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Necrotic arachnidism: the mythology of a modern plague

Geoffrey K Isbister
Grief stricken, Arachne strangled herself with a noose, but Athena took pity and transformed her into a spider; as such, she and her descendants practice the art of weaving forever. Morford and Lenardon. Classical Mythology.1
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involving drivers or passengers in Australia, but no deaths from spider bites.7 Why then is there such irrational fear of spiders and why have many medical myths been based on the effects of their bites?

Clinical Envenoming Research Group, University of Newcastle, Newcastle Mater Misericordiae Hospital, Waratah NSW 2298, Australia (G K Isbister FACEM) Correspondence to: Geoffrey K Isbister gsbite@ferntree.com

Spider phobia
The cause of spider phobia is undecided, but several models have been proposed. The rst is the nonassociative model, which assumes that spider phobia occurs without any previous negative experience or association.8 This model is Darwinian-based and suggests that spider phobia exists because it represents innate human fear of evolutionary dangerseg, venomous spiders.9 However, there are several problems with this model: the fear of spiders seems to be mainly a western (European) trait, and in many other parts of the world cultures have revered spiders or seen them as good-luck symbols.10 The main opposition to this theory is a three-pathways model, which suggests that spider phobia depends on conditioning, modelling, and negative information experiences.9 There is evidence to support the contribution of conditioning events to development of childhood spider phobia, and this contradicts the previous non-associative model.9 A more novel model proposed for spider fears, which can explain the high prevalence of spider mythology too, is the association of spider phobia with disgust sensitivity. Davey has shown that patients with spider phobias have an increased tendency to fear other animals that evoke disgust (eg, slugs and maggots11) and that individual disgust sensitivity is an important predictor of fear of invertebrates.2 This theory is supported by another study that shows the only notable predictor of an offsprings fear of spiders was the disgust sensitivity shown by their parents, rather than the parental fear of spiders.12 Therefore, spider fear might be transmitted within families by social learning of the nature and intensity of disgust reactions rather than any type of genetic inheritanceagain challenging the non-associative model.10

Spiders have inuenced cultures throughout the ages and remain creatures that are both intriguing to some and feared by others. Considerable mythology exists about spiders, and fear of spiders is common. In a study of 261 adults, 32% of women and 18% of men reported that spiders made them feel anxious, nervous, or very frightened, and in European studies spiders are one of the four most feared animals.2 Spider phobias are likewise one of the most common simple phobias and in some cases can have a substantial effect on a persons quality of life. However, spiders have affected human beings in more signicant ways than simple fear in individuals. Many myths have developed about spiders and the effects of their bites and toxins. An example is the myth that daddy longlegs (spiders belonging to the family Pholcidae) are the most venomous spiders, despite no reported bites and the venom never having been studied. Of greater concern is the modern fear of spiders stemming from the belief that many types cause necrotic ulcers and gangrenethe disorder referred to as necrotic arachnidism. Several theories have been proposed as to why spiders have such an inuence on individuals and society, and the origin of spider phobia and spider mythology has been studied by some researchers. Putting aside emotion and dislike for these creatures, and based on a rational assessment of the risks, the fear or concern about spiders is unfounded. Most spiders do not pose a medical risk.3 Even spiders that can cause clinically signicant human envenoming cause very little mortality or severe morbidity.4 Scorpions are responsible for a far greater burden of illness worldwide.4 In Australia and the USA, bee and wasp stings account for many more deaths than spider bites. A recent review from Australia identied 45 deaths from bee and wasp stings during a 20-year period (197998).5 During the same period there were no deaths from spider bites. In fact, only 26 deaths from spiders have been recorded in Australia in the past century.6 Therefore, the risk of severe effects from spider bites is negligible compared with hymenoptera allergy. Spiders can also be compared with cars. The fear of cars is rare, and there are few myths about the medical effects of car travel even though more deaths occur from motor vehicle accidents each year than from spider bites, and people take a great risk every time they travel in a car. In 2001, there were 1183 motor vehicle deaths
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Spider mythology, plagues, and tarantism

Although the reason for an association between spiders and mythology is not clear, the link should be appreciated so that the fear of spiders and the unfounded attribution by medical practitioners, for example, of ulcers to spider bites can be prevented. The third model of spider phobias linking fear of spiders to disgust sensitivity purports that the association originated in the Middle Ages.10 There are several examples of spiders being associated with illness throughout this period of history in Europenotably,
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Figure 1: Male white-tail spider (Lampona spp) (A) and wolf spider (Lycosa Tasmanicosa spp) (B) from southern Australia

the belief that spiders were the harbingers of the Great Plagues.10 The association with plague is thought to result from the fear of a disease of unknown cause and the need to attribute the disease to an external agent. Spiders, therefore, became a plausible external cause linked to areas where disease occurred. Thus, fear of disease
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manifested as anxiety and hysteria about spiders.10 Similarly, the fear and uncertainty about chronic necrotic ulcers has focused attention on spider bites as the putative cause because patients and medical practitioners are more comfortable with an identiable cause for a difcult-to-diagnose and sometimes debilitating disorder. A more fantastical association occurred with tarantism (tarantismo or tarantolismo) which is a mythical or alleged disease that arose about 500 years ago in Europe and was thought to be caused by bites from tarantula spiders (Lycosa tarantula).13,14 The modern city of Taranto in the Italian region of Apulia was the centre of this epidemic during the 15th to 17th centuries before it spread across most of southern Europe.14 The disease is still sporadically reported in parts of Spain, southern Italy, and Sardinia.14 Tarantism referred to a collection of hysterical disorders caused by ignorance and superstition. Some of the descriptions are consistent with bites by widow spiders (Latrodectus spp), where symptoms included sweating, tremor, rigors, insomnia, pains, rigidity, and weakness.13 These symptoms caused great fear and generated the legend of tarantism that was associated with a spider bite. However, the tarantula was unlikely to have been involved and widow spider bites would only account for some cases. The only cure for tarantism was believed to be violent and energetic dancing for 34 days. In some places the disease was associated with madness, in other places it eventually developed into popular dancing festivals that were attended in summer, and the Apulians used tarantism as an opportunity to resurrect orgies and attribute their unseemly behaviour to spider bites.13 Over time the dance has been immortalised as the tarantella.14 Although many ancient myths about spider bites are likely to exist, tarantism is the oldest and most fanciful spider myth that is well reported in modern times. The myth shows the great effect that spiders and spider bites have had on western society for centuries. In Europe, a strong association developed between spiders and risk of disease. The reason is possibly that attributing the diseases to an obvious external cause helped the sufferers, rather than leaving them facing the unknown. Since that time both of these myths have been debunked with the discovery that eas spread plague, and that, although some cases of tarantism might have been the results of widow spider bites, most were a mixture of hysterical and psychological disorders. However, a 20th-century complaint has now been associated with spider bitesthe so-called modern plague.

The modern myth: necrotic arachnidism

The current myth asserts that many types of spider are responsible for necrotic ulcers. This is a perception of both patients and medical practitioners. Despite
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signicant advances in the biomedical sciences and increasing focus on evidence-based medicine, the diagnosis of a spider bite continues to be based mainly on suspicion and fear of spiders, and diagnosis of a chronic ulcer on stories of suspected spider bites causing devastating necrotic fasciitis. Necrotic arachnidism is a poorly dened clinical disorder. The usual denition is of necrotic lesions or ulcers that result directly from a spider bite, with or without systemic features. The denition is most applicable to bites by Loxosceles spp (loxoscelism) and there is much clinical and laboratory evidence that bites by these spiders can cause direct cytotoxicity and necrotic effects.15,16 Apart from loxoscelism, the use of the term necrotic arachnidism is ambiguous and problematic, and is blamed on bites of many different spiders around the world, making diagnosis and treatment impossible. Australia is one of the only continents in the world where Loxosceles spp are not native, and where the only introduced species L rufescens has remained conned to a small area,17 yet the clinical diagnosis of necrotic arachnidism has become entrenched in modern medical literature. Necrotic arachnidism was rst assumed to have occurred in Australia in 1982.18 The possibility that two spiders could be involved was suggested: the white-tail spider (Lampona spp), and the wolf spider (Lycosa spp) (gure 1).18 However, in none of the described cases in which patients developed necrotic ulcers was a spider seen biting the patient.6,18 The ulcers were linked to spider bites on the basis of spiders being found in the house or garden in the days after the onset of illness.6 White-tail spiders are ubiquitous and occur in many houses in southern and eastern Australia so it is not surprising that they were found. Wolf spiders are common in Australia, but the supposed association between ulcers and this spider was inuenced by spiders from the same family being blamed for necrotic lesions elsewhere in the world.19,20 The association between wolf spiders and necrotic ulcers in Brazil was subsequently disparaged, and attention in Australia focused on white-tail spiders.20 In 1987, a probable case of necrotic arachnidism was reported in an Australian patient who developed severe skin necrosis and systemic effects. In this report, no spider was seen and the diagnosis was made after exclusion of other causes of necrotic ulcers.21 Both the article,21 and the accompanying editorial22 blamed the effects on the white-tail spider with minimum evidence. The editorial stated that white-tail spiders might have been caught in the act, but this statement is not referenced and is based on previous suspected cases.22 Further cases of suspected white-tail spider bites were published in Australia23,24 and New Zealand.25 No reports of denite bites (where the spider was caught and identied by an expert) causing necrosis were published.24 However, a series of eight denite white-tail
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Figure 2: Suspected white-tail spider bites Ulcer A was ultimately diagnosed as chronic staphylococcal infection after skin biopsy and culture and treated with antibiotics, and ulcer B was diagnosed as pyoderma gangrenosum after histopathological examination and resolved with intralesional corticosteroids.

spider bites causing only minor effects was published.26 One study showed that white-tail spider venom was not necrotic27 and Australian arachnologists questioned the association between white-tail spiders and necrotic lesions, reporting large numbers of denite bites with no major effects.28 However, despite all of this evidence and no previous reports in the 200 years leading up to the 1980s, the myth strengthened and the diagnosis of white-tail spider bite became clearly associated with necrotic ulcers by both the general and medical community.24 In a relatively short period of time, a previously almost unheard-of spider had come to the forefront of medicine and was feared by the general community. Many doctors simply made the diagnosis of white-tail spider bite on the basis of the appearance of a necrotic ulcer. The most concerning problem was that necrotic ulcers were not being appropriately investigated and other disorders were being misdiagnosed as white-tail spider bites (gure 2).24,29,30 Unfortunately, the misattribution of necrotic ulcers to spider bites is not conned to Australasia. In the USA, loxoscelism is diagnosed in most parts of the country
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Despite this evidence, wolf spiders have been blamed for necrotic lesions since early last century.13,19,20 In Brazil, this inaccuracy has been rectied with a study of 515 denite bites by identied wolf spiders, none of which caused necrosis.20 However, elsewhere in the world, wolf spiders continue to be implicated in necrotic arachnidism.6,33 Thus, history seems to have repeated itself: we have a widespread, albeit low-key, modern plague of necrotic arachnidism. Once again a disorder (or more likely a collection of difcult to diagnose necrotic skin ulcers) is being attributed to spiders because they are a plausible external cause and are found commonly in gardens and houses. This association remains despite no signicant evidence to support the involvement of spiders in necrotic ulcers. The medical community is by no means immune to the myth of necrotic arachnidism and is responsible for its persistence by not questioning the evidence or investigating necrotic ulcers in the same way as any other disorder.

Debunking the myth of necrotic arachnidism

The myth of necrotic arachnidism must be debunked by accurately dening the effects of denite spider bites and simultaneously investigating necrotic ulcers to determine a cause. First, identication of the effects of different groups of spiders requires well-designed prospective follow-up studies of denite bites by expertly identied spiders. This technique has been described in detail and establishes causality between spider bites and their effects.34 A large Australian study in which this technique was used has shown that necrotic ulcers are highly unlikely to result from spider bites3 and in particular no ulcers resulted from 130 denite bites by the widely incriminated white-tail spider (gure 3).35 Second, necrotic ulcers and other skin lesions that have been blamed on spider bites need more thorough investigation by medical practitioners. A recent study has shown that, although many disorders can lead to necrotic ulcers, in almost all cases the ulcers were not caused by a spider bite.29 The misdiagnosis of necrotic ulcers prevents appropriate treatment and in some cases can result in signicant morbidity. There have been reports of delayed treatment of basal cell carcinoma, anthrax, and bacterial and fungal infections.24,29 Figure 2 shows two necrotic ulcers that were initially diagnosed as white-tail spider bites but had alternative diagnoses and appropriate treatment after proper investigation. Medical practitioners need to investigate necrotic ulcers properly rather than attribute them, in the absence of evidence, to spider bites.
Conict of interest statement None declared. Acknowledgments I would like to thank Sophie Langford for her psychological expertise on spider phobias and Tony Smith for critically reading the manuscript.

Figure 3: Examples of denite white-tail spiders bites with minimal local effects (A) and an itchy red area that lasts for an average of 1 week (B)

even though Loxosceles is conned to the south and west.31 Likewise, the hobo spider (Tegenaria agrestis) has been associated with necrotic ulcers in the USA, again on the basis of a series of suspected bites, not denite bites by identied spiders.32 In fact, the hobo spider is an introduced European species that has never been reported to be harmful in Europe. Although the European wolf spider Lycosa spp was cleared of causing tarantism, more recently, bites from wolf spiders have been implicated in necrotic arachnidism in Europe13 and South America.20 The evidence for wolf spiders causing necrosis is circumstantial and based on single reported cases in Europe of bites where no spider was collected13 and on animal experiments that must be interpreted with caution (see below). Necrotic effects were also ascribed to wolf spiders in So Paulo, Brazil20 in the 1920s prompting studies of venom gland extracts which were injected into animals. However, only the intradermal injection of large quantities of venom from the South American wolf spider (Lycosa raptoria or L erythrognatha) caused necrosis; subcutaneous and intramuscular injection had no effect.13,19 In Europe, Maretic repeated similar experiments with venom from L tarantula and only produced necrosis with intradermal injection.13
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References 1 Morford MPO, Lenardon RJ. Classical mythology, 7th edn. New York: Longman Press, Chapter 8. 2 Davey GCL. Self-reported fears to common indigenous animals in an adult UK population: the role of disgust sensitivity. Br J Psychol 1994; 85: 54154. 3 Isbister GK, Gray MR. A prospective study of 750 denite spider bites, with expert spider identication. QJM 2002; 95: 72331. 4 White J, Warrell D, Eddleston M, Currie BJ, Whyte IM, Isbister GK. Clinical toxinology: where are we now? J Toxicol Clin Toxicol 2003; 41: 26376. 5 McGain F, Winkel KD. Bee and wasp sting related fatalities in Australia. Paris: IST, 2000. 6 Sutherland SK, Tibballs J. Australian animal toxins, 2nd edn. Melbourne: Oxford University Press, 2001. 7 Australian Transport Safety Bureau. Road crash data and rates Australian States and Territories 1925 to 2001. Canberra: Department of Transport and Regional Services, Australian Transport Safety Bureau, 2002. 8 Menzies RG, Clarke JC. The etiology of phobias: a non-associative account. Clin Psychol Rev 1995; 15: 2348. 9 Merckelbach H, Muris P. The etiology of childhood spider phobia. Behav Res Ther 1997; 35: 103134. 10 Davey GCL. The disgusting spider: the role of disease and illness in the perpetuation of fear of spiders. Soc Animals 1994; 2: 1725. 11 Davey GCL. Characteristics of individuals with fear of spiders. Anxiety Res 1992; 4: 299314. 12 Davey GCL, Forster L, Mayhew G. Familial resemblances in disgust sensitivity and animal phobias. Behav Res Ther 1993; 31: 4150. 13 Maretic Z. Other European araneism: araneism. Belgrade: Nolit Publishing House, 1979: 172205. 14 Anon. The tarantulapoison spider or a case of mistaken identity? Adverse Drug React Toxicol Rev 1996; 15: 199202. 15 Sezerino UM, Zannin M, Coelho LK, et al. A clinical and epidemiological study of Loxosceles spider envenoming in Santa Catarina, Brazil. Trans R Soc Trop Med Hyg 1998; 92: 54648. 16 Futrell JM. Loxoscelism. Am J Med Sci 1992; 304: 26167. 17 Southcott RV. Spiders of the genus Loxosceles in Australia. Med J Aust 1976; 1: 40608. 18 Sutherland SK. Necrotic arachnidism: a possible new Australian syndrome. Toxicon 1982; 20 (suppl 1): 59 (abstr).

19

20

21 22 23

24 25 26

27

28 29 30

31

32

33 34

35

Bettini S, Brignoli PM. Review of the spider families, with notes on the lesser-known poisonous forms. In: Bettini S, ed. Arthropod venoms, 1st edn. Berlin: Springer-Verlag, 1978: 10318. Ribeiro LA, Jorge MT, Piesco RV, Nishioka SA. Wolf spider bites in Sao Paulo, Brazil: a clinical and epidemiological study of 515 cases. Toxicon 1990; 28: 71517. Spring WJ. A probable case of necrotizing arachnidism. Med J Aust 1987; 147: 60507. Sutherland SK. Watch out, Miss Muffet! Med J Aust 1987; 147: 531. Gray M. A signicant illness that was produced by the whitetailed spider, Lampona cylindrata. Med J Aust 1989; 151: 11416. White J. Debunking spider bite myths. Med J Aust 2003; 179: 18081. St George I, Forster L. Skin necrosis after white-tailed spider bite? N Z Med J 1991; 104: 20708. White J, Hirst D, Hender E. 36 cases of bites by spiders, including the white-tailed spider, Lampona cylindrata. Med J Aust 1989; 150: 40103. Atkinson RK, Wright LG. Studies of the necrotic actions of the venoms of several Australian spiders. Comp Biochem Physiol C 1991; 98: 44144. Raven RJ, Harvey MS. Necrotising arachnidism in Australia. Med J Aust 1991; 154: 208. Isbister GK, Whyte IM. Suspected white-tail spider bite and necrotic ulcers. Intern Med J 2004; 34: 3844. Kemp DR. Inappropriate diagnosis of necrotizing arachnidism: watch out Miss Muffetbut dont get paranoid. Med J Aust 1990; 152: 66971. Vetter RS, Bush SP. The diagnosis of brown recluse spider bite is overused for dermonecrotic wounds of uncertain etiology. Ann Emerg Med 2002; 39: 54446. Vest DK. Necrotic arachnidism in the northwest United States and its probable relationship to Tegenaria agrestis (Walckenaer) spiders. Toxicon 1987; 25: 17584. Sams HH, Dunnick CA, Smith ML, King LE Jr. Necrotic arachnidism. J Am Acad Dermatol 2001; 44: 56173. Isbister GK. Data collection in clinical toxinology: debunking myths and developing diagnostic algorithms. J Toxicol Clin Toxicol 2002; 40: 23137. Isbister GK, Gray MR. White-tail spider bite: a prospective study of 130 denite bites by Lampona species. Med J Aust 2003; 179: 199202.

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