional imaging, and autism spectrum disorder which limited the patient’s ability to communicate. Another unforeseen complication was the difficulty of assessing the degree of erythema and induration at the site of the spider bite. This was due to the patient’s skin color and lack of images of brown recluse bites in patients of color (POC) for comparison. It is becoming increasingly apparent that medical literature and study aids do not use pictures of POC when giving examples of common dermatologic findings. In turn, this leads to delays in diagnosis and care.
Conclusions: This case demonstrates a rare instance of systemic loxoscelism secondary to a brown recluse spider bite initially misdiagnosed as cellulitis. In this case, urinalysis, CBC, and CMP were the studies used to confirm the presence of acute hemolytic anemia. Given that there is no antivenom for Loxosceles reclusa bites, supportive care is the standard of care. In the future, we hope this case study will prompt further investigation into antivenom as a treatment and development of a diagnostic test to confirm envenomation. Additionally, by documenting this case of a brown recluse bite complicated by loxoscelism in a POC, we aim to bring attention to the lack of representation of patients of color in medical literature.
