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Widow spider bites: Clinical manifestations and diagnosis

Widow spider bites: Clinical manifestations and diagnosis
Literature review current through: Jan 2024.
This topic last updated: Dec 15, 2023.

INTRODUCTION — This topic will review the biology of widow spiders (genus Latrodectus) and the clinical manifestations, diagnosis, and differential diagnosis, of their bites. Management of widow spider bites, an overview of spider bites, and the management of bites of other spiders are discussed separately. (See "Diagnostic approach to the patient with a suspected spider bite: An overview" and "Bites of recluse spiders".)

ARACHNOLOGY — Both widow spiders and false widow spiders are of medical importance, although the bites of the former are generally of greater concern.

Widow spiders (Genus Latrodectus) — Widow spiders belong to the family Theridiidae, genus Latrodectus. Latrodectism is the term for the medical manifestations of bites by widow spiders [1,2]. (See "Diagnostic approach to the patient with a suspected spider bite: An overview".)

There are approximately 30 species of widow spiders found worldwide [3]. Not all have been implicated in human bites, although this may be partly due to the remote distribution of the spiders away from human populations. Female widow spiders are responsible for most significant bites. Males have less venom, smaller fangs, and weaker biting muscles.

Identification — Most adult widow spiders are shiny black with red markings on the body, although this is not universal. American widow spiders range from 5 to 15 mm (0.25 to 0.5 inch) in total body length with an abdominal diameter of about 10 mm (0.5 inch). The most common species of medical importance are the following:

The American species has a red hourglass or anvil-shaped mark on the ventral portion of the abdomen, which can range from a perfect hourglass to two separated triangles, to one triangle and a barely perceptible lower red mark (picture 1 and picture 2).

The southern black widow has a red dot just dorsal to the anal region (picture 3).

The Mediterranean species has a smattering of 13 red dots on the dorsum of the abdomen but lacks ventral red markings.

The Australian redback is notable for a conspicuous dorsal red stripe running from the anal region forward to about halfway the distance of the abdomen (picture 4 and picture 5).

Other widow species may not be black. The brown widow has an orange hourglass and a series of white stripes on a tan abdomen, giving it a mottled appearance [4]. Other species in the eastern hemisphere are nearly white.

In addition to color variations among species, immature widow spiders often look very different from the adults (picture 6 and picture 7).

Geographic distribution — Widow spiders are found in warm climates worldwide but can exist in colder climates with routine winter snows, such as Colorado and in Canada (table 1).

In the United States, two species are most commonly implicated in envenomations: the southern black widow spider, L. mactans, and the western black widow spider, L. hesperus (picture 8).

The western black widow spider is very abundant throughout the southwestern United States where it is not uncommon to collect 60 or more an hour in supportive habitats. This species seems more tolerant of cold temperatures than eastern relatives as it is a common species in urban Colorado and in the dry interior region of Washington State.

There are three other widow species in the United States, which are of less concern: L. variolus in the northern Midwest, the red-legged widow L. bishopi, in palmetto habitats of Florida, and brown widows.

The brown widow, L. geometricus, is found in Florida and more recently, in the deep South from Texas to South Carolina and in coastal southern California [5]. Brown widow spiders are also found in many other parts of the world [6]. Their bite is usually mild with pain upon fang penetration and slight erythema at the bite site [7,8]. Rarely, severe pain, nausea, vomiting, hypertension, and fasciculations can occur [9-11].

The redback spider, L. hasselti, is found throughout Australia, except in the hottest deserts and coldest mountains and is the only widow species on that continent (picture 4 and picture 5). It also has become established in Japan in the Osaka Prefecture and has been reported in Europe and Dubai [12]. In New Zealand, L. katipo is typically only found very close (<1 km) to the coast in native habitat and is also being supplanted by a South African spider and colonies of the Australian redback spider [13].

In South America, L. curacaviensis is widespread and L. geometricus has also caused significant bites [10].

In the Mediterranean region, L. tredecimguttatus is the most common biting widow spider. Because the Mediterranean species is found in many countries, it is known by a colorful array of common names, some of which translate into "black hag" (region formerly known as Yugoslavia) and "black wolf" (Russia) [1].

Habitat — Widow spiders typically live outdoors in the clutter surrounding homes and garages, in woodpiles, in rarely used garden equipment, in pots, and in tools. It is rare to find a widow spider indoors unless there is significant insect traffic inside a structure. Bites typically occur as people place their hands into gardening gloves or feet into boots, or compress spiders under potted plants, patio furniture, or toys [14]. (See 'Epidemiology' below.)

Venom properties — Black widow venom contains excitatory neurotoxins of the latrotoxin type, including a vertebrate-specific toxin called alpha-latrotoxin, a large protein toxin (120 kDa) that triggers massive exocytosis from presynaptic nerve terminals and in a variety of neurosecretory cells [15,16]. Acetylcholine, norepinephrine, dopamine, glutamate, and enkephalin systems are all susceptible to the toxin [8,15,17-20]. It appears this toxin is present in the venom of all medically important widow spiders, and this has clear implications for cross reactivity of anti-Latrodectus antivenoms.

False black widow spiders (Genus Steatoda) — False black widow spiders are found around the world and have a bite that causes mild symptoms of latrodectism, sometimes called steatodism. Although their venom also contains a form of alpha-latrotoxin, it is molecularly distinct from that of black widow spiders and causes less serious effects [16].

Identification — Steatoda spiders are in the same family (Theridiidae) as the black widows and hence, share a similar body form and size (total length 5 to 15 mm [0.25 to 0.5 inch] and abdominal diameter of about 10 mm [0.5 inch]) which may cause confusion in identification (picture 9 and picture 10). They are typically chocolate brown to black in color and may have some tan stripes or markings on the abdomen. Unlike black widows, they do not have red markings on their bodies.

There are many species in the genus Steatoda. Most are too small to inflict a medically-important bite due to small fang size, low-venom gland content, or inability of musculature to cause fang penetration in human skin, or a combination of these traits.

Geographic distribution — False black widows are found in Europe, the United States, and Australia (table 1).

In North America, the false black widows are found commonly along the Pacific Coast from southern California through Washington State into British Columbia. In the United States, Steatoda grossa (picture 9) is the most frequent culprit in bites while Steatoda nobilis (picture 11 and picture 12) is the largest species [21].

In Europe, S. paykulliana is the most medical important species, although S. grossa and Steatoda nobilis also exist [1].

In Australia, S. grossa is the medically important species, widely distributed and common in urban environments.

Habitat — Like black widow spiders, false black widows are found in trash and clutter. In contrast to black widows, however, they are much more likely to be found inside homes. They do not appear to have the same high-food requirement as black widows and can thus survive indoors where insect traffic is greatly diminished. Steatoda spiders prefer places that are not disturbed and are often found under and within cupboards.

Consequences of misidentification and overreaction to invasive species — Due to the occasional red stripe on the dorsal abdomen, immature native North American black widows have been misidentified by non-arachnologists as the Australian redback, sparking a high level of concern [2,22]. This response is unwarranted because, although widow bites are unpleasant, symptoms are short-lived and unlikely to be fatal and, even if symptoms are serious, widow spider antivenom is effective across many Latrodectus species due to venom homology [23].

The discovery of the relatively benign Steatoda nobilis in Great Britain resulted in an excessive public health response consisting of school closures and fumigation (a short-term fix as spiders will quickly reinfest from elsewhere) [24]. This approach also likely raised unwarranted fear of spiders in affected students and their families. Dispersal of this spider species was presumed to be through shipping ports.

EPIDEMIOLOGY — Widow spiders and their webs are found outdoors in garages, trash piles, potted plants, trash cans, woodpiles, dry storage areas, outhouses (developing nations and rustic recreational areas), and outdoor furniture. (See 'Habitat' above.)

Common patterns of widow bites around the home include [2]:

Crushing of a spider when putting on gardening shoes, boots, or gloves that were kept in a garage or storage shed

Encountering a spider while gathering or chopping wood

Disturbing a spider while moving or sitting upon lawn furniture

Acquiring a bite while taking out the garbage or bagging trash

Widow spider bites may also occur during outdoor activities such as camping, hiking, orienteering, or rock climbing. In the natural environment, spiders may be found under stones or logs or in shrubs or trees [2]. Before indoor plumbing, many American and Australian bites by widow spiders occurred in outhouses. Victims were often men, and bites often occurred predominantly on the penis, scrotum, or buttocks [1,3]. This has become such common-place knowledge that it was enshrined in song in Australia ("There's a redback on the toilet seat"). However, with the advent of indoor plumbing, there was a shift in bite location from the central genitalia to the peripheral limbs, although outhouse encounters are still a potential problem for campers.

In Europe, widow bites were considered an occupational hazard of wheat farmers who compressed the spider against their bodies as they harvested the crop and by other out-of-doors workers, including farm laborers and greenhouse keepers [2,7]. Widow spider bites caused by Latrodectus tredecimguttatus still take place frequently among wheat farmers in Mediterranean agricultural regions.

In one large series of almost 24,000 widow spider bites reported to United States poison control centers over several years, widow spider bites most commonly occurred during summer or fall among young adult males [25]. Of approximately 10,000 spider bites that had follow-up information, there were no deaths, and the severity of clinical effects was as follows:

Minor effects (local wound without systemic symptoms indicating mild envenomation): 65 percent

Moderate effects (systemic symptoms requiring medical therapy consistent with moderate or severe envenomation): 34 percent

Major effects (life-threatening or causing residual disability): 1 percent

Of note, expert identification of the biting spider was not performed in most of these cases [26]. Thus, some of the bites causing minor effects may be caused by spiders other than widow spiders or may not be spider bites at all.

CLINICAL MANIFESTATIONS

Black widow spiders — Latrodectism is the medical term for the manifestations (both local and systemic) of bites by widow spiders [1,2,27].

History — Patients presenting with widow bites typically have a recent (<8 hours) history of an at-risk activity, such as gardening, chopping wood, using outdoor furniture, or cleaning out a garage. Approximately 75 percent of bites are on the extremities, particularly the lower extremities. Most bites are either initially asymptomatic or cause mild pain at the bite site [28]. The time of onset of more generalized symptoms is approximately 30 to 120 minutes from the time of the bite but may be longer on occasion.

Muscle pain is the most prominent feature in systemic reactions and can affect the extremity muscles, abdomen, and back. Severe abdominal pain with abdominal wall rigidity is characteristic. Abdominal pain from a widow bite has been mistaken for a variety of abdominal surgical emergencies, including appendicitis and acute cholecystitis [29]. (See 'Differential diagnosis' below.)

The pain is self-limited and typically resolves within 24 to 72 hours of the widow spider bite if no specific treatment is given. (See "Widow spider bites: Management", section on 'Efficacy'.)

Other symptoms may include tremor, weakness, shaking of the extremity, and local paresthesias. Patients may also report headaches, nausea, and vomiting [7,30].

In infants and young children, latrodectism may present nonspecifically as a distressed and inconsolable child who is refusing food and drink and has generalized erythema. A classic story would be of a newborn who develops the above clinical findings after being brought home and placed in a cot that had been stored in a garage. In such cases, a squashed widow spider may be found on searching the area in which the infant was lying or sleeping.

Physical findings — Findings of black widow spider bites include [7,28]:

Vital signs – Vital signs are normal in approximately 70 percent of patients. Tachycardia, tachypnea, and/or hypertension may arise from pain, anxiety, and/or venom effects.

Musculoskeletal examination – Intermittent muscle rigidity and tenderness either adjacent to the bite wound or involving the abdomen, chest, or back is described in up to 60 percent of cases. Patients with abdominal muscle rigidity usually have normal bowel sounds. Muscle tenderness may be accompanied by weakness, tremor, and myoclonus.

Neurologic – Symptoms and signs are predominantly autonomic.

Diaphoresis – Diaphoresis that corresponds to the affected muscle groups is a classic feature but is only reported in about 20 percent of patients. Diaphoresis may also be generalized or present at areas distant from the bite.

Wound site and local symptoms – The typical black widow bite consists of a blanched circular patch with a surrounding red perimeter and a central punctum (picture 13). This “target” lesion may be seen in up to 50 percent of cases. Some bites resemble a wheal and flare reaction. Local diaphoresis and lymphadenopathy may also be present [31]. Of note, black widow bites do not become necrotic and secondary infection with cellulitis or abscess is also rare.

Pediatric findings – In addition to the findings above, significantly envenomated children may also demonstrate [32]:

Infants and preschool children:

-Tachycardia

-Irritability or agitation

-Sialorrhea (most prominent sign in one small series)

-Diffuse erythema

-Facial swelling

-Muscle weakness

-Muscle tremors

-Paresthesias

-Nystagmus

-Tetany

-Seizures

Older children and adolescents:

-Paresthesias (most common symptom in one small series)

-Headache

-Anxiety

-Sialorrhea

-Localized pain (verbal patients)

Latrodectus facies ("facies latrodectismica")Latrodectus facies is a rare manifestation that consists of masseter trismus, grimacing, periorbital edema, lacrimation, and blepharospasm occurring several hours after a widow spider bite [33]. It has been described in both children and adults and associated with widow spider bites in North and Central America and in Europe. In one case, Latrodectus facies was misdiagnosed as an allergic reaction, which complicated therapy and led to premature withdrawal of analgesic medications [34]. Latrodectus facies is distinguished from anaphylaxis by typical findings of widow spider bite described above and the absence of oral edema, throat tightness, wheezing, and urticaria.

Other findings – Patients presenting more than 24 hours after latrodectism, irrespective of the bite location, can manifest burning pain in the soles of the feet, pain in the legs, below the knee, and profuse sweating below knees.

Rare findings include intestinal ileus, priapism, cardiomyopathy, pulmonary edema, and cardiovascular collapse [35-38]. Hematuria, Horner syndrome, compartment syndrome, rhabdomyolysis, and toxic epidermal necrolysis are additional findings that have been reported [39-42]. The few cases of latrodectism with documented rhabdomyolysis show a moderate but not large rise in serum creatine phosphokinase. Death is unusual, even in children, who are generally more affected by envenomations [43].

Laboratory abnormalities — Laboratory findings are non-specific and not necessary to make the diagnosis of latrodectism, especially in patients with mild envenomation. If obtained, initial abnormal laboratory studies at presentation most frequently include hematuria and elevations in white blood cell counts and serum concentrations of creatine phosphokinase, glucose, and/or liver enzymes [28].

Additional studies may be necessary to exclude other diagnoses such as appendicitis (eg, limited ultrasound or computed tomography of the abdomen with contrast) or myocardial infarction (eg, electrocardiogram, serum cardiac biomarkers, cardiac magnetic resonance imaging). (See 'Differential diagnosis' below.)

False black widow spiders — False black widow (Steatoda species) bites can cause symptoms that are similar but typically less severe than black widow bites. Reports of documented bites by Steatoda nobilis, particularly in Ireland and the United Kingdom provide a range of clinical features [44,45]:

History – The false black widow is found in trash and clutter and is much more likely to be found inside homes. In two series from Australia, Ireland, and Great Britain that included descriptions of almost 40 verified Steatoda bites, most bites occurred indoors, often while in bed or dressing [44,46], which is not typical of many Latrodectus spp bites. Bites occurred throughout the year.

Physical findings – Based upon case series from Australia, Ireland, and the United Kingdom, physical findings after bites include:

Local pain that can be excruciating but typically subsides in 24 to 48 hours [7,44-47]

Local reaction beginning as a papule with annular erythema; blistering and skin damage/ulceration at the bite site with radiating erythema [44], features not commonly associated with classic Latrodectus spp bites and more suggestive of secondary infection

Regional diaphoresis (uncommon) [44,47]

Systemic symptoms consisting of tremor, headache, nausea, lethargy, hypotension, and malaise (rare) [44,46]

Nearly all bites are painful, and pain may increase during the first hour [7,45,46]. In the Australian series, median duration of pain was six hours, and one-third of victims sought medical attention for systemic symptoms, including nausea, headache, lethargy, and malaise [46]. There was no associated diaphoresis in this series, though it was described in a S. nobilis bite in the United Kingdom, closely mimicking latrodectism [47].

DIAGNOSIS — A presumptive diagnosis of a widow spider bite is most often based upon the history and clinical presentation, especially in regions where these spiders are common. Significant widow spider envenomation often causes acute muscle pain and a target lesion. Local diaphoresis in the affected limb is also highly suggestive of a widow bite. If the bite is on the lower extremities, the muscular pain may extend to the abdomen; upper extremity pain may extend to the chest. (See 'Black widow spiders' above.)

False black widow (Steatoda) bites can have similar features but are not typically associated with diaphoresis or pain lasting longer than 24 hours. (See 'False black widow spiders' above.)

Of note, the diagnosis of a widow spider bite can only be considered definitive if both of the following criteria are fulfilled:

A spider was observed inflicting the bite.

The spider was recovered, collected, and properly identified by an expert arachnologist, entomologist, clinical toxinologist, or other person with appropriate expertise. Identification can frequently be made from a low-resolution picture. (See 'Additional resources' below.)

If both of the above criteria are not met, then other conditions must be considered and where appropriate, excluded. A surgical abdomen, myocardial infarction, or infections with rabies or tetanus may mimic systemic symptoms of a widow spider bite. The most common disorders that are mistaken for local reactions to spider bites include infections and the bites of other insects. Widow spider bites do not become necrotic and rarely become infected. (See "Diagnostic approach to the patient with a suspected spider bite: An overview", section on 'Differential diagnosis' and 'Differential diagnosis' below.)

However, these criteria for definitive diagnosis will only be fulfilled in a minority of cases and it is sometimes necessary to make a working diagnosis of latrodectism based on more limited criteria, such as the following:

Clinical features consistent with latrodectism and a history of a bite by an unseen or unidentified organism in a setting where widow spiders might occur.

The spider was seen, the description suggests a widow spider, and the patient has clinical features consistent with latrodectism.

In either case, progression to treatment for latrodectism is appropriate. (See "Widow spider bites: Management", section on 'Approach'.)

The general approach to the clinical diagnosis of a spider bite, as well as the differential diagnosis of a non-necrotic spider bite, is reviewed separately. (See "Diagnostic approach to the patient with a suspected spider bite: An overview".)

DIFFERENTIAL DIAGNOSIS — The painful muscle spasms of latrodectism may mimic a variety of other painful conditions.

Surgical abdomen — Abdominal muscle spasms and pain may be mistaken for a surgical abdomen, as mentioned previously [29]. Other signs and symptoms may help distinguish latrodectism from other entities. For example, patients with a surgical abdomen caused by peritonitis tend to be tired-appearing, tachycardic but with a normal or low blood pressure, and have constant pain. Patients with latrodectism are more likely to be hypertensive, hyperactive, and have intermittent muscle spasms. (See "Emergency evaluation of the child with acute abdominal pain".)

Myocardial ischemia or infarction — The severe pain of systemic latrodectism can cause severe chest pain, with hypertension, sweating and nausea that can simulate the clinical presentation of myocardial ischemia or infarction. Serial ECG and cardiac biomarkers adequately differentiate the etiology of chest pain (see "Diagnosis of acute myocardial infarction"). Latrodectism acute myocarditis has been reported but is extremely rare (four literature reports.) Cardiac magnetic resonance imaging can distinguish this from acute myocardial ischemia [48].

Rabies — Latrodectism may also be confused with rabies. Patients with rabies present with excessive motor activity, excitation, and agitation with seizures and a characteristic "fear of water" (hydrophobia) due to a painful, violent, involuntary contraction of pharyngeal and laryngeal muscles. In most cases of rabies, patients can report a definite bite or at least direct contact with an animal. (See "Clinical manifestations and diagnosis of rabies".)

Tetanus — Tetanus may mimic the muscle spasm associated with systemic latrodectism. Tetanus causes increased muscle tone and generalized spasms, particularly of the central muscles, and increased tone in the masseter muscle (trismus). Patients may have autonomic hyperactivity, presenting as irritability, restlessness, sweating, and tachycardia. In later phases of illness, profuse sweating, cardiac arrhythmias, labile hypertension or hypotension, and fever are often present. (See "Tetanus".)

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Envenomation by snakes, arthropods (spiders and scorpions), and marine animals".)

SUMMARY AND RECOMMENDATIONS

Arachnology – There are approximately 30 species of widow spiders worldwide (picture 1 and picture 2 and picture 3 and picture 4 and picture 5 and table 1). Steatoda spiders ("false" black widow spiders) are in the same family (Theridiidae) as the black widows and hence, share a similar body form which may cause confusion in identification (picture 9 and picture 10). (See 'Widow spiders (Genus Latrodectus)' above and 'False black widow spiders (Genus Steatoda)' above.)

Habitat – Widow spiders and their webs are found outdoors in garages, trash piles, potted plants, trash cans, woodpiles, dry storage areas, outhouses (developing nations), and outdoor furniture. Widow spider bites occur when the spiders or their webs are disturbed by human activity. The false black widow is more likely to be found inside homes. (See 'Epidemiology' above and 'False black widow spiders' above.)

Clinical manifestations

Black widow spiders (picture 1 and picture 2 and picture 3) – Patients presenting with black widow spider bites typically have a recent (<8 hours) history of some outdoor activity such as gardening, sitting in outdoor furniture, chopping wood, or cleaning out a garage. Approximately 75 percent of widow bites are on the extremities. (See 'Epidemiology' above and 'History' above.)

Muscle pain is the most prominent symptom. The time of onset is approximately 30 to 120 minutes from the time of the bite but may be longer on occasion. Pain is self-limited and typically resolves within 24 to 72 hours if no specific treatment is given. Other symptoms include muscle spasms, local paresthesias, headache, nausea, and vomiting. (See 'History' above.)

Latrodectism is the medical term for the manifestations (both local and systemic) of bites of widow spiders. The typical black widow bite is a mild lesion consisting of a blanched circular patch with a surrounding red perimeter and a central punctum (picture 13). Most bites are either asymptomatic or cause local pain. (See 'Epidemiology' above and 'Clinical manifestations' above.)

Moderate envenomation causes prominent muscle pain and localized diaphoresis in the affected limb. Pain may spread to the abdomen, chest, or back. With severe envenomations, tachypnea, diaphoresis, hypertension, nausea, and painful muscle spasms may be seen. In infants and young children, irritability and diffuse erythema have been described. (See 'Clinical manifestations' above.)

Steatoda species ("false" black widow spiders (picture 10 and picture 11)) – False black widow bites cause symptoms that are marked by local pain that can be severe with significant skin changes at the bite site; regional diaphoresis and systemic symptoms are described but appear to be less common and less severe than black widow spider bites. (See 'False black widow spiders' above.)

Diagnosis – A presumptive diagnosis of a widow spider bite is most often based upon the history and clinical presentation, especially in regions where these spiders are common. In most instances a working diagnosis is established by history and physical examination. However, the diagnosis of a widow spider bite can be considered definitive only if both of the following criteria are fulfilled (see 'Diagnosis' above):

A spider was observed inflicting the bite.

The spider was recovered, collected, and properly identified by an expert arachnologist, entomologist, clinical toxinologist or other person with appropriate expertise.

Differential diagnosis – A surgical abdomen, myocardial infarction, or infections with rabies or tetanus may mimic systemic symptoms of a widow spider bite. The most common disorders that are mistaken for local reactions to spider bites include infections and the bites of other insects. Widow spider bites do not become necrotic and rarely become infected. (See 'Differential diagnosis' above and "Diagnostic approach to the patient with a suspected spider bite: An overview", section on 'Differential diagnosis'.)

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Topic 88938 Version 22.0

References

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