The initial bite of the black widow spider may be unnoticeable to the victim. A mild local pain may be felt at most in adults while infants may present with persistent crying [6]. The autonomic and the neuromuscular signs of spasms and muscle fasciculation sets in after a few hours to few days.

Some patients complain of muscle pain especially in the abdomen with increasing severity in time. These abdominal signs may be coupled by nausea and vomiting in some cases of Latrodectism. Systemic signs of fever, chills and hypertension are the direct effect of the excessive neurotransmitter released from the presynaptic cleft of the neuromuscular junctions which eventually make its way to the bloodstream.

• Fever

  When Kailyn developed a fever a few days later, her pediatrician sent her immediately to the ER. No one yet realized the girl was likely suffering from the bite of a venomous black widow spider. [today.com]

  Kailyn's father thought it was a bug bite that happened to be accompanied by a fever stemming from a cold. [newsweek.com]

• Weakness

  Hours 3-12: Clammy skin Labored breathing Weak pulse Delirium Increasing pain and cramps Pregnant women may go into labor Morphine and barbiturates may be used to ease the increasing pain and convulsions. [businessinsider.com]

  Symptoms of a black widow bite can include anxiety, difficulty breathing, painful muscle cramps, headache, high blood pressure, increased saliva, increased sweating, sensitivity to light, muscle weakness, nausea and vomiting, numbness, and restlessness [refinery29.com]

  Because black widow venom affects the nervous system, reactions can range from mild localized pain and a pruritic rash to severe muscle cramps followed by headache, weakness, tremor, and dizziness. [journals.lww.com]

  The local pain may be followed by localized or generalized severe muscle cramps, abdominal pain, weakness, and tremor. In severe cases, nausea, vomiting, faintness, dizziness, chest pain, and respiratory difficulties may follow. [webmd.com]

  Weakness, restlessness, and general pain can continue for months before the cat will make a full recovery. [wagwalking.com]

• Inflammation

  It can calm spider bite inflammation and redness and also encourage healing. Simply combine a few drops of lavender oil with coconut oil and put it directly on the spider bite. [draxe.com]

  The lesion that forms will be white in color, with a dark scab in the middle, and a zone of reddish inflammation around the bite. [healthypets.mercola.com]

  Additional toxins are then injected into the bite victim, all of which contribute to local inflammation and tissue necrosis (death). "Black widow envenomation affects the whole body, causing muscle tremors and other neurologic effects. [vcahospitals.com]

  Medications such as NSAIDs, designed to reduce pain and inflammation, will typically be administered at this time. Although antivenin is available for black widow bites and may be used if it is available, it is not commonly kept on hand. [wagwalking.com]

• Asymptomatic

  Investigators reviewed their medical records and categorized symptom severity as mild (asymptomatic or local pain only, 9%), moderate (muscle or abdominal pain with normal vital signs, 37%), or severe (generalized back, chest, or abdominal pain; nausea [mdedge.com]

  Grading Grade 1 Asymptomatic other than localized pain at Envenomation site Normal Vital Sign s Grade 2 Muscle pain in extremity with Envenomation Pain radiation into chest (arm bites) or Abdomen (leg bites) Local extremity diaphoresis Normal Vital Sign [fpnotebook.com]

• Dyspnea

  […] throbbing at bite site Next 2 to 3 hours: Latrodectism Musculoskeletal symptoms Diffuse, progressive myalgias in 100% of patients Gene ralized sweating Cardiopulmonary symptoms (associated with upper extremity bites) Crampy Chest Pain or chest tightness Dyspnea [fpnotebook.com]

  The systemic effects and symptoms of black widow envenomation include: severe pain, nausea, tachycardia, myocarditis, hypertension, pyrexia, dyspnea, vomiting, muscle weakness, rigidity, spasm, cramping and tetany, hyperreflexia, paresthesia, salivation [omicsonline.org]

• Vomiting

  Since vomiting is a symptom of a black widow spider bite, if the cat has eaten the spider and then vomits it up, it takes the guesswork out of what's wrong with the cat and, more importantly, the species of the sneaky spider. [pets.thenest.com]

  If possible, take a sample of your dog's stool and/or vomit with you to the veterinary clinic, this can help your doctor to make the diagnosis that much faster. [petmd.com]

• Abdominal Pain

  Investigators reviewed their medical records and categorized symptom severity as mild (asymptomatic or local pain only, 9%), moderate (muscle or abdominal pain with normal vital signs, 37%), or severe (generalized back, chest, or abdominal pain; nausea [mdedge.com]

  This can cause pain, numbness, tingling, redness, and swelling at the bite site. Other symptoms include muscle cramps all over the body and severe abdominal pain. [mountnittany.org]

  However, he returned later that day because his abdominal pain had worsened, so doctors sent him to a larger hospital for additional testing. [livescience.com]

  The first symptom is acute pain at the site of the bite though there may only be a minimal local reaction. The local pain may be followed by localized or generalized severe muscle cramps, abdominal pain, weakness, and tremor. [webmd.com]

• Severe Abdominal Pain

  This can cause pain, numbness, tingling, redness, and swelling at the bite site. Other symptoms include muscle cramps all over the body and severe abdominal pain. [mountnittany.org]

  Other symptoms include: Muscles that begin to hurt and become stiff, usually within 8 hours Nausea or vomiting Difficulty breathing Severe abdominal pain or cramping Excessive sweating Rash and itching Swollen eyelids Weakness or tremors. [webmd.com]

  You have severe abdominal pain. Your wound turns blue or black and smells foul. Your muscles become stiff and start to cramp or spasm. You have tremors or trouble breathing, talking, or walking. Your heart is racing. [drugs.com]

• Abdominal Cramps

  The venom is thought to be 15 times more potent than that of a rattlesnake, and can cause severe muscle pain and spasms, as well as abdominal cramps, for up to a week. "She never felt it bite her," a surprised Donovan told CBS Boston. [cbsnews.com]

  cramping (64%) Board-like rigidity Nausea and Vomiting (36%) Facial Symptoms Flushed sweating face Contorted, Painful grimace Conjunctivitis Trismus of masseters Facial edema Neurologic Symptoms Headache (27%) Restlessness Paresthesia s Seizure s Weakness [fpnotebook.com]

  abdominal cramps, back pain, excessive sweating, and hypertension. [wikihow.com]

  Black Widow Bite Symptoms & Treatment The biggest danger is the latrotoxin in their venom (a type of protein venom), which can cause systemic effects, like: Abdominal cramps Muscle pain Tachycardia Hyperhidrosis Muscle spasms Nausea Sweating Hypertension [pestwiki.com]

  The person who was bitten has severe pain, abdominal cramping or a growing ulcer at the bite site. You are unsure whether or not the bite was from a poisonous spider. [draxe.com]

• Acute Abdomen

  Mimics of black widow envenomation may include scorpion and snake bites, an acute abdomen, myocardial infarction, alcohol withdrawal, organophosphate poisoning and tetanus. [tandfonline.com]

  Victims also may have significant hypertension, autonomic and central nervous system dysfunction, and abdominal pain severe enough to be mistaken for an acute abdomen. 2 Our literature search didn’t find any RCTs comparing the efficacy of general symptomatic [mdedge.com]

  Latrodectism can be confused with an acute abdomen secondary to the significant muscle cramping and abdominal rigidity that can occur with a black widow spider bite. [clinicaladvisor.com]

  Severe cases of latrodectism should be distinguished from acute abdomen, rabies, or tetanus. Spiders are identified by location and markings. [msdmanuals.com]

• Hypertension

  The widow venom, a powerful neurotoxin known as a-latrotoxin, causes muscle pain, diaphoresis, tachycardia, flushing, and hypertension. Treatment is usually symptomatic with a combination of opioid analgesics and muscle relaxants. [ncbi.nlm.nih.gov]

  A bite may manifest with a clinical syndrome of headache, nausea, vomiting, muscle cramping, joint stiffness, hypertension and diaphoresis otherwise known as Latrodectism. [symptoma.com]

  Within minutes to hours of the bite, victims may develop localized pain, which may further progress to intense muscle spasms, nausea, vomiting, tachycardia, and hypertension. [nursingcenter.com]

  Hypertension, Tachycardia ) Headache Nausea and Vomiting References Clark (1992) Ann Emerg Med 21(7): 782-7 [PubMed] X. Differential Diagnosis XI. [fpnotebook.com]

  Widow spider bites cause immediate pain and sometimes regional or generalized manifestations such as muscle cramping, diaphoresis, hypertension and tachycardia, and weakness. Diagnose spider bites (often falsely suspected by patients) clinically. [msdmanuals.com]

• Tachycardia

  The widow venom, a powerful neurotoxin known as a-latrotoxin, causes muscle pain, diaphoresis, tachycardia, flushing, and hypertension. Treatment is usually symptomatic with a combination of opioid analgesics and muscle relaxants. [ncbi.nlm.nih.gov]

  Hypertension and tachycardia may occur in children. What's your assessment? David's history, description of the spider, and signs and symptoms lead you to suspect he was bitten by a black widow. [journals.lww.com]

  Hypertension, Tachycardia ) Headache Nausea and Vomiting References Clark (1992) Ann Emerg Med 21(7): 782-7 [PubMed] X. Differential Diagnosis XI. [fpnotebook.com]

  Within minutes to hours of the bite, victims may develop localized pain, which may further progress to intense muscle spasms, nausea, vomiting, tachycardia, and hypertension. [nursingcenter.com]

  Widow spider bites cause immediate pain and sometimes regional or generalized manifestations such as muscle cramping, diaphoresis, hypertension and tachycardia, and weakness. Diagnose spider bites (often falsely suspected by patients) clinically. [msdmanuals.com]

• Increased Sweating

  Symptoms of a black widow bite can include anxiety, difficulty breathing, painful muscle cramps, headache, high blood pressure, increased saliva, increased sweating, sensitivity to light, muscle weakness, nausea and vomiting, numbness, and restlessness [refinery29.com]

  In general, the signs and symptoms may include: Sharp pain at the bite site Severe muscle cramps from effects of the toxin/venom Nausea and vomiting Drooling and increased sweating General weakness Light-sensitivity Neurological symptoms including anxiety [dovemed.com]

  Possible symptoms resulting from a spider bite include: Itching or rash Pain radiating from the bite site Muscle pain and cramping Reddish to purplish color or bite site blistering Increased sweating Difficulty breathing Headache Nausea and vomiting Fever [doh.wa.gov]

  The following symptoms can also occur: Anxiety Difficulty breathing Headache High blood pressure Increased saliva Increased sweating Light sensitivity Muscle weakness Nausea and vomiting Numbness and tingling around the bite site, then sometimes spreading [ufhealth.org]

• Erythema

  Disorders That Mimic Spider Bites Category Examples Insect bites Ant bites Bedbug bites Flea bites Fly bites Reduviid (eg, assassin, wheel, kissing) bug bites Other arachnid bites Mite bites Tick bites Skin disorders Erythema chronicum migrans Erythema [msdmanuals.com]

  The patient had mild erythema without swelling at the bite site. She complained of severe pain and muscle cramps in the shoulder, neck, and back. [ncbi.nlm.nih.gov]

  Cutaneous symptoms are generally not a prominent feature in black widow envenomation and may include mild erythema with a surrounding halo or localized diaphoresis. [nursingcenter.com]

  Blanching and cyanosis slowly develop at the central core with spreading erythema and progression to dermonecrosis [ 9 ]. [omicsonline.org]

  Published online: 26 April 2018 Figure 3: Flushing and bite site with surrounding erythema. Figure 3: Flushing and bite site with surrounding erythema. [tandfonline.com]

• Flushing

  The widow venom, a powerful neurotoxin known as a-latrotoxin, causes muscle pain, diaphoresis, tachycardia, flushing, and hypertension. Treatment is usually symptomatic with a combination of opioid analgesics and muscle relaxants. [ncbi.nlm.nih.gov]

  Published online: 26 April 2018 Figure 3: Flushing and bite site with surrounding erythema. Figure 3: Flushing and bite site with surrounding erythema. [tandfonline.com]

  Cardiopulmonary symptoms (associated with upper extremity bites) Crampy Chest Pain or chest tightness Dyspnea Gastrointestinal Symptoms (associated with lower extremity bites) Abdominal cramping (64%) Board-like rigidity Nausea and Vomiting (36%) Facial Symptoms Flushed [fpnotebook.com]

• Dermatitis

  A few considerations include: contact dermatitis, cellulitis with staphylococcal and streptococcal species, Lyme disease, sporotrichosis, ecthyma gangrenosum, anthrax, herpes simplex, herpes zoster, leukocytoclastic vasculitis, and, of course, bites by [clinicaladvisor.com]

  Common differentials for necrotic arachnidism are: pyoderma gangrenosum, staphylococcus and streptococcus infections, herpes, diabetic ulcers, fungal infections, chemical burns, toxicodendron dermatitis, squamous cell carcinoms, vasculitis, syphilis, [omicsonline.org]

• Cold, Clammy Skin

  In more serious cases, a weak pulse, cold clammy skin, unconsciousness, or convulsions may occur. Treating a Black Widow Spider Bite If you get bit, remain calm. [tripsavvy.com]

• Muscle Cramp

  After a bad bite, severe pain and muscle cramps can start in a couple of hours. Muscle cramps start in the area of the bite (often a hand or foot) and move towards the center of the body. [poison.org]

  These include: Muscle cramps and spasms that start near the bite and then spread and increase in severity for 6 to 12 hours. Chills, fever, nausea, or vomiting. Sweating. Severe belly, back, or chest pain. Headache. Stupor, restlessness, or shock. [mottchildren.org]

• Painful Muscle Cramps

  Symptoms of a black widow bite can include anxiety, difficulty breathing, painful muscle cramps, headache, high blood pressure, increased saliva, increased sweating, sensitivity to light, muscle weakness, nausea and vomiting, numbness, and restlessness [refinery29.com]

  Brad Poreus' five days of pain, muscle cramping, incoherence, pouring night sweats, delirium, and narcotics may seem like a nightmare worthy of Hunter Thompson, but it represents the worst case for most people who get bitten by a black widow. [tested.com]

  […] out from the bite Restlessness Seizures (usually seen just before death in children who are bitten) Very painful muscle cramps Pregnant women may have contractions and go into labor. [ufhealth.org]

• Myalgia

  Myalgias and muscle spasms resulting from widow spider bites respond poorly to muscle relaxants and calcium salts. Symptomatic envenomation is initially treated supportively. [msdmanuals.com]

  Symptoms Initial Bite felt as pinprick with minimal initial pain First 10 to 20 minutes Pain and throbbing at bite site Next 2 to 3 hours: Latrodectism Musculoskeletal symptoms Diffuse, progressive myalgias in 100% of patients Gene ralized sweating Cardiopulmonary [fpnotebook.com]

• Muscle Twitch

  […] if it occurs secondary to the muscle twitches Oxygen therapy if needed for respiratory difficulty Dogs may recover with aggressive treatment for black widow spider bites. [doghealth.com]

• Headache

  Headache. Stupor, restlessness, or shock. Severe high blood pressure. What should I do if a black widow spider bites me? If you believe you have been bitten by a black widow spider: Get medical help immediately. [mottchildren.org]

• Tremor

  The local pain may be followed by localized or generalized severe muscle cramps, abdominal pain, weakness, and tremor. In severe cases, nausea, vomiting, faintness, dizziness, chest pain, and respiratory difficulties may follow. [webmd.com]

  This substance causes massive excitation of neurons (the cells within the nervous system), leading to the muscle tremors and other effects seen in black widow envenomation. [vcahospitals.com]

  Black widow venom attacks the nervous system, and although it is often undetectable initially, the poison may soon trigger nausea, sweating, elevated blood pressure, tremors and increased white blood cell counts. [newsweek.com]

• Dizziness

  In severe cases, nausea, vomiting, faintness, dizziness, chest pain, and respiratory difficulties may follow. The severity of the reaction can depend on the age and physical condition of the person bitten. [webmd.com]

  Occasionally, a severe allergic reaction can occur, causing symptoms such as breathing difficulties, dizziness and a swollen face or mouth. This requires immediate medical treatment (see below). [beaconmedicalgroup.nhs.uk]

  Other signs of a black widow spider bite include: Rigid muscles in the shoulders, chest, back, and abdomen Restlessness Anxiety Dizziness Headache Excessive sweating Weakness Drooping or swelling of the eyelids Continue Learning about First Aid For Animal [sharecare.com]

  […] symptoms may include: Sharp pain at the bite site Severe muscle cramps from effects of the toxin/venom Nausea and vomiting Drooling and increased sweating General weakness Light-sensitivity Neurological symptoms including anxiety, feeling restless, and dizziness [dovemed.com]

• Seizure

  If the veterinarian suspects a black widow bite, treatment can include: IV treatment with antivenin Monitoring and treating for seizures Watching for and treating high blood pressure Muscle relaxers and pain medications if needed Treating low blood sugar [doghealth.com]

  […] heart rate Drooling or excessive salivation Vomiting Diarrhea Restlessness Seizures Death Types Widow spiders come in several types, all of which contain powerful venom that acts as a neurotoxin. [wagwalking.com]

  In some instances, seizures and shock can develop. Symptoms peak two to three hours after onset but can last several days. [livestrong.com]

  Your cat needs to be taken to a veterinary hospital immediately, where they may need to provide oxygen treatment, intravenous fluid therapy, muscle relaxants, pain killers, anti-seizure medications, and anti-venom. Works Cited David R. Nelsen, W. [cathealth.com]

  Management: Antivenin (horse serum) Indications (rarely indicated) Critical Envenomation (Grade 3 bites) Respiratory arrest Seizure s Hypertensive heart disease Young Children or elderly Pregnant women Dosing Skin test first before dosing Evaluate for [fpnotebook.com]

• Confusion

  The spider is particularly prevalent in the Southwest, Southeast and California, and symptoms from its bite are painful and may be confusing to clinicians. [ncbi.nlm.nih.gov]

  False widows ( Steatoda sp.) are sometimes confused for black widow spiders ( Latrodectus sp.) and are mistakenly thought to be as dangerous. Both have a similar dark-coloured, globular body. [nhm.ac.uk]

  SWNS:South West News Service Spider experts compared the painful bite to a harmless bee or wasp sting but doctor's said it was toxic Confused as to why his bite hadn't healed, Matt researched his symptoms. [thesun.co.uk]

  Cobweb spiders that are most easily confused with widows are in the genus Steatoda. These cob web spiders are similarly black and have the same enlarged abdomen as widow spiders. [extension.colostate.edu]

  Call the Poison Center for additional information or if you are confused about what to do: Poison Centers across the country now have a new national emergency phone number - 1-800-222-1222 Or visit their web site: http://www.calpoison.org Common Questions [desertusa.com]

The diagnosis of the Latrodectus bite may require a detailed history of the incident with detailed account on the part of the eyewitnesses. The accurate chronology of the clinical signs can aid in the actual diagnosis of the arachnid bite. When the spider specimen is available, experts may be called in to identify the species of the spider.

Black widow spiders have the characteristic shiny black body with large rounded abdomen, it has the red hourglass mark at the ventral abdomen, and a general body length measure of 11 to 13 cm.

Blood tests may show increased polymorphonuclear activity with eosinophilia but are relatively inconclusive. The serum Creatine Kinase (CK) markers are usually elevated [7].

The pre-hospital treatment of the black widow spider bite includes the washing and cleaning of the bite site with soap and water.

Suspicion of envenomation may benefit from a tourniquet at the upper portion of the bitten limb to impede circulation of the venom to distal organs. The affected extremity is elevated to slow down the spread of the venom. Oral analgesics like aspirin and acetaminophen may relieve signs of pain. The introduction of the antivenom in the field is grossly discouraged with the fear of serious allergic reactions [8].

It is important to bring the specimen of the spider to the hospital along with the patient for proper identification. Hospital phase of treatment is geared towards supportive care of the airways and cardiac support. Antivenoms should be considered when there is there is an eminent threat in pregnancy, loss of limb and patient has refractory tolerance to pain [9].

In general, bites from the black widow spider are self-limiting without intervention. The antivenom may shorten the bothersome clinical course which may debilitate the patient for a few days to weeks if left untreated.

Rare cases of fatal bites may result to bronchorhea and pulmonary edema especially when there are allergic reactions involved in the immune response.

Complications

It is well established that there are very rare instances where a black widow spider bite may cause complications and may even lead to death. Most of these cases involve the very young and the very old segments of the population with concomitant illnesses.

In allergic reactions in the bronchus, severe phlegm formation may clog the airways and cause difficulty in breathing. The autonomic dysfunction of the diaphragm puts the patient at risk for pulmonary edema which could be fatal if not brought to hospital attention.

To determine the definitive cause of the spider bite and dictate the course of treatment, one must be keen in identifying the offending spider.

The black widow spider has distinct marking in the ventral abdomen in a shape of an hourglass. This red-orange symbol is clearly visible in the shiny black body of the arachnid. The female widows are the only ones capable of envenominating humans measuring from half to one inch long. It is also noteworthy that not all venomous Latrodectus are black, the Latrodecus geometricus are brown which are also found in North America and the red back widow or Latrodectus hasselti which are endemic in Australia.

Widow spider bites number to approximately 2300 bites in the year 2012 according to the Annual Report of the American Association of Poison Control Centers’ (AAPCC) National Poison Data System (NPDS) [3]. Almost all of the bites recorded in the US at that time were not serious and non-fatal since 1983.

The American Association of Poison Control Centers has given an estimated average of 2500 widow spider bites per year in the United States [4]. The known average of widow spider death in the United States since was 4 deaths per year [5].

The venom of the Latrodectus spider is virtually a neurotoxin identified as the alpha-Latrotoxin which affect the neuromuscular junctions in the presynaptic end and opens cation channels to release myriads of neurotransmitters.

The excessive neurotransmitters in the blood stream causes the clinical manifestations like the spastic cramping of abdomen and stiffness of the extremities. Other autonomic implication of the neurotoxins are the persistent pain and hypertension associated with the black widow spider bite.

The Latrodectus spider only bites humans in defense and when its habitat is disturbed. The main objective of the black widow spider bite prevention is to lower down contact between spiders and human.

Useful tips include:

• Wearing of gloves, long sleeves and hat when visiting the attic, sheds and untouched parts of the garage.
• Shake off clothing, cloves and shoes which were not used for a while.
• Insect proofing the house with repellants and the installation of tight screen fixtures.
• Keeping stored items elevated from the floor while discarding old boxes and other unwanted effects where the spiders may live.
• Vacuuming spiders and webs by placing them in a sealed plastic container to prevent them from inhabiting back in the house.

The Latrodectus mactans mactans or black widow spiders can inflict a noxious bite to humans that can cause a number of symptoms. A bite may manifest with a clinical syndrome of headache, nausea, vomiting, muscle cramping, joint stiffness, hypertension and diaphoresis otherwise known as Latrodectism [1].

Envenomation from dangerous spiders are relatively rare thus, the identification of the biting arachnid is paramount in the anti-venom vaccination of the patient. Black widow spiders lives in dirty places with minimal movement and lots of flies, more commonly in the attics, garage, outhouse, sheds and foliage where they usually come in contact with humans [2].

It is imperative that one should respect these spiders especially when found in their habitat. Removing them by hand will agitate them and bite in self-defense. When it is totally necessary to study them, one should use protective gloves and the proper instruments in handling them.

The female black widow spiders are the ones responsible for envenomation and are active during night time because they are nocturnal hunter [10].

1. Hoyte CO; Cushing TA; Heard KJ. Anaphylaxis to black widow spider antivenom Am J Emerg Med. 2012; 30(5):836.e1-2 
2. Boyer Hassen LV, McNally JT, Binford GJ. Spider bites. In: Auerbach PS, ed. Wilderness Medicine. 4thed. St. Louis: Mosby-Year Book; 2001:807-838.
3. Mowry JB, Spyker DA, Cantilena LR Jr, Bailey JE, Ford M. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila). Dec 2013;51(10):949-1229
4. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917
5. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wilderness Environ Med. Feb 1997;8(1):8-16. 
6. Woestman R, Perkin R, Van Stralen D. The black widow: is she deadly to children?. Pediatr Emerg Care. Oct 1996;12(5):360-4. 
7. Clark RF, Wethern-Kestner S, Vance MV, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. Jul 1992;21(7):782-7. 
8. Allen RC, Norris RL. Delayed use of widow spider antivenin. Ann Emerg Med. Sep 1995;26(3):393-4.
9. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med. Apr 2005;45(4):414-6. 
10. Bush SP, Naftel J. Injection of a whole black widow spider. Ann Emerg Med. Apr 1996;27(4):532-3.