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Clinical evidence of necrosis following bites by the Noble false widow spider Steatoda nobilis – a response to Paolino & colleagues

toxins, d-latroinsectotoxins, latrodectins and enzymes [2], which explains both systemic and local clinical signs, like ulceration and erosion. Necrosis is an inappropriate term referring to a spectrum of morphologic changes that follow cell death in tissues, and it is divisible in six main types: coagulative, liquefactive, caseous, gangrenous, fat and fibrinoid necrosis [3]. Gangrenous necrosis is the one mainly involved in spider bites, as it is induced mostly by proteolytic enzymes that cause cell death (e.g., sphingomyelinase in Loxosceles sp.) [4]. Necrosis induced by spider bites clinically shows specific and progressive pathognomonic aspects, such as prodromal swelling and blisters, followed by a cutaneous discoloration ranging from pale to blue, purple, black, bronze or red. The damaged tissue develops into dark black color, always resulting in a clinically evident scar due to dermal and hypodermic damage. In the case highlighted by the authors, shown in their Figure 1 [1], there are no evident signs of necrosis, but rather of an ulceration with yellowish areas, most likely induced by secondary bacterial super-infection. To confirm this assertion, the figure has been evaluated by four independent expert dermatologists (R.P., E.M., C.C., F.V.), initially without showing them the entire content of the article, to avoid conditioning: three out of four diagnosed ulceration and one, erosion. After reviewing the entire article, the dermatologists confirmed their respective answers. Indeed, ulceration can be defined as a deeper defect, with loss of at least the entire epidermis plus superficial dermis and sometimes sub-cutis, that may be caused by different factors, including spider bites. Furthermore, the probable bacterial super-infection present in the ulcerated lesions reported in the article confirms prior reports, where S. nobilis has been found to be a reservoir for medically important, and antibiotic resistant, bacteria on their body surfaces and fangs [5]. In Steatoda sp., nausea, vomiting, headache, local swelling, tremors, fatigue, hypotension, secondary bacterial infections, with local erythema, swelling and blistering may arise, inducing a cluster of manifestations called “steatodism”. However, there are not enough data to justify necrosis as a consequence of this spider bite. Acknowledgments