Black widow spiders (Latrodectus mactans) are found throughout the US. Though bites are relatively uncommon, they pose a significant health problem with over 2500 reported to American poison control centers annually. Black widow spider bites cause a characteristic envenomation syndrome consisting of severe pain, muscle cramping, abdominal pain, and back pain. The significant pain associated with envenomation is often refractory to traditional analgesics. Antivenom (Antivenin Latrodectus mactans) is available and effective, but is often withheld because of a fear of acute hypersensitivity reactions. We report four cases of symptomatic black widow spider envenomation. One of the reported cases was managed without antivenom, and, in contrast, three were treated successfully with Antivenin Latrodectus mactans. We believe that these cases demonstrate safe and effective use of black widow antivenom. This article presents the rationale for use of antivenom in these cases, and a nonsystematic review of the pertinent literature.