Brown spiders (Loxosceles) are taking hold in Pernambuco, Brazil: a case series, 2018-2022

ABSTRACT Objective To describe accidents involving brown spider (genus Loxosceles) bites notified by the Pernambuco Poison Information and Care Center (CIATox-PE), Brazil, from January 2018 to December 2022. Methods This was a case series study of brown spider bites notified by the CIATox-PE. Results The study included 22 cases with median age of 35 years, the majority being female (13); the cases occurred in rural and urban areas (12 versus 10), at night (10); Petrolina was the municipality with the highest number of notifications (6); spider bites occurred mainly in the lower (11) and upper (9) limbs, almost exclusively inside households (21); specific serum therapy was not indicated for 8 cases because the time for its effectiveness had already elapsed. Conclusion Loxoscelism cases occurred more frequently in females, in both rural and urban areas and mainly at home, with delays in seeking medical care.


INTRODUCTION
2][3][4][5] Brown spiders are arachnids comprising different species of the genus Loxosceles that can cause spider bite injuries. 6,7In the Northeast region of Brazil, especially in the state of Pernambuco, an increase in notifications of loxoscelism cases on the Brazilian System for Recording Poison Information and Care Center Poisoning Data (DATATOX) was seen between 2018 and 2022. 8xosceles bites give rise to a characteristic syndrome, given the dermonecrotic and hemolytic action of the venom, forming an ulcer at the site of the bite, this being the most common clinical finding of cutaneous loxoscelism.5][16][17][18] However, underreporting and little epidemiological importance given to accidents involving venomous animals means that loxoscelism continues to be part of the group of neglected diseases. 18,19,21,24e to lack of information, people affected by Loxosceles do not attach importance to the initial bite injury and delay seeking health services, thus hindering timely diagnosis and appropriate therapeutic actions. 6,11,20,24e objective of this study was to describe Loxo s ce l e s a cc i d e n t s n o t i f i e d by t h e Pernambuco Poison Information and Care Center (Centro de Informação e Assistência Toxicológica de Pernambuco -CIATox-PE), between 2018 and 2022.

METHODS
This study analyzed a series of cases notified on the DATATOX, the CIATox-PE case recording system. 8Pernambuco has approximately 9 million inhabitants, distributed over 98,067.877km² and 184 municipalities, which in turn are grouped into 12 Regional Health Management Districts (Gerências Regionais de Saúde -GERES). 25e database chosen for this study was the DATATOX, a computerized system for recording, monitoring, storing, processing and retrieving data on cases of exposure to toxic agents, cared for by CIATox throughout Brazil.The study content and concepts, involving notification forms used by some CIATox, were based on the

Main results
The 22 cases described represent an alert for the presence of a venomous species not reported in previous studies in Pernambuco.The severity of cases may be associated with delays in seeking medical care, especially due to the population's lack of information.

Implications for services
Identify the presence of brown spiders in households in the region and the potential severity of poisonings.Alert health professionals to recognize the clinical picture with a view to appropriate early treatment.

Perspectives
Develop research on poisoning by venomous animals and educational actions alerting the population to prevent these accidents and updating health professionals on care.

model of the American Association of Poison Control Centers (AAPCC) and the International Program on Chemical Safety (INTOX/IPCS).
We also sought to verify other poisoning notification models that exist in Brazil, such as the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notif icação -SINAN) and the Health Surveillance Notif ication System (Sistema de Notif icações em Vigilância Sanitáriae-Notivisa); however, DATATOX is an exclusive system for cases reported by the CIATox, while the SINAN covers a wide range of diseases and conditions subject to compulsory notification and consequently does not monitor the evolution of each notified case. 26e DATATOX system was accessed by the researchers remotely, on January 13, 2023.Loxosceles accidents f rom January 2018 to December 2022 notified on electronic medical records were included in the study, while cases with unconfirmed information were excluded.

RESULTS
Of the 25 cases reported as loxoscelism, 22 were eligible; the remaining three were excluded due to lack of conclusive information about diagnosis.
The distribution of the 22 cases analyzed, according to the year and month of the accident, is shown in Figure 1: 3 cases in 2018; 4 in 2019; 3 in 2020; 7 in 2021; and 5 in 2022.Median age was 35 years, with an interquartile range of 20 to 45; there was a predominance of females, accounting for 13 cases.

RESEARCH NOTE
Brown spiders (Loxosceles) in Pernambuco Epidemiological and clinical characteristics of the spider bites are summarized in Table 1.
These accidents occurred in rural areas (12) and in urban areas (10), with greater occurrence at night (10).The bites occurred, almost exclusively, inside households (21).Bite topography was distributed almost equally between the lower (11)  The majority of cases were classif ied as moderate and severe (17).Reversible kidney injury occurred in one of the cases and the most frequent complication was wound infection, in 6 cases.Two individuals were lost to follow-up, and the majority (19) were cured; a single case, which presented pyoderma gangrenosum, required amputation of the lower left limb.

DISCUSSION
The epidemiological characteristics of the notified cases were similar to those of the cases described in the literature, differing only in terms of the greater frequency of moderate and severe clinical conditions, probably associated with taking more time to seek medical care.
Adults were most affected, with no difference between the sexes.These results are in line with those of other research carried out in the southern region of Brazil for the period 2019-2021. 5,6,27The first notifications corresponded to the Sertão region of the state of Pernambuco, followed by occurrences in municipalities closer to the coast, suggesting geographic displacement of cases.Rural and urban areas had similar notifications in numbers, unlike the cases cited in the Ministry of Health manual for the years 2001-2019, for which the urban area was the main place of occurrence, perhaps due to the greater demographic density in rural areas in northeast Brazil when compared to rural areas the southern region of the country. 2,3,25As the Loxosceles spider usually inhabits domestic spaces, almost all accidents occurred in households, the expected habitat of these spiders, according to findings from other research carried out in southern Brazil for the period 2001-2019. 2,3,5,28dian time elapsed between the victim being bitten and receiving care was 48 hours, this being higher than that found in reviews of the literature and research on endemic areas in the state of Paraná and in Chile for the period 2021-2022, probably due to a lack of common knowledge about brown spiders, diff iculty in accessing health services and initial injury not characteristic of brown spider bite. 6,14,27his time interval is worrying as it implies a prognosis for those affected: use of specific serum is indicated in moderate and severe cases, being more effective the sooner it is applied.The Ministry of Health recommends that it be administered within 36 hours. 3,10,14A considerable number of moderate and severe cases did not receive serotherapy because the time needed for its adequate use had already elapsed. 14inical classification as "severe cutaneous form" and "moderate cutaneous form" was probably more f requent due to the delay in seeking medical assistance, which led to the worsening of the condition, unlike cases

RESEARCH NOTE
Brown spiders (Loxosceles) in Pernambuco that receive serum therapy in time. 6,26,29Most cases were hospitalized and were treated with antimicrobials, given the presence of signs of infection in the wound, requiring debridement.Cases reported as being of the "severe cutaneous form" had larger lesions, slower evolution and longer hospitalization.Lack of information among the population about the severity of accidents could possibly account for underreporting of mild cases, and could have increased the proportion of severe and moderate cases.
The majority of accident victims recovered without sequelae.However, one of them took 24 days to seek health care and developed pyoderma gangrenosum as a complication, requiring 60 days of hospitalization and amputation of their lower left limb.Excluding this case did not lead to an important change in the assessment of the time elapsed -considered high -before seeking health services.
Given the small number of cases in the sample, the results and hypotheses raised have limited applicability, and further research is recommended.The loxoscelism cases in Pernambuco presented epidemiological characteristics similar to those described for AUTHOR CONTRIBUTIONS Amorim MLP and Mello MJG contributed to the study concept and design, analysis and interpretation of the results, drafting and critically reviewing the contents of the manuscript.Simão DGO and Albuquerque JPVS contributed to acquisition, analysis and interpreting of the results, drafting the initial version and critically reviewing the contents of the manuscript.Ramos BMT and Silva GJL contributed to drafting and reviewing the contents of the manuscript, through research supervision, grammatical assistance and technical editing.All the authors have approved the final version of the manuscript and are responsible for all aspects thereof, including the guarantee of its accuracy and integrity.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.Associate editor: Thaynã Ramos Flores endemic regions.The delay in seeking health care should serve as a warning for health surveillance and health care services, so that the population and health professionals involved be better informed about the presence of the brown spider (Loxosceles), the possible complications arising from brown spider bites and the importance of prevention measures, aiming to reduce morbidity caused by them.

ASSOCIATED ACADEMIC WORK
and upper (9) limbs.Median time elapsed between being bitten and receiving medical care was 48 hours, with 12 of the individuals treated after 36 hours.Hospitalization occurred in 18 cases, with a median hospital stay of 5.5 days.Among the treatments carried out, serotherapy with anti-arachnid serum or anti-loxocelic serum was adopted in 11 cases, while corticosteroids were used in 14 cases and antimicrobials in 16.Due to having exceeded the effective time of anti-arachnid serum therapy, 8 individuals did not receive specific serotherapy.Wound debridement was performed in 7 cases.

Figure 1 -
Figure 1 -Distribution of DATATOX a loxoscelism notifications, by month and year of occurrence, Pernambuco, Brazil, 2018-2022 a) DATATOX = Brazilian System for Recording Poison Information and Care Center Poisoning Data (Sistema Brasileiro de Registro de Intoxicações dos Centros de Informação e Assistência Toxicológica).

Figure 2 -
Figure 2 -Geographic distribution of loxoscelism cases notified by the CIATox-PE, a Pernambuco, Brazil, 2018-2022 Legend: PE = Pernambuco; BA = Bahia; PB = Paraíba.a) CIATox-PE = Pernambuco Poison Information and Care Center (Centro de Informação de Assistência Toxicológica de Pernambuco).Notes: The black circles correspond to the number of cases per municipality, scale 1:2,500,000, with map orientation (north) corresponding to the convention.Circles outside Pernambuco correspond to two cases exposed in Juazeiro (Bahia) and Conde (Paraíba).
This article was derived from the scientific initiation project and undergraduate thesis entitled Brown spiders are arriving in Pernambuco: case reports and epidemiological alert, to be submitted by Diógenes Gayo de Oliveira Simão at the Student Congress of the Faculdade Pernambucana de Saúde/Medicine Course in the second semester of 2023.Correspondence: Maria Lucineide Porto Amorim | lucineideporto0@gmail.comReceived: 09/08/2023 | Approved: 20/10/2023