Andrew Graziano chose the subject of spider bites as for his RLRA research paper- specifically the brown recluse spider.

His paper, and the background research that it entailed, led to a real-life hospital diagnosis that made him a standout in his rotation.

A unique and integral part of the Saba University curriculum is the "Research: Literature Review and Analysis" module. Its purpose is to further develop students’ abilities to evaluate and assimilate scientific evidence and to reinforce the skills required to critically appraise the ever-changing body of medical knowledge.

For his RLRA paper, Andrew Graziano choose the topic “Loxosceles recluse: A review of literature with the purpose of determining accurate diagnosis for physicians in nonendemic areas”

When a patient in Kansas City entered the hospital during Andrew’s internal medicine rotation he knew right away that the patient had a brown recluse spider bite (the patient had been previously misdiagnosed). While the attending physician at the hospital correctly diagnosed the bite, Andrew Graziano stood out among his peers as the only student with a good knowledge of the bite, possible complications of the bite and best treatment options.

1) Why did you choose this topic for your RLRA?

I knew I wanted to work with Dr. Robson from the start. I wanted her as my mentor. She is a professor who truly values her student's education. I went to her office and said, "Dr. Robson, I want to do an RLRA where you are my mentor. And I want to try and publish." She turned to me and said, "Spider bites." And we went from there. As the paper began to take shape, we focused more on the fact that the brown recluse is blamed for a lot of bites in the entire USA, even where it is not endemic. Our paper became more of a Systematic Analysis of submitted cases. With the goal of creating a tool for recognition and treatment.

2) Did you recognize the bite on the patient right away when they came into the hospital? Where was this internal medicine rotation?

Yes. When the team I was on received the patient it was clearly evident that it was a Loxosceles reclusa exposure. There was an indurated area (referred to as a volcano lesion) with surrounding necrosis and erythema. The endemic area of L. reclusa drapes over all of the state of Missouri. The patient presented with a text book story of how a brown recluse would be prompted to bite someone.

3) What was the role of your attending physician and how did you interact with him/her regarding the patient’s bite?

Our attending was very well versed in treating L. reclusa bites. She asked us what we would expect to see as possible severe complications of a bite. I was able to answer correctly, knowing that hemolysis and disseminating intravascular coagulopathy were two severe outcomes. More uniquely, I was able to describe Systemic Loxoscelism that is very different than sepsis. In systemic loxoscelism the patient is usually hemodynamically stable but presenting with hematuria, elevated bilirubin, and elevated lactate dehydrogenase. I was also able to describe that treatment is just supportive care rather than severe interventions.

4) How do you think your RLRA paper helped you diagnose this bite, and what was the response of your attending physician to your understanding of the bite? Was he/her impressed?

The RLRA was key to my ability to contribute to this case. Dr. Robson insisted that I find as many cases as possible, find as many pictures of bites as possible, and find the specific limits to the endemic spread of the spider. Her standards allowed for me to succeed in this situation. And yes, my attending was impressed.