East and Central African Journal of Surgery Association of Surgeons of East Africa and College of Surgeons of East Central and Southern Africa ISSN: 1024-297X EISSN: 2073-9990 Vol. 13, Num. 1, 2008, pp. 122-123

East and Central African Journal of Surgery, Vol. 13, No. 1, March-April 2008, pp. 122-123

Subcutaneous Face and Neck Surgical Emphysema Secondary to Presumed Spider Bite

W. Mulwafu,

Department of surgery, College of Medicine, Private Bag 360 Chichiri, Blantyre 3 – Malawi. Email: wakisamulwafu@yahoo.co.uk

Code Number: js08021

Case report

We report a case of a 35 year old gentleman who presented to us from a secondary hospital with two day history of swelling of right side of face after having been bitten by a small grey looking jumping spider. He could not pinpoint to which part of the face he was bitten. There was no evidence of the original bite. Past medical history was unremarkable and didn’t report any allergies. At a secondary hospital, he had given hydrocortisone 200mg, promethazine 25mg, Cloxacillin and gentamycin on assumption of an allergic reaction and he carried a differential diagnosis of orbital cellulitis.

On examination, he was apyrexial and had a blood pressure of 151/79 and a pulse rate of 56. He had swollen right side of face with palpable surgical emphysema which extended to the neck.  There was no sweating of the face. The rest of head and neck including Ear Nose and Throat   and dental examination were normal

He had a white cell count of 12.5 x 10⁹ /l and C-reactive protein of 11.8. Facial and lateral neck x-rays done at the secondary hospital (Figure 1) showed extensive subcutaneous surgical emphysema . Chest x-ray was normal.

The patient was admitted to our unit on antibiotic cover of Penicillin and Flagyl. As far as we are aware, there are no anti-spider venom preparations available here.  Over the next 48 hours, the swelling and surgical emphysema had subsided and patient was discharged. He defaulted follow-up two weeks later.

Discussion

Spiders are ubiquitous in southern Africa¹.  A review by Newlands et al² described four spiders known to be medically important in Southern Africa and they divided them into two categories according to the action of their venom- neurotoxic and cytotoxic. The three genera that represent the cytotoxic group in Southern Africa are the Chiracanthium, Loxosceles and Sicarius. A single species, latrodecus indistinctus, represents the neurotoxic group in southern Africa.  Muller et al³ reviewed 45 cases of spider bites of the genera Latrodectus, also known as widow spiders and locally known as black and brown button spiders. He found out that black widow spiders caused more severe form of envinomation than brown widow spiders. Surgical emphysema was not reported.

Only four cases of spider bites have been reported in the otolaryngology literature and all of them have been cases of brown recluse spider (Loxosceles reclusa) bites to the head^4,5. None of the above cases had surgical emphysema.

In our case, the patient was referred to otolaryngology department carrying a differential diagnosis of orbital cellulitis which was ruled out upon review of the patient and his x-rays.  The finding of extensive surgical emphysema with no particular source of infection or perforation of upper aerodigestive tract was peculiar. Searching the literature, surgical emphysema is not reported to be one of the clinical effects of spider bites.

References

1. Visser LH and Khusi SN .Pulmonary oedema from a widow spider bite. A case report. S Afr Med J. 1989 Apr 1; 75(7):338-9.
2. Newlands G and Atkinson P. Review of southern African spiders of medical importance, with notes on the signs and symptoms of envenomation S Afr Med J. 1988 Feb 20;73(4):235-9.
3. Muller GJ. Black and brown widow spider bites in South Africa. A series of 45 cases. S Afr Med J. 1993 Jun; 83(6):399-405.
4. Donepudi SK, Ahmed KA, Stocks RM, Nelson D and Thompson JW. Aural involvement in loxoscelism: case report and literature review. Int J Pediatr Otorhinolaryngol. 2005 Nov;69(11):1559-61. Epub 2005 Jun 6.
5. Leach J, Bassichis B, Itani K Brown recluse spider bites to the head: three cases and a review. Ear Nose Throat J. 2004 Jul;83(7):465-70

© 2008 East and Central African Journal of Surgery

The following images related to this document are available:

Photo images