Transcript presentation

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
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
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)
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).
Results - continued
Spider/Arthropod Investigations
Period
# of
Patient
s
Housing Type
Arthropod Survey
Results
POCs
Ft. Meade, MD
Sum, 05
1
DINFOS Barracks
No med-imp
arthropods
Pagac
Ft. Meade, MD
Spr, 04
3
DINFOS Barracks
No med-imp
arthropods
Fay
Ft. Lee, VA
Win, 04
23
AIT Barracks
No med-imp
arthropods
Malley
Fort McNair, D.C
Fall, 04
6
Old Guard
Barracks
Neoscona spp
Pagac
APG, MD
Fall, 04
6
Barracks
No med-imp
arthropods
Sheikh
Ft. Benning, GA*
04**
unk
Barracks
No med-imp
arthropods
Kuhr
Camp Merrill, GA
Fall, 04
unk
Barracks
No med-imp
arthropods
Kuhr
Ft. Monmouth, NJ
Sum, 03
10
Cadet Barracks
No med-imp
arthropods
Miaullis
Installation/Location
* 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
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 patient’s 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?
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 patient’s 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)
DISCUSSION
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.
Discussion - continued
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
(Photos: A. Miaullis)
(Photos: A. Miaullis)
Discussion - continued
The Brown Recluse
- rufescens
Courtesy - Rick Vetter
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..
Sticky Trap Results
88 Trap Nights
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, > 2,000 Recluses, 3 month period
• How many confirmed bites per year?
• Hundreds?
• Dozens?
• < 2 per year (ave)
oo
oo
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)
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.
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 <10 infestations outside endemic
range, generally restricted to 1 building.)
• Recluses are limited in their dispersal potential.
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.