AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Australian funnel-web spiders (family Hexathelidae, subfamily Atracinae, genera Atrax and Hadronyche) are the most venomous spiders in the world based on clinical experience in Australia and animal lethal dose studies. Funnel-web spiders belong to the suborder Mygalomorphae, a primitive group of spiders that also includes tarantulas. Funnel-web spiders of medical importance comprise 40 species within 2 genera, Atrax and Hadronyche, in the family Hexathelidae, subfamily Atracinae. The Atrax genus contains 3 species, including Atrax robustus, the Sydney funnel-web spider. The remaining 37 species are members of the genus Hadronyche. Funnel-web spiders are primarily found on the eastern coast of Australia. Related funnel-web spiders can also be found in New Guinea and the Solomon Islands.

Funnel-web spiders are medium-to-large robust spiders that tend to be dark or black in color. These spiders measure up to 5 cm. They have stout legs and prominent fang-bearing chelicerae that deliver a neurotoxic venom. The common name derives from the funnel-like entrance to silk-lined subterranean burrows built by both males and females. The Sydney funnel-web spider (A robustus) is responsible for most reported envenomations and the only confirmed deaths in humans. However, bites from other funnel-web spiders, particularly the northern tree spider, Hadronyche formidabilis, are likely to cause serious envenomation syndromes and are potentially deadly if untreated.

In Australia, 77 severe envenomations were documented between 1999 and 2003. Ten to twenty-five percent of bites produce toxicity. Male spiders are responsible for most bites. Unfortunately, the venom of male spiders is also more toxic than that of female spiders. Male funnel-web spiders exhibit a seasonal wandering behavior in search of female mates, which often brings them into houses and in contact with humans. Humans and other primates suffer severe life-threatening toxicity from the venom, while other vertebrates, such as rabbits and cats, are almost unaffected. Since 1981 when an antivenom was first used clinically, no fatalities have occurred.

Pathophysiology

The venom components responsible for mortality and morbidity are labeled delta-atracotoxins (formerly robustotoxin in A robustus and versutoxin in Hadronyche versuta). While the amino acid structure of delta-atracotoxins differs slightly between species of funnel-web spiders, strong antigenic cross-reactivity exists between their venoms. Funnel-web spider antivenom, derived from purified immunoglobulin G (IgG) of rabbits hyperimmunized with A robustus venom, is also effective against venom of Hadronyche species. Delta-atracotoxins are polypeptide neurotoxins that induce spontaneous, repetitive firing and prolongation of action potentials in presynaptic autonomic and motor neurons. 

Delta-atracotoxins bind to the outer surface of tetrodotoxin-sensitive sodium channels. After binding, they induce excitability of these voltage-dependent sodium channels. The toxins also interfere with the conformational changes necessary for gating and inactivation of the channel. The ensuing massive neurotransmitter release results in an autonomic storm. The excessive release of endogenous acetylcholine, norepinephrine, and epinephrine is responsible for many of the clinical findings of funnel-web spider envenomation.

Envenomation is heralded by substantial pain at the bite site. Most funnel-web spider bites do not proceed to severe systemic symptoms, causing only mild or local neurotoxic effects. In severe cases, the onset of symptoms is rapid, with a median onset of 28 minutes. Agitation and vomiting are common. Autonomic effects include diaphoresis, salivation, piloerection, lacrimation, and pupillary changes. Cardiovascular changes commonly include hypertension and tachycardia. Hypotension and bradycardia occur more rarely. Pulmonary edema occurs in more than half of severe envenomations, with dyspnea and pink, frothy sputum often accompanied by respiratory failure. Skeletal muscle fasciculation, muscle spasms, and oral paresthesias are frequent neurologic findings. Coma or loss of consciousness occurs in about 10% of patients who experience severe envenomation.

Rhabdomyolysis is common in serious envenomation with massive increases in serum creatine kinase (CK) levels and risk of renal failure.

Frequency

International

Funnel-web spiders of medical importance are found in eastern and southern Australia. The Sydney funnel-web spider (A robustus) is distributed in a roughly 75-mile radius around the city of Sydney. Hadronyche species have a much wider distribution, from southeast Queensland to Victoria, Tasmania, and parts of South Australia.

Sixteen confirmed cases of funnel-web spider bites were reported to poison control centers or hospitals in Australia from 1999-2003. A minority of patients (10-20%) require treatment with antivenom.¹

Mortality/Morbidity

• The mortality rate is difficult to determine from data from the era before antivenom. From 1927-1980, 13 deaths attributed to A robustus were reported in the medical literature and news media. No deaths have occurred since the introduction of antivenom.²
• Deaths occurred in children and adult females with bites. In all cases where the spider was identified, the culprit was the Sydney funnel-web spider, A robustus. Severe envenomation, but not death, has been reported following bites by Hadronyche species.
• Death occurs between 15 minutes and 3 days following the bite. In children, death is usually early and caused by pulmonary edema. In adults, death usually occurs later and is caused by persistent hypotension and cardiovascular collapse. In the late 1970s, two deaths occurred despite modern intensive care units. Death in these cases occurred from multisystem organ failure days after the bite.³

Age

Bites are equally common in adults and children. However, envenomation in children is more severe because of the greater venom load per kilogram of body mass. Children may experience life-threatening envenomation within an hour of the bite and require immediate treatment.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

• The spider usually is seen, and its bite is extremely painful for hours to days (the fangs are large and enter with considerable force).
• Early symptoms of systemic envenomation may occur rapidly, with a 28-minute median onset. A pressure-immobilization dressing can delay onset of symptoms.
• The following are symptoms of a serious envenomation:
  
  
  • Perioral tingling
  • Lacrimation
  • Salivation
  • Abdominal pain
  • Nausea
  • Vomiting
  • Diaphoresis
  • Severe dyspnea
• Muscle fasciculations and spasms are common.
• Agitation and confusion can occur.
• Unconsciousness occurs in a minority of patients.

Physical

• Erythema, piloerection, diaphoresis, and muscle fasciculation may be seen at and around the bite site.
• Generalized diaphoresis, lacrimation, and salivation may be noted.
• Fasciculations and muscle spasms are frequent findings in severe envenomation; however, paralysis does not appear to occur.
• A brief period of hypotension and tachycardia is followed by severe hypertension.
• Cardiac arrhythmias and cardiac arrest may occur.
• Severe pulmonary edema that is poorly responsive to loop diuretics occurs early and may be fatal.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• No assay is available for the clinical detection of funnel-web spider venom.
• Perform laboratory studies to assess the effects of envenomation or in consideration of differential diagnoses and coexistent conditions.
• Obtain arterial blood gas measurements, serum electrolyte levels, and creatinine clearance to assess for hypoxia, acidosis, hyperglycemia, and renal impairment.
• Measure serum glucose level in any patient with altered mental status to exclude hypoglycemia.
• CK elevation is typical and may be massive.
• CBC results may demonstrate hemoconcentration, and coagulation studies may demonstrate a coagulopathy.

Imaging Studies

• A chest radiograph may demonstrate pulmonary edema.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Prehospital Care

• If possible and when expedient and safe, the spider should be killed and collected for identification.
• A pressure immobilization bandage identical to that applied in the management of Australian snakebite should be applied immediately. The dressing prevents migration of venom via lymphatics to the central circulation. Simultaneous immobilization (with a splint and/or sling) diminishes the muscle-pump effect on lymphatics and venous flow. Tourniquets are to be avoided.
• Pressure immobilization must be maintained until the patient arrives at a hospital where antivenom is available.
• Supportive care, including cardiac and respiratory life support, should be performed as necessary and according to the advanced cardiac life support (ACLS) protocol.

Emergency Department Care

• Most bites do not result in severe envenomation, although local pain at the site of the bite is common. When severe envenomation occurs, resuscitation measures and antivenin therapy should be instituted as necessary.
• Funnel-web spider antivenom (CSL, Melbourne) is prepared by hyperimmunizing rabbits with the venom of A robustus. It has been effective in treating victims of a variety of species of Australian funnel-web spiders.
  
  
  • Antivenom has been highly successful in the treatment of A robustus envenomation. Complete resolution of symptoms has occurred in 97% of patients treated with antivenom after confirmed funnel-web spider bites. Antivenom has been used successfully in pregnant women, breastfeeding women, and children.
  • Anaphylaxis is a risk when giving antivenom. In a recent review, adverse effects consistent with anaphylaxis occurred in 2 patients of 75 treated with antivenom. One patient of the 75 developed serum sickness within 7 days of administration of antivenom.²
• Premedication with an antihistamine and steroid to prevent anaphylaxis may be considered. However, premedication with epinephrine is contraindicated because of elevated catecholamine levels induced by the venom. Administration of epinephrine is appropriate if anaphylaxis occurs.
  
  
  • Antivenom should be given in the ED or intensive care unit with close monitoring by medical and nursing staff. The initial dose of antivenom is 2 bottles intravenously, but most cases require 4 or more bottles.
  • Antivenom is indicated if any of the following are present:
    
    
    • Muscle fasciculation
    • Marked salivation or lacrimation
    • Piloerection
    • Significant tachycardia
    • Hypertension in a previously normotensive patient
    • Hypotension or shock
    • Dyspnea
    • Disorientation
    • Confusion
    • Depressed level of consciousness
• As with any bite, ensure that tetanus immunization status is up to date.

Consultations

• Referral to an intensive care specialist may be necessary in cases of moderate-to-severe envenomation.
• Advice from an experienced toxicologist practicing in an endemic area (eg, Sydney, Newcastle) should be sought in all funnel-web spider bites.
• The New South Wales Poisons Information Centre (emergency phone number, 61-2-9845-3111) has toxicologists available 24 hours a day.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Pharmacologic therapy is indicated for patients with severe envenomations.

Drug Category: Antivenin

This agent neutralizes the toxins from the spider bite.

Drug Category: Antihistamines

These agents prevent the histamine response in sensory nerve endings and blood vessels. They are more effective in preventing histamine response than in reversing it.

Drug Category: Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Inpatient Care

• Patients who respond to antivenom may be discharged within a day or so if no complications occur.
• Management is more difficult if antivenom is unavailable; in such cases, the patient may need to spend many days in intensive care.
• Important insights into management before the availability of antivenom have been provided by Fisher et al.³
• Prolonged ventilation in the intensive care unit may be required for treatment of respiratory failure. Adequate sedation is essential.
• Atropine has been used to provide parasympathetic blockade.
• In the early stages, hypertension may be treated with alpha-blockers, but massive doses may be required.
• Reversible agents are preferred because of the possible development of hypotension as envenomation progresses.
• Theoretically, beta-blockade may be lethal (because of unopposed alpha-stimulation) and is not advocated.

Further Outpatient Care

• Routine follow-up is not required; however, the theoretical risk of serum sickness caused by the foreign protein load of antivenom mandates that the patient be advised to report symptoms. Nevertheless, serum sickness has not yet been reported following treatment with funnel-web spider antivenom.

Complications

• Once successfully treated with antivenom and recovered from the acute illness, patients are unlikely to experience further complications. As with all patients receiving antivenom, the patient should be advised to seek medical care if signs of serum sickness occur.

Prognosis

• Only 1 in 10 people bitten by a funnel-web spider displays signs of envenomation; however, if envenomation occurs, mortality rates are high in patients who receive no antivenom treatment. Most patients who survive until antivenom can be administered are able to make a complete recovery.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  The Sydney funnel-web spider, Atrax robustus. Male (left) and female (right). Photograph courtesy of the Australian Venom Research Unit, Department of Pharmacology, University of Melbourne, Australia.
	View Full Size Image
Media type:  Photo

Media file 2:  Female funnel-web spider. Image courtesy of Glenn DuBois, CEO, http://www.termite.com/spider-identification.html.
	View Full Size Image
Media type:  Image

Media file 3:  Male funnel-web spider. Image courtesy of Glenn DuBois, CEO, http://www.termite.com/spider-identification.html.
	View Full Size Image
Media type:  Image

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

1. Isbister GK, Gray MR. Bites by Australian mygalomorph spiders (Araneae, Mygalomorphae), including funnel-web spiders (Atracinae) and mouse spiders (Actinopodidae: Missulena spp). Toxicon. 2004;43(2):133-40. [Medline].
2. Isbister GK, Gray MR, Balit CR, Raven RJ, Stokes BJ, Porges K, et al. Funnel-web spider bite: a systematic review of recorded clinical cases. Med J Aust. Apr 18 2005;182(8):407-411. [Medline]. [Full Text].
3. Fisher MM, Carr GA, McGuinness R, Warden JC. Atrax robustus envenomation. Anaesth Intensive Care. Nov 1980;8(4):410-20. [Medline].
4. Dieckmann J, Prebble J, McDonogh A, Sara A, Fisher M. Efficacy of funnel-web spider antivenom in human envenomation by Hadronyche species. Med J Aust. Dec 4-18 1989;151(11-12):706-7. [Medline].
5. Harrington AP, Raven RJ, Bowe PC, Hawdon GM, Winkel KD. Funnel-web spider (Hadronyche infensa) envenomations in coastal south-east Queensland. Med J Aust Med J Aust. Dec 6-20 1999;171(11-12):651-3. [Medline]. [Full Text].
6. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation. Med J Aust. Dec 5-19 1994;161(11-12):695-700. [Medline].
7. Sutherland SK. The Sydney funnel-web spider (Atrax robustus). 3. A review of some clinical records of human envenomation. Med J Aust. 1972;2:642-6.
8. Sutherland SK, Duncan AW. New first-aid measures for envenomation: with special reference to bites by the Sydney funnel-web spider (Atrax robustus). Med J Aust. Apr 19 1980;1(8):378-9. [Medline].
9. Sutherland SK, Duncan AW, Tibballs J. Local inactivation of funnel-web spider (Atrax robustus) venom by first- aid measures: potentially lifesaving part of treatment. Med J Aust. Oct 18 1980;2(8):435-7. [Medline].
10. White J, Cardoso JL, Fan HW. Clinical toxicology of spider bites. In: Handbook of Clinical Toxicology of Animal Venoms and Poisons. CRC Press; 1995:272-83.

Article Last Updated: Jun 26, 2007