Skin lesions in barracks: consider community-acquired methicillin-resistant Staphylococcus aureus infection instead of spider bites

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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 Ronald Reiland
MEDDAC, Fort Lee, VA D. Bolesh MEDDAC, Fort Lee,
VA D. Swanson Dept. of Dermatology, Mayo Clinic,
Scottsdale, AZ
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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
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Introduction

• Fall, 2004 - DC Installation DPW pest management
  requests CHPPM assistance for Brown Recluse
  bites in barracks
• DPW were highly encouraged to spray for the
  problem
• 4-member inspection team examined interior and
  exterior of building for spider evidence and
  contributing factors
• One of the six bite patients was available and
  allowed photograph of lesion
• Consult with R. Vetter, UC Riverside spider
  specialist suggested CA-MRSA
• Follow-up CA-MRSA culture of one patient was
  inconclusive
• Revisted previous reports of multiple mysterious
  bites in barracks (e.g., NJ Army installation in
  2003)

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Results

• No arthropods of confirmed medical importance
  were found in barracks at 7 military
  installations having reports of a spider bite
  problem.
• At Fort Lee, lesions were documented in at least
  23 personnel, from which confirmation of CA-MRSA
  was made in two barracks residents who were room
  mates.
• In one example (Fort McNair) 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 Fort McNair, an orbweaver spider (Neoscona,
  Araneidae) was found.
• ( of no medical importance).
• False spider reports persisted at one facility,
  even if education/awareness was previously
  established (due to turnover of medical and other
  authorities).

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Results - continued
Spider/Arthropod Investigations
Also see investigation, spring 1997 (MSMR, June
1997), Authors N.A. Nee, et. al. See
Poster Community Acquired MRSA Fort Benning,
Georgia, January 2001 March 2005 Authors
Nikki Jordan, CPT Andrew Plummer, MAJ Sam Jang,
James Patrick, MAJ Darlene Burns
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Methods Spider Survey
Questions What are the building number(s), Room
number(s) of patients? How many patients?
(contact information). Have patients seen a
doctor? (name?). Was the lesion cultured for
CA-MRSA? Did doctor say it was a spider bite, or
did the patient suggest it? Did the Doctor or
patient say that it was a Brown Recluse
Bite? When did each of the patients first notice
lesion or bite? Did the patient remember the
actual moment of the bite, or did they wake up,
or otherwise notice the lesion. Describe the
bite. Are there 2-puncture (fang) holes in
lesion? (sometimes, but not always visible) Did
the patient actually see a spider? Are there any
spiders present in the rooms/areas? (collect if
available) Was the patient previously in a
region/area known to be infested by spiders or
Brown Recluse Spiders? Is there any spider
webbing in rooms? (check corners, both at floor
and ceiling level) Are there dropped ceilings in
the patients rooms? Were the areas above dropped
ceilings examined? (look for spiders or webbing,
or, dead insects) Are there any sanitation issues
noted? Is equipment that normally would be
outdoors (e.g., ruck, boots, tents, tarps) stored
in near patients room? Are window screens
present? Are there gaps under exterior doors that
permit entry by crawling insects/spiders? Are
there other dead insects (e.g., on windowsills?)
which would serve as prey for spiders? Did the
exterior of the building have any attractive
features or harborage? (e.g., lighting that
attracts insects that, in turn, attracts spider
predators). Do the patients use work-out
equipment at the same location? Do the patients
share a break room or reside in the same room?
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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)
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DISCUSSION
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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.
• 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, familiy members working in health
  care, and conditions that may predispose to
  breaches in skin integrity such as harsh physical
  activity.

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Evidence supporting a non-spider causeespecially
CA-MRSA
Discussion - continued

• Close-quartered living
• Multiple lesions on one individual
• Multiple individuals with lesions
• No spider
• Not in Brown Recluse range

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(Photos A. Miaullis)
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(Photos A. Miaullis)
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The Brown Recluse
Discussion - continued
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- rufescens
Courtesy - Rick Vetter
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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..
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Those evil recluses

• One floor 597 Recluses
• (88 days X 176 traps 15,488 trap/nights)
• Extrapolate 3 floors X 597 1,791 Recluses
• So, gt 2,000 Recluses, 3 month period
• How many confirmed bites per year?
• Hundreds?
• Dozens?
• lt 2 per year (ave)

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2 New 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)

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Major points

• Recluse bites are typically self-limited and
  self-healing, without long-term consequences.
• There is not good evidence that other N. American
  spiders can cause necrosis e.g., wolf, crab,
  yellow sac, (hobo?)
• 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, lymphomatoid
  papulosis, chemical burn, erythemas, 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.

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Major points

• The Brown Recluse Challenge 2000-2005, UCR
  website identify any spider submitted from U.S.
  that was perceived to be a brown recluse.
• Results 1,773 arachnids submitted from 49
  states 324 recluses from 15 states all but
  four specimens were submitted from states
  historically considered to be within known
  distribution.
• Recluses are rare in nonendemic areas,
  translocation unproven, and lt10 infestations
  outside endemic range, generally restricted to 1
  building.)
• Recluses are limited in their dispersal potential.

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Conclusions

• CA-MRSA infections in 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.