Grand Rounds

Obese Man With Severe Pain and Swollen Hand

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Initial supportive treatment for this patient included cleaning the bite area with antiseptic soap and water. A cold compress was applied to the bite area at 20-minute intervals, and the right hand was elevated. Hydrocodone bitartrate/acetaminophen (5/325 mg qid) was administered to alleviate pain. The patient was also given a tetanus booster because the date of his last immunization was unknown.

After two hours of monitoring, the patient was no longer able to move his hand, swelling around the affected area increased, and the bite site began to appear necrotic. Cephalexin (500 mg bid) was ordered along with dapsone (100 mg/d). The patient was referred for consultation with wound care and infectious disease specialists because of possible tissue necrosis.


Brown recluse spider bites are uncommon, and most are unremarkable and self-healing. Patients who present following a brown recluse bite typically can be managed successfully with supportive care (RICE) and careful observation. In rare cases, however, bites may result in significant tissue necrosis or even death.

The diagnosis is typically based on thorough physical examination, with attention to the lesion characteristics and appropriate questions about the spider and the development of the lesion over time. Diagnosis through identification of the spider seldom occurs, since patients typically do not capture the spider and bring it with them for identification. The geographic region where the bite occurs is an important factor as well, since brown recluse envenomation is higher on the differential diagnosis of necrotic skin lesions in areas where these spiders are endemic (the lower Midwest, south central, and southeastern regions of the US).


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