Clinical Practice Review

Brown recluse spider (Loxosceles reclusa)

envenomation in small animals
Lonny B. Pace, DVM and Richard S. Vetter, MS
Abstract
Objective To provide a comprehensive review of relevant literature regarding the brown recluse spider
(BRS) and to dene those criteria that must be satised before making a diagnosis of brown recluse
envenomation.
Etiology The complex venom of the BRS contains sphingomyelinase D, which is capable of producing all the
clinical signs in the human and some animal models.
Diagnosis There is no current commercially available test. In humans there are many proposed guidelines to
achieve a denitive diagnosis; however, there are no established guidelines for veterinary patients.
Therapy Currently, no consensus exists for treatment of BRS envenomation other than supportive care,
which includes rest, thorough cleaning of the site, ice, compression, and elevation.
Prognosis Prognosis varies based on severity of clinical signs and response to supportive care.
(J Vet Emerg Crit Care 2009; 19(4): 329336) doi: 10.1111/j.1476-4431.2009.00440.x
Keywords: dermonecrotic, Loxosceles, matrix metalloproteinases, sphingomyelinase D
Introduction
Brown recluse spiders (BRS), Loxosceles reclusa, are con-
sidered, in human and veterinary medicine, to be one of
the most clinically important spiders in North America.
In spite of their importance, there is a paucity of vet-
erinary literature addressing arachnid-companion ani-
mal BRS envenomation (BRSE). Almost all available
recommendations regarding the effects of BRSE in
companion animals is extrapolated from bite manifes-
tations in humans. In 1872, Caveness became the rst
clinician to report specic symptoms following an as-
sumed brown recluse spider bite (BRSB) in a human. In
1928, Schmaus was the rst to report symptoms fol-
lowing a documented BRSB and Macchiavello, in 1937,
reported that dermonecrotic lesions were associated
with the South American species, Loxosceles laeta. In
1957, Atkins and colleagues
1
denitively identied BRS
venom as a potential source of necrotic lesions. A de-
nitive diagnosis is difcult to obtain and clinicians
must base their diagnosis on multiple criteria including
geography, clinical signs, and preferably, authoritative
identication of the spider. While Loxosceles spiders are
distributed throughout the world, the endemic range of
the BRS is limited, even within the United States.
1
The
biology, natural history, and distribution of Loxosceles
spiders are poorly documented. Unfortunately, numer-
ous clinical cases are based on presumptive bites that
lead to misconceptions and misdiagnoses.
2,3
BRS
venom is highly complex with only some of the com-
ponents described in the literature. Still, the manifes-
tations of envenomation are highly variable and are
intimately linked with the bodys immune response.
Clinical signs range from minor local irritations to
death.
1,47
Diagnosis of BSRE remains problematic be-
cause there is no specic laboratory test to facilitate
diagnosis and histopathology is nonspecic.
1
The ab-
sence of a broadly accepted treatment protocol in hu-
man literature adds confusion,
812
so caution must be
exercised when extrapolating from human data.
The Spider
Range
Loxosceles spiders are indigenous in the temperate re-
gions of the Americas, Africa, and Europe. Of the ap-
proximately 100 species, over 80% are found in the
Americas. Within the United States there are 11 indig-
The authors have declared no conicts.
Address correspondence and reprint requests to
Dr. Lonny B. Pace, Central California Veterinary Specialty Center, Fresno,
CA 93710, USA.
Email: mokis_dvm@yahoo.com
From the Central California Veterinary Specialty Center, Fresno, CA 93710
(Pace); the Department of Entomology, University of California, Riverside,
CA 92521 and Biology Division, San Bernardino County Museum, Red-
lands, CA, 92373 (Vetter).
Journal of Veterinary Emergency and Critical Care 19(4) 2009, pp 329336
doi:10.1111/j.1476-4431.2009.00440.x
& Veterinary Emergency and Critical Care Society 2009 329
enous and 2 nonindigenous species.
8
Many species
exist in areas devoid of human populations or are ex-
tremely rare, with few documented specimens.
13
The
distribution of the BRS in the United States is primarily
Midwestern (see Figure 1). Other species dwell in the
sparsely inhabited deserts from southeastern California
through Texas.
13,14
Despite the well-established range
of Loxosceles spiders, medical professionals continue to
diagnose BRSE in areas not endemic to the spider. In 1
study, medical professionals reported 216 BRSE within
41 months in Colorado, Washington, California, and
Oregon; however, only 35 veried BRS, or Mediterra-
nean brown spiders, have ever been found in these
states.
15
In a separate 6 year study, medical personnel
from 3 Florida poison control centers reported 124
BRSB; however, in the past 100 years there have been
only 11 Florida sites, where Loxosceles spiders have been
identied by arachnologists and most of these were
single specimen reports.
16
In 2004, South Carolina phy-
sicians diagnosed 738 BRSE despite the fact that only 44
BRS had been veried in 6 locations since 1953.
17
Skep-
tics argue that interstate transplantation of the spider
could occur during household relocations and may ac-
count for bites out of the reported range. However, the
sheer number of people moving and goods being
shipped between endemic and nonendemic areas is not
proportional to the very small number of BRS found
outside of the range. The BRS has not shown the ability
to readily expand its range.
The heightened awareness of BRS outside of their
range also exists for the general public. In a 4.5 year
study, identifying any creature suspected to be a Lox-
osceles spider, 1773 arachnids were submitted to the
University of California Riverside from 49 states.
13
Of
these, 324 BRS were submitted, with only 2 nds em-
anating from outside the reported range. Of the many
patients from nonendemic Loxosceles areas, who were
diagnosed with a BRSE and subsequently submitted a
spider for identication, not one was a recluse. One
Texas medical school was using non-Loxosceles spiders
(Kukulcania hibernalis, Psilochorus sp.) as teaching spec-
imens of BRS for their medical students. Pest control
personnel, county health ofcials, and a veterinarian
also made misidentications.
13
Identication
The mature BRS is 813 mm in body length, with legs
measuring 2030 mm. They tend to be brown, but
shades may vary from light or yellow-brown to gray-
brown. The BRS has a characteristic violin shape on its
dorsal cephalothorax, which may not be evident in im-
mature spiders. Instead of the usual 8 eyes found in
most spiders, Loxosceles spiders have 6 eyes arranged in
pairs called dyads positioned on both lateral aspects
and anteriorally
8,12
(see Figure 2). As a way of identi-
fying a Loxosceles spider, the eye pattern is far more
diagnostic and less readily misinterpreted than the vi-
olin pattern. The spiders fangs open in a side-to-side
manner placing them in the suborder, Araneomorphae.
This distinguishes them from tarantulas and Australian
funnel web spiders, which have parallel fangs. Their
legs are long in comparison with their body and have
ne recumbent hairs.
Natural history
The BRS is found either indoors or out and true to its
name, is usually reclusive by nature preferring dark
Figure1: Map of the distribution of the most widespread Lox-
osceles spiders in North America. Recluse spiders will be com-
mon and frequently encountered in the middle of their range
but will dissipate toward the margins as the populations
diminish to nonexistence.
Figure2: Brown recluse spider, Loxosceles reclusa. Although the
violin mark is conspicuous in this spider, it is not as well
demarcated in other species or immatures. The 6-eye pattern
is more diagnostic for identication.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00440.x 330
L.B. Pace & R.S. Vetter
areas. In nature, it prefers to remain beneath rocks and
under tree bark. However, Loxosceles spiders easily co-
habitate within human domiciles, being commonly
found under clothes piles, bedding, in or under boxes,
in cellars, and any other undisturbed areas. The BRS is
reluctant to bite and given its shy nature, human en-
venomation rarely occurs. In a 6-month period, 2055
BRS were found in 1 Kansas home. Despite this infes-
tation, none of the occupants reported a bite
18
during
the study or in the 5.5 years prior, although, in the 11th
year of home occupancy, the rst known bite did occur
in this highly infested house.
19
The spiders are more
active in the warmer months but can withstand tem-
peratures from 8431C.
1,20
BRSs are nocturnal, hunting
spiders, are not prolic web spinners but do produce a
cottony, irregular-shaped web as a retreat. They do not
use webs to capture prey although the web may
alert a spider to the presence of a temporarily entan-
gled insect that they attack quickly then retreat until the
venom paralyses the creature. They can live for 612
months without food and water.
19
In the laboratory
setting these spiders have lived 1755 days, with
the average female living 627 days. Newly emerged
spiderlings of Loxosceles intermedia lack the poten-
tially dangerous venom components, which are not
detectable until the third-instar spiderling (ie, an instar
is the growth period between 2 successive molts in
arthropods).
12
Venom
Loxosceles spider venom is a complex mixture of com-
ponents creating literally a constellation of different
clinical signs ranging from local to systemic. At least 8
subcomponents have been found within the venom
including the 35 kDa protein sphingomyelinase D
(SMase D), hyaluronidase, alkaline phosphatase, col-
lagenase, esterase, ribonuclease, deoxyribonuclease,
and several different proteases.
3,4
The complex venom
is remarkable when considering the amount of venom
injected compared with the severity of the clinical
signs. The average amount of venom injected by
the Eastern diamondback rattlesnake is 200850 mg
21
compared with Loxosceles envenomation of 3065 mg of
protein.
7,12
There are 4 major phospholipids in the mammalian
cell membrane including sphingomyelin, which is
mostly found in the membranes outer leaflet. Phospho-
lipases like SMase D are common components of an-
imal venoms. In the animal kingdom, SMase D is found
only in Loxosceles spiders and close taxonomic relatives
of the genus Sicarius (found in African and South
America).
22
The only other known source of SMase D
is an exotoxin from certain Corynebacterium spp, and
Arcanobacterium hemolyticum.
22
A full understanding on how 30 mg of venom can
cause extensive local tissue injury and sometimes de-
velop into life-threatening systemic disease is the sub-
ject of active research. SMase D is capable of inducing
all the clinical signs of whole venom.
23
It will activate
endogenous matrix metalloproteinases (MMPs), cleav-
ing sphingomyelin into its 2 components, ceramide-
1-phosphate and choline and catalyzing the release of
choline from albumin-bound lysophosphatidylcholine
in the presence of Mg
21
.
24
The hydrolysis of albumin-
bound lysophosphatidylcholine creates lysophosphati-
dic acid and choline. Lysophosphatidic acid stimulates
platelet aggregation, causing endothelial hyperperme-
ability, and is strongly proinammatory.
24
Loxosceles spider venom activates certain MMPs. Ac-
tivation of these endopeptidases is suspected to be one
source of the massive neutrophilic inltration seen in
envenomation and likely has other roles in the wound
propagation. SMase D changes and cleaves proteins on
the surface of the erythrocyte, activating both classic
and alternative complement cascades. This leads to the
formation of the membrane attack complex and subse-
quent cellular lysis. SMase D is capable of antagonizing
activation of protein C, potentially creating a pro-
coagulatory state.
25
Induction of complement, activation of MMPs, alter-
ation of transmembrane proteins, preventing activation
of protein C, and apoptosis appear to be involved in the
propagation of the profound immune response leading
to dermonecrosis.
22,23,2630
The female spider has a
higher biological activity suggesting its venom is more
toxic and likely accounting for some of the variability
between bites.
31
The variability of responses to BRSE in
veterinary medicine
Research involving BRSE in companion animals is al-
most nonexistent. Veterinary literature extrapolates
data from the human literature without evidence that
dogs and cats will follow the human model. There is
tremendous variability to spider envenomation among
mammalian species,
9,3234
hence, extrapolation could
lead to grievous errors. As an example of the extremes
that can manifest in mammals in response to a spider
bite, an Australian report retrospectively documented
bites from theraphosid spiders (ie, tarantulas) on hu-
mans and dogs over 23 years. The 9 human victims
suffered mild effects, including pain and puncture
marks, while all 7 dogs died. Two of the dogs were in
the human weight range (4050 kg) and in 2 cases,
the same spider envenomated both the human and
the dog with widely dichotomous outcome for the bite
victims.
33
Similarly, Loxosceles venom also produces
differential mammalian toxicity. Rats and mice do not
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00440.x 331
Brown recluse spider envenomation
develop dermonecrotic lesions from Loxosceles spider
venom while guinea pigs and rabbits do, although
there appears to be variability between studies.
6,8
BRS
venom will lyse erythrocytes of humans and pigs, but
not those of dogs, rats, or guinea pigs.
10,11
The in vivo
effects of BRS venom on 9 dogs demonstrated that fol-
lowing intravenous injection, all animals developed
poor feeding, dehydration, and apathy with 2 pro-
gressing to jaundice and bleeding manifestations after
24 hours. A striking reticulocytopenia was noted in all
patients within 2 hours of injection along with in-
creased hemoglobin, and corresponding decreases in
hematocrit suggesting red cell lysis and corresponding
elevation of free hemoglobin. Coombs test and liver
function tests were all negative with the exception of
transient indirect bilirubinemia in the 2 severely af-
fected animals. All dogs recovered fully within 72120
hours.
11
It is difcult to extrapolate too much informa-
tion from this study as envenomations are usually in-
tradermal not intravenous. A Chilean study
34
rated
susceptibility based on weight/dose relationships in
several different animals to L. laeta venom. Rabbits,
mice, guinea pigs, and dogs were rated as high sus-
ceptibility; hamsters, pigeons, chickens, and toads had
moderate susceptibility; frogs were low; and rats and
sh exhibited no response to the venom. Dogs (n 52)
succumbed to the venom after the contents of 417
venom glands (8.5 spiders cumulative venom) were
injected intradermally while dogs (n 54) injected with
115 glands survived with no effects. Intradermal in-
jections of 0.753 venom glands/kg in these dogs
caused only small local lesions while similar injections
in rabbits reproduced the same dermonecrotic lesion as
seen in humans.
34
However, even with rabbits, there is
a different response compared with humans in that
rabbits heal more quickly and do not develop chronic
ulceration.
35
Clinical Implications of the BRSB
Clinical signs
Because of the paucity of primary research performed
on Loxosceles venom in companion animals, the
descriptions of clinical signs are based primarily on
the human response to BRSE. In humans, the hallmark
lesion produced by the BRS is a dermonecrotic skin
lesion, although there is a great range of venom man-
ifestation. There are 3 categories of clinical signs in
loxoscelism.
31,3638
The rst clinical category incorpo-
rates the majority of all bites and is characterized by no
clinical signs or local irritation. The bite is usually not
felt by the victim or is described as a small pinch.
39
Necrotic arachnidism, gangrenous arachnidism, or
cutaneous loxoscelism are used to describe the second
category of clinical signs.
1,5,36,37
These occur in approx-
imately 4% of the cases
12
and mild to severe pain may
be encountered 28 hours post-envenomation. Tran-
sient pruritis and erythema may be noted initially, fol-
lowed at 1224 hours by a vesicle surrounded by
ischemic tissue often called a bulls-eye or red, white,
and blue lesion. During the subsequent 2448 hours,
the wound may progress to a necrotic lesion of dark
blue or violet. At 37 days an eschar may form and the
following week the area will become indurated. The
eschar will subsequently fall off exposing an ulcer that
may take up to 68 weeks to heal.
4,12
The third category
is progression to systemic disease or viscerocutaneous
loxoscelism
31
and is extremely rare, occurring in o1%
of all BRSE cases
12,39
that progressed to the second cat-
egory. Children are the most susceptible to systemic
loxoscelism.
39,40
Mild systemic effects include fever,
malaise, pruritis, exanthema, nausea, and vomiting.
3
Prolonged coagulation times (depletion of FVIII, FIX,
FXI, and FXII), thrombocytopenia, hemoglobinuria,
proteinuria, intravascular hemolysis, and renal failure
are all manifestations of systemic loxoscelism.
25,37,41
Anemia, leukocytosis, elevated liver, and renal
values are not uncommon ndings with the most se-
vere envenomations progressing to shock, pulmonary
edema, renal failure, and death.
1,42,43
One report doc-
uments 8 deaths from 1983 to 2004. However, in all
cases the BRSE was presumed, with no denitive
diagnosis.
1
Diagnostic testing
Diagnosing the envenomation of BRS or other Loxosceles
species is difcult and has presented veterinarians and
physicians with serious challenges. The lack of a de-
nitive test has led to the rampant over-diagnosis of
loxoscelism and subsequent inappropriate treatment.
The inability to properly diagnose BRSE has led some
to suggest reporting standards for the diagnosis of lox-
oscelism. The following are suggested criteria for
grouping envenomations in the human patient. For a
case to be classied as a proven envenomation, the
spider must be recovered immediately and in close
proximity to the clinical reaction on the skin. It also
must be identied by an experienced entomologist or
arachnologist. The specimen must be kept and com-
plete records of case details, including follow-up and
resolution, should be maintained. To be classied as
probable envenomation, one must nd a veried Lox-
osceles spider in the immediate vicinity, must be in a
region where loxoscelism is medically known to occur,
and the lesion must be wholly typical of the spider bite
as dened by clinical experts. Possible envenomations
must show a lesion typical of loxoscelism and must
occur in an area considered endemic to the species.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00440.x 332
L.B. Pace & R.S. Vetter
Focal necrosis of the skin is suggested as a diagnostic
category when the region has no or few Loxosceles spi-
ders, proven loxoscelism is uncommon and no Lox-
osceles spiders are recovered in the immediate vicinity
of the patient.
Recommended laboratory tests for suspected lox-
oscelism include baseline hemoglobin, hematocrit, and
platelet counts as well as urinalysis for hemoglobinuria,
hematuria, or proteinuria. Other testing recommended
in higher risk patients should include full serum chem-
istries, including liver and renal screening, and lactate
dehydrogenase. Full coagulation testing including pro-
thrombin time, partial thromboplastin time, bleeding
time, brinogen, and D-dimers are indicated if systemic
disease is suspected.
4,41
Biopsies are currently not rec-
ommended in human patients due to risk of scarring
and lack of microscopic ndings exclusive to lox-
oscelism. Histopathologic ndings from rabbits injected
with the venom are nonspecic. Early stages include
edema, hemorrhage, degeneration of blood vessel
walls, plasma exudation, thrombosis, neutrophil accu-
mulation, and intensive diapedesis.
1,12,44,45
As the dis-
ease progresses, the major changes noted are massive
neutrophil inltration into the tissues, hemorrhage, and
subsequent myonecrosis.
12,4446
At the time of writing there are no commercially
available tests for loxoscelism. A passive hemagglutinin
inhibition test exhibited 90% specicity for diagnosing
venom in guinea pigs 3 days after envenomation.
47
An
ELISA has shown the ability to detect venom in wound
aspirates, hair follicles, and punch biopsies in rabbits 7
days post-envenomation.
47
Cross-reactivity to other
North American arthropod venoms was observed
when higher venom amounts were assayed.
4750
In
2006, Missouri physicians diagnosed a BRSE by prop-
erly identifying the offending spider and submitting a
swab sample for ELISA in which 34.4 pg of Loxosceles
venom was recovered.
50
Securing an accurate diagnosis
is vital for properly treating the patient because large
numbers of disease processes produce dermonecrotic
lesions. If inaccurately diagnosed as loxoscelism, severe
consequences can result. There are at least 50 differen-
tial diagnoses in the human patient (see Table 1). Lyme
disease, cutaneous anthrax, chemical burns, and bacte-
rial infections have all been initially misdiagnosed as
BRSE in the human patient.
1,8,14,39,51
Treatment
Currently, no consensus exists for treatment of BRSE
other than supportive care, which includes rest, thor-
ough cleaning of the site, ice, compression, and eleva-
tion. Most treatment protocols attempt to attenuate the
dramatic inux of neutrophils, activation of comple-
ment, and subsequent tissue destruction. Steroids,
dapsone, antihistamines, colchicine, surgical excision,
vasodilators, hyperbaric oxygen, antibiotics, anticoag-
ulants, shock therapy, topical nitroglycerine, high doses
of vitamin C, and meat tenderizer have all been pro-
posed. To date, none of these have been consistently
effective and in some cases have proven to be
Table1: A list of medical conditions that have been or could be
misdiagnosed as loxoscelism
Infections
Atypical mycobacteria
Streptococcus
Staphylococcus (especially MRSA)
Lyme borreliosis
Cutaneous anthrax
Syphilis
Gonococcemia
Ricketsial disease
Tularemia
Deep Fungal
Sporotrichosis
Aspergillosis
Cryptococcosis
Ecthyma gangrenosum (Pseudomonas aeruginosa)
Parasitic (Leishmaniasis)
Viral (herpes simplex, herpes zoster [shingles])
Vascular occlusive or venous disease
Antiphospholipid-antibody syndrome
Livedoid vasculopathy
Small-vessel occlusive arterial disease
Venous statis ulcer
Necrotising vasculitis
Leukocytoclastic vaculitis
Polyarteritis nodosa
Takayasus arteritis
Wegeners granulomatosis
Neoplastic disease
Leukemia cutis
Lymphoma (eg, mycosis fungoides)
Primary skin neoplasms (basal cell carcinoma, malignant melanoma,
squamous cell
carcinoma)
Lymphomatoid papulosis
Topical and exogenous causes
Burns (chemical, thermal)
Toxic plant dermatitis (poison ivy, poison oak)
Factitious injury (ie, self-induced)
Pressure ulcers (ie, bed sores)
Other arthropod bites
Radiotherapy
Other conditions
Calcic uremic arteriolopathy
Cryoglobulinemia
Diabetic ulcer
Langerhans-cell histiocytosis
Pemphigus vegetans
Pyoderma gangrenosum
Septic embolism
Adapted from Swanson MD, Vetter RS. N Engl J Med 2005;352:700707.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00440.x 333
Brown recluse spider envenomation
detrimental.
1,8,46,5153
Surgical excision, once widely re-
commended, has also fallen out of favor.
8,46
Treatment
of secondary manifestations such as demonstrated co-
agulopathies or bacterial infections should be consid-
ered when appropriate.
Dapsone
The use of dapsone is controversial due to mixed re-
ports of efcacy but has been recommended as a po-
tential therapy for the small animal veterinary patient
by one author.
4,8,20,37,39,40
Dapsone or diamino-diphenyl
sulphone is an antimycobacterial used for the treatment
of leprosy in both humans and felines as well as an
alternative treatment for pemphigus in the small ani-
mal veterinary patient.
54
It inhibits inux of neutro-
phils; however, adverse effects of dapsone can be severe
and are similar to BRSE. Reported adverse effects in-
clude hepatotoxicity, anemia, thrombocytopenia, neu-
tropenias, gastrointestinal signs, neuropathies, and
cutaneous drug eruptions in the small animal veteri-
nary patient.
55
In humans who are decient in glucose-
6-dehydrogenase, the hemolytic adverse effects can be
catastrophic.
8
Dapsone is ineffective if not given within
hours of a bite.
46,51,52
Because of severe adverse effects
and lack of conclusive evidence, its administration is
not recommended.
1,8,12,36,52
Antivenin
Specic antivenin has shown some success in animal
studies when given within 1 hour of envenomation.
Antigen binding fragments specic for anti-Loxosceles
attenuate the lesion if given within 4 hours of the
bite.
5,56
In Brazil, loxoscelism is commonly diagnosed
and treated with antivenins. The efcacy of antivenins
in human retrospective studies suggests that a benet
may exist but there is no empirical evidence to support
this.
5,20,35
Tetracyclines
Tetracycline protects against dermonecrosis in rabbits
when topically applied as a lanolin cream but not when
injected.
57
Doxycycline was less effective than tetracy-
cline but was still capable of preventing an increase in
size of the lesion and oral administration of both tet-
racycline or doxycycline was much less effective pos-
sibly due to the level of concentration achieved.
57
Tetracyclines have the ability to inhibit protein synthe-
sis by binding the bacterial ribosomal subunit 30S, but
they also have the ability to bind metal ions including
calcium (Ca
21
) and zinc (Zn
21
). MMPs are a major
group of enzymes regulating cell-matrix composition
and are integral in normal and pathological processes
including wound healing, inammation, neovasculari-
zation, neoplasia, and embryogenesis. SMase D, the
major component of Loxosceles venom, binds to the cell
surface and activates MMPs including MMP-9, which
plays a crucial role in diapedesis of neutrophils, lym-
phocytes, and eosinophils. Ca
21
and Zn
21
ions are re-
quired to maintain the correct conformation and
hydrolytic activity of MMPs. In vivo studies report
topical treatment with tetracycline considerably de-
creases MMP-2 and MMP-9 activity presumably by
binding the metal ion.
Conclusion
While the BRS is commonly associated with dermone-
crotic lesions in the small animal veterinary patient, a
diagnosis of BRSE should be made with extreme cau-
tion. These authors were unable to nd any clinical re-
search to support the belief that dermonecrotic lesions
occur in canine or feline patients. In fact, only 2 in vivo
studies were found that evaluated the effects of BRS
venom in dogs.
11,34
No similar studies using cats as
subjects were found. Detection of venom from a hair
shaft or from a properly prepared swab appears to have
promise, but at the time of publication, these tests were
not commercially available. Until the ELISA becomes
commercially available, adhering strictly to the criteria
for a documented bite, as proposed in the human lit-
erature, appears to be the most prudent course. Misdi-
agnosis of wounds leads to poor patient care and
proliferates the distribution of misinformation about
the BRS.
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