1. Skin lesions in barracks: consider community-acquired methicillin-resistant Staphylococcus aureus infection instead of spider bites Benedict Pagac CHPPM-North, Fort Meade, MD Richard Vetter Dept. of Entomology, University of California Riverside, CA The views expressed in this presentation are those of the author and do not reflect the official Policy or position of the Department of Army, Department of Defense, or the US Government.

2. ACKNOWLEDGEMENTS: CPT Aaron Miaullis, CHPPM PAC 1LT F. Priest, KAHC-Fort Lee, VA CPT Peters, KAHC-Fort Lee, VA Ms. S. Bokenko, KAHC-Fort Lee, VA MAJ Kevin Smith, KAHC-Fort Lee, VA Mr. Mills, EMO, Fort Lee, VA LTC Patrician Malley, KAHC-Fort Lee, VA CPT Kelly, KAHC-Fort Lee, VA Mr. Abdul Sheikh, DPW, APG, MD Mr. Ronald Purvis, DPW, Fort Myer, VA Mr. Kevin Faye, DPW, Fort Meade, MD LT Amber Hayden, PVNTMED, USMA, NY MAJ Trent Talbert, DTHC, Ft. McNair, Wash. DC SSG Crawford-Adams, KUSAHC, APG, MD Mr. Karl Neidhardt, CHPPM-North, FGGM, MD MAJ Samuel Jang, CHPPM, APG, MD CPT Andrew Plummer, CHPPM, APG, MD Ms. Nikki Jordan, CHPPM, APG, MD Mr. James Patrick, MACH, Ft. Benning, GA Mr. Richard Townsend, MACH, Ft. Benning, GA COL William Corr, MACH, Ft. Benning, GA Mr. Anthony Diederich, MACH, Ft. Benning, GA Mr. Robert Pawloski, MACH, Ft. Benning, GA MAJ Darlene Burns, MACH, Ft. Benning, GA Mr. Denny Kuhr, CHPPM-W, Ft. McPhereson, GA Mr. Derrick Pehlman, ILNG, Camp Lincoln, IL Mr. Adam Clemens, ILNG, Camp Lincoln, IL

3. Introduction Fall, 2004 - DC installation pest management section requests assistance for Brown Recluse bites in barracks Pest management were highly encouraged to spray for the problem 4-member inspection team examined interior and exterior of building for spider evidence and contributing factors Similar problems were reported at other installations by military entomologists One of the six bite patients was available and allowed photograph of lesion

5. Methods – Spider Survey Tools: Flashlight Sticky traps [note, mark dates on them, use a lot (at least 5-10 per average room), place them in secluded, dark places at floor/wall interface, check them after 3 days and at least weekly afterward). Digital Camera (to photograph rooms, potential contributing factors, insects, spiders, and the patients lesion (if given permission). Collection Vials (to use anything captured) Collection Vials (to give to occupants) Ladder (to access dropped ceiling) Portable vacuum (most valuable spider tool) Magnifying glass (to look at lesion as well as spider/insects)

7. Spider/Arthropod Investigations Installation/Location Period# of Patients Housing TypeArthropod Survey Results POCs Ft. Meade, MDSum, 051DINFOS BarracksNo med-imp arthropods Pagac Ft. Meade, MDSpr, 043DINFOS BarracksNo med-imp arthropods Fay Ft. Lee, VAWin, 0423AIT BarracksNo med-imp arthropods Malley Fort McNair, D.CFall, 046Old Guard Barracks Neoscona sppPagac APG, MDFall, 046BarracksNo med-imp arthropods Sheikh Ft. Benning, GA*04unkBarracksNo med-imp arthropods Kuhr Camp Merrill, GAFall, 04unkBarracksNo med-imp arthropods Kuhr Ft. Monmouth, NJSum, 0310Cadet BarracksNo med-imp arthropods Miaullis * Also see investigation, spring 1997 (MSMR, June 1997), Authors: N.A. Nee, et. al. Results

8. No arthropods of confirmed medical importance were found in barracks at 7 military installations (4 states & DC) having reports of a spider bite problem. In one example (Fort McNair, DC) at least 80 manhours were expended for survey and control of a non-existent medical pest problem. Operators at a minimum of four installations applied pesticides (e.g., permethrin), even though no medically important arthropods were present. At some installations spider species of no medical importance were found, such as the orb weaver spider (Neoscona spp: Araneidae). Spider reports persisted at one facility even after repeated unproductive visits and education/awareness attempts (due to turnover of medical and other authorities). At Fort Lee, VA, lesions were documented in at least 23 personnel. At the urging of the authors, medical authorities cultured the lesions of at least 2 of these soldiers (who were roommates), and determined…..

9. Results cont…. …the lesions were positive for CA-MRSA

10. What is CA-MRSA? Methicillin-resistant Staphylococcus aureus is an emerging cause of skin and soft-tissue infections due to increased resistance of the bacteria to antibiotics. Approximately 30% of the human population colonized w/ Staph (skin, nose); approximately 1% of the population colonized with resistant (MRSA) staph. (CDC) In the last half-decade it has become more commonplace in the community (i.e., CA-), whereas before it was mainly associated with health-care settings. Most infections are mild, but some advance to more serious systemic infection, bacteremia, and death. Reported from sports participants, jail inmates, and children. Some predisposing risk factors: close skin-to-skin contact, close person-person proximity, contaminated environment, suboptimal hand and personal hygiene, roommate with skin infection, family members working in health care, and conditions that may predispose to breaches in skin integrity such as harsh physical activity. Veterinary cases of equine>human and human>equine transmission. Other animals/pets act as reservoirs and/or are infected (Weese, Ontario Veterinary College; Rankin, Univ of PA School of Vet Med)

12. Evidence supporting a non-spider cause especially CA-MRSA Close-quartered living Multiple lesions on one individual Multiple individuals with lesions No spider Not in Brown Recluse range

13. (Photos: A. Miaullis)

15. The Brown Recluse Discussion - continued

16. Courtesy - Rick Vetter - rufescens

17. This young woman experienced a stinging sensation on her thigh while cleaning the basement in the early spring. An itchy red urticarial plaque was followed by central crusting 6-8 hours later. The next morning she developed a painful central necrotic ulcer. She was treated with oral dapsone, and the ulcer healed with minimal scarring 3 weeks later.. Photos from emedicine/Dale Losher

21. - 0 - 1 to 4 - 5 to 9 - 10 to 17 3 rd Floor, 88 Nights

22. Oh my gosh…… One floor: 597 Recluses –(88 days X 176 traps = 15,488 trap/nights) Extrapolate: 3 floors X 597 = 1,791 Recluses So, > 2,000 Recluses, 3 month period How many confirmed bites per year? Hundreds? Dozens? < 2 per year (ave)

23. oo o oo

24. 2 Relevant Papers…. Bites of Brown Recluse Spiders and Suspected Necrotic Arachnidism (Swanson & Vetter, New England Journal of Medicine, February 16 2005) Arachnids Submitted as Suspected Brown Recluse Spiders (Araneae: Sicariidae): Loxosceles Spiders are Virtually Restricted to Their Known Distributions but Are Perceived to Exist Throughout the United States. (Vetter, Journal of Medical Entomology, July 2005) - Brown Recluse Challenge: 2000-2005, UCR website

25. Major points Recluse bites typically self-limited & self-healing, w/out long-term consequences. No commercially available test exists to identify spider venom in wounds. Other things cause conditions frequently misdiagnosed as brown recluse bites: e.g., staph, strep, herpes, diabetic ulcer, fungal infection, pyoderma gangrenosum, chemical burn, Lyme disease, squamous-cell carcinoma, and much more… Physicians should be skeptical of any undocumented history of a spider bite. There is no therapy with proven efficacy for loxoscelism. Best approach – conservative simple first aid and local wound care. Recluses are rare in non-endemic areas, translocation unproven, and <10 infestations outside endemic range, generally restricted to 1 building.)

26. Conclusions CA-MRSA infections in military barracks are becoming a common phenomenon in the NE. It is probable that CA-MRSA is the causative agent when dealing with multiple patients with lesions and patients with multiple lesions, living in the same barracks, with no spider evidence. It is highly improbable that a brown recluse spider would be responsible for a necrotic lesion in areas outside the recluse range. Even in heavy recluse infestations, bites are infrequent. True spider bites on the whole are not as common as believed or as medically diagnosed. Increased awareness of the dynamics and spread of CA-MRSA, including the involvement of animal hosts and human-animal transmission, is warranted.