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5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019
| Contributor Information
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Image courtesy of Wikimedia Commons | Insects Unlocked.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
The stinger of a red paper wasp (Polistes carolina) is shown.
Many species of the phylum Arthropoda, which includes insects, arachnids, crustaceans, and myriapods, are weaponized, ie, capable of exuding toxins, of injecting venom through a stinger or fangs, or of causing mechanical damage by biting or pinching. Moreover, while most arthropods are harmless or mere nuisances, a few can trigger serious reactions. Often, anticoagulants and enzymes contained in arthropod saliva cause pain, localized irritation, and (sometimes potentially fatal) allergic reactions, with arthropod venom capable of affecting cellular and nervous functions.[1] Can you recognize the following signs of arthropod envenomation?
Image courtesy of Ginger Parker.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A 2-year-old boy is brought by his parents to an emergency department (ED) in Arizona at 2 am. His family reports that he awoke from sleep screaming. They report no significant past medical history, recent illnesses, fevers, congenital abnormalities, recent travel, or known sick contacts. On examination, the boy is afebrile, extremely restless, and crying inconsolably, with chaotic thrashing of the extremities. You note a small area of erythema on the child's right calf (shown), as well as mydriasis and hypersalivation. What is the likely diagnosis?
Methamphetamine poisoning
Scorpion envenomation
Allergic reaction
Bedbugs
Image courtesy of Wikimedia Commons | JAdams1776.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: B. Scorpion envenomation
This image shows the stinger of a bark scorpion.
Scorpion stings cause a wide variety of symptoms. Most scorpion envenomations result only in a painful local skin reaction that responds to supportive care. Indeed, of the 1750 or so scorpion species worldwide, only about 25 (mostly in the family Buthidae) are considered medically significant,[2] with envenomations from these capable of causing serious reactions, including neurologic, cardiovascular, and respiratory complications.
Of the naturally occurring species in the United States, only the bark scorpions (genus Centruroides, especially C sculpturatus) are medically important;[3] indeed, C sculpturatus could be responsible for the patient presentation on the previous slide. Bark scorpion venom affects sodium-channel gating in nerve cells, leading to membrane hyperexcitability, excessive neuromuscular activity, and autonomic dysfunction.[4] Antivenin alleviates symptoms in minutes but may have side effects when used in children.[5] No scorpion-related deaths have been reported in the United States for over 20 years, but scorpion envenomations are a significant problem in tropical countries, causing more deaths than attacks by dangerous snakes do.[6]
Image courtesy of Wikimedia Commons | Musides.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
C sculpturatus (shown), the Arizona bark scorpion, found throughout Arizona, New Mexico, and parts of Texas and California, is the only scorpion in the United States that possesses venom potent enough to cause systemic toxicity (although some species of Centruroides outside the United States can also induce systemic symptoms). However, while systemic effects from C sculpturatus can be severe, particularly in children, they rarely cause mortality in victims older than 6 years.[7,8]
Most scorpion venoms contain small peptide toxins that target both insect and mammalian ion channels.[9]
Image courtesy of Armed Forces Pest Management Board | James A Swaby.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
An airman deployed to the Middle East presented with a blister at the base of his big toe (shown) 2 days after being stung by an unidentified species of scorpion. The patient had no additional symptoms other than the initial pain, swelling, and headache.
Following a scorpion sting, immediate onset of pain and paresthesia in the affected extremity are common.[7] In more severe cases, cranial nerve abnormalities develop, resulting in wandering eye movements, blurred vision, pharyngeal muscle incoordination, hypersalivation (sialorrhea), tongue fasciculation, and slurred speech. Excessive motor activity may occur, including ataxia, emprosthotonos (tetanic spasm, with flexion of the body so that the head and feet move toward one another), muscular fasciculations, restlessness, or thrashing or jerking of the extremities; this last can resemble seizurelike activity but without the stereotyped and repetitive tonic-clonic characteristics of seizure.[6,7,10] Nausea, vomiting, tachycardia, and severe agitation may also be present. Without antivenin treatment, symptoms can last 24-48 hours. If death occurs, it is often the result of cardiogenic shock and pulmonary edema.
Stings from scorpions in the family Buthidae outside of the United States can also cause acute myocarditis, tachydysrhythmia and bradydysrhythmia, cardiovascular collapse, respiratory failure, and cardiac arrest.[10]
Image courtesy of BugGuide | Arlo Pelegrin.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
All scorpions fluoresce under ultraviolet light. An Arizona stripetail scorpion (Vaejovis spinigerus) is shown.
Management of a scorpion envenomation includes local wound care, tetanus prophylaxis, and pain management. In young children or patients with severe toxicity, hospitalization may be required. Administration of antivenin depends on the severity of symptoms. One must also weigh the benefits versus the risks of antivenin—that is, quicker resolution of symptoms versus potential harm (ie, anaphylaxis or serum sickness).[5] Continuous intravenous (IV) midazolam infusion has been used for C sculpturatus envenomation until abnormal motor activity and agitation have resolved. Pediatric patients may also be treated with benzodiazepine boluses, but this should not be combined with antivenin, as it may cause oversedation.[10] Atropine has been used to reverse the excessive oral secretions in C sculpturatus envenomation.[7]
Image courtesy of DermNet NZ.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A 14-year-old boy presents to the ED after "feeling a pinch" on his left foot, with localized erythema (arrow) observed. On arrival, his heart rate is 125 bpm, his blood pressure is 172/122 mm Hg, his temperature is 99.6°F (37.6°C), his respiratory rate is 22 breaths/minute, and his oxygen saturation is 98%. He is diaphoretic and complaining of diffuse muscle cramps in his extremities and trunk. The electrocardiogram, routine laboratory tests, and toxicology screens are negative. What envenomation could produce this reaction?
Brown recluse spider
Centipede
Black widow spider
Tick
Hymenoptera
Image courtesy of Dendane T, Abidi K, Madani N, et al. Case Rep Med. 2012;2012:794540. PMID: 22319538 PMCID: PMC3272799.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: C. Black widow spider (genus Latrodectus)
The above echocardiogram shows hypokinesis of the septum and parietal wall of the left ventricle in a 35-year-old man who experienced acute myocarditis due to a black widow spider's bite. This is a rare effect of black widow venom.
Although most spiders produce venom, the majority lack fangs capable of delivering it through human skin. Additionally, fangs are food-acquisition weapons and are used defensively only as a last resort. Black widow spiders and brown recluses are the only North American spiders capable of delivering a medically significant bite.
Image courtesy of the US Centers for Disease Control and Prevention (CDC) | James Gathany.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Of the black widows, only the females, identified by the ventral markings on the abdomen (shown), are dangerous. The markings are not invariably evident, however, especially in the Western black widow (L hesperus). The neurotoxin α-latrotoxin, the active component of the black widow's venom, is responsible for envenomation syndrome in humans. This agent, which binds to specific receptors in the presynaptic endplate, causes a massive release of neurotransmitters, predominantly acetylcholine and norepinephrine.[7,11]
Image courtesy of Flickr | David O'Connor.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Of the 31 species of widow spider worldwide, three species of black widow spiders are found in the United States: the Northern black widow (L variolus), the Southern black widow (L mactans), and the Western black widow (L hesperus). Black widow spiders usually bite when their web is disturbed or upon inadvertent exposure in shoes and clothing.[7] Most bites are felt immediately as a pinprick sensation at the bite site, followed by increasing local pain that may spread quickly to include the entire bitten extremity. The bite mark tends to be limited to a small puncture wound (shown) or a wheal-and-flare reaction that often is associated with a halo. The effects from the bite spread contiguously. Two other species of widow spiders occur in the United States: the red widow (L bishopi) and the brown widow (L geometricus). Confirmed reports of bites by these spiders are extremely rare. Although their venom has a similar action to that of the black widow, the effect is much milder and not of clinical concern.[12]
Image courtesy of Wikimedia Commons | Mikael Häggstrâm, (background) Dreamstime | Sharplaninac.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
The effects of black widow envenomation range from no symptoms to local pain at the envenomation site with normal vital signs to consequences such as muscular pain at the site with migration of pain to the trunk, diaphoresis at the bite site, diaphoresis distant from the bite site, and generalized myalgia to the back, chest, and abdomen, with nausea, vomiting, headache and abnormal vital signs. Restlessness, priapism, and compartment syndrome at the bite location have also been reported.[11] Envenomation severity can be graded from mild (grade 1) to severe (grade 3). Serious symptoms can include severe abdominal cramping, hypertension, nausea, perspiration, and urinary retention.[13,14]
Image courtesy of Dendane T, Abidi K, Madani N, et al. Case Rep Med. 2012;2012:794540. PMID: 22319538 PMCID: PMC3272799.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
The above magnetic resonance imaging (MRI) scan demonstrates hyperintensity of the posterolateral wall of the basal left ventricle, a sign of hypokinesia, in the same patient as in the figure on slide 8.
Management of black widow bites includes basic wound evaluation, local wound care, and tetanus prophylaxis. Treatment should primarily emphasize supportive care.[15] Pain management ranges from the use of cold packs and nonsteroidal anti-inflammatory drugs (NSAIDs) to the administration of IV opioids, depending on the severity of symptoms. In addition to controlling muscle spasms, benzodiazepines provide sedation and anxiolysis.[7] Rarely reported complications of envenomation include myocarditis (as mentioned), atrial fibrillation, myocardial infarction, respiratory distress, and death.[7]
Image courtesy of Wikimedia Commons | Chuck Evans (mcevan).
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A black widow spider antivenin does exist, but the risks of possible allergic reaction and complications from its use should be weighed against the potential benefits. Antivenin is rapidly effective and curative; however, due to the potential for anaphylaxis and serum sickness, administration should be considered only for patients with systemic symptoms and severe reactions (ie, hypertensive crisis or intractable pain) that are uncontrolled by or unresponsive to supportive care.
Image courtesy of Medscape | Michael Cardwell, Victorville, California.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A 6-year-old girl in Nebraska is brought to the ED by her mother for evaluation of a pruritic rash. The child's mother mentions that she noticed her daughter scratching her elbow while the girl was playing on a woodpile behind a shed about 6 hours ago. Worrying that her daughter might have been bitten by a spider, the mother investigated the play site and found a small brown spider (shown), which she caught and brought with her in a jar. What is the name of this spider?
Image courtesy of BugGuide | Arlo Pelegrin.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: Brown recluse spider (Loxosceles reclusa)
Recluse spiders (also known as violin or fiddleback spiders) have a brown, violin-shaped mark on the dorsum of the cephalothorax and six eyes arranged in three dyads (shown). The venom is cytotoxic, its two main constituents being hyaluronidase, which facilitates the penetration of the venom into tissue, and a group of destructive enzymes called phospholipases D (formerly, sphingomyelinases D), which cause necrosis and red blood cell hemolysis.[11,16,17] Early on, polymorphonuclear leukocytes collect perivascularly, accompanied by hemorrhage and edema, with advancement to intravascular clotting. Coagulation, occluding the microcirculation, gives rise to necrosis.[1,7] There are 11 species of recluse spiders native to the United States, as well as two introduced species, the Mediterranean recluse spider (L rufescens; shown) and the Chilean recluse spider (L laeta). Only L reclusa and L laeta have been confirmed to have medically significant bites.
Image courtesy of the CDC.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A brown recluse bite is shown 4 months after envenomation. Localized tissue necrosis occurred in this patient.
The mother of the 6-year-old girl discussed in slide 14 reports no fever, nausea, or vomiting; no changes in appetite, bowel movements, or urination; and no increase in the size of the affected area. Upon examination, the youngster is smiling, playful, and intermittently scratching her right elbow. Her vital signs are normal, and she appears to be in no distress. What is the correct management of this patient?
Admit to the hospital for 24-hour monitoring
Administer dapsone and colchicine and observe in the ED
Provide local management with wound care, immobilization, tetanus prophylaxis, analgesics, and antipruritics as needed
Consult plastic surgery specialists for immediate wound debridement
Image courtesy of Wikimedia Commons | Br-recluse-guy.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: C. Provide local management with wound care, immobilization, tetanus prophylaxis, analgesics, and antipruritics as needed
In this case, no spider was witnessed causing the injury, so a degree of diagnostic caution should be observed. The presence of a spider in the general location where an injury was sustained is not proof of spider involvement. Also, many recluse bites do not cause serious symptoms. If needed, debridement and plastic surgery can be performed several weeks after adequate tissue demarcation has occurred.[7] Patients manifesting systemic symptoms or those with expanding necrotic lesions should be admitted to the hospital. Administration of the polymorphonuclear white blood cell inhibitors dapsone and colchicine and provision of antivenin are considered experimental; randomized, controlled clinical trials are lacking.[7] The brown recluse spider (L reclusa) is shown.
Image courtesy of Wikimedia Commons | Bob the Wikipedian | National Atlas of the United States.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
This map shows the distribution range of L reclusa. Although single specimens of the brown recluse are occasionally collected outside of this range, the number of extralimital brown recluse bite diagnoses greatly exceeds the number of actual specimens.[18]
Brown recluse spider bites can be clinically divided into three major categories. In the first category, very little venom is injected through the bite, with the resulting lesion being a small erythematous papule that may become firm prior to healing; a localized urticarial response may arise in association.[1]
Image courtesy of Medscape | Thomas Arnold, MD.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
The second category includes bites characterized by a cytotoxic reaction. The lesion's diameter may grow, with a central hemorrhagic blister demarcated.[1,7]
Image courtesy of Dale Losher.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Having sustained a brown recluse bite, the above patient demonstrated swelling and blue and dark red coloration by the evening of the first day.
The third category of brown recluse bites includes the rarer systemic effects of the venom, none of which are predicted by the cutaneous reaction's extent. They will occur 24-72 hours after the bite and can manifest as fever, chills, weakness, ecchymosis, edema, nausea, vomiting, arthralgia, petechiae, rhabdomyolysis, and disseminated intravascular coagulation, as well as hemolysis that can result in anemia, hemoglobinuria, renal failure, and death. Jaundice and icteric sclera may develop.[1] Often, bite victims show eruptions on the trunk (petechial, morbilliform, and scarlatiniform).[17]
Image courtesy of Armed Forces Pest Management Board | James A Swaby.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
In the typical progression of a category 2 brown recluse envenomation, the central blister undergoes necrosis 3-4 days after the bite, with eschar developing after 5-7 days. Induration of the wound occurs after 7-14 days, with the eschar falling off and the resulting ulceration healing by secondary intention.[1,11,19] Fatty regions, including the thighs, buttocks, and abdomen, are the sites of more extensive local necrosis.[1,7] Correct diagnosis of a brown recluse envenomation without definitive spider identification is impossible. In patients who are suspected of having been bitten and who exhibit signs and symptoms of envenomation, a complete blood count, blood urea nitrogen levels, creatinine levels, and a coagulation profile should be obtained.
Image courtesy of the US Department of Agriculture | Daniel Wojcik.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A 25-year-old Florida man presents to the ED complaining of a burning itch after being stung by fire ants. He is in no acute distress and denies fever, nausea, or dyspnea. His temperature is 98.7°F (37.1°C), his pulse is 88 bpm, his blood pressure is 127/88 mm Hg, and his respiratory rate is 18 breaths/minute. Bites are noted only over his right lower extremity, and they are extremely pruritic. What is the best management strategy?
Patient reaction is localized; therefore, treat with cold compresses and clean with soap and water
Treat symptoms with oral corticosteroids, antihistamines, and analgesics
Immediately administer intramuscular epinephrine
Both A and B are correct
A, B, and C are all correct
Image courtesy of Medscape | BM Drees, Texas Imported Fire Ant Project Coordinator, Texas A&M University, College Station, Texas.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: A. Patient reaction is localized; therefore, treat with cold compresses and clean with soap and water
Local reactions to fire ant bites can be treated with cold compresses and cleansing with soap and water. Some authors recommend topical or injected lidocaine with or without 1:100,000 epinephrine or topical vinegar and salt mixtures to decrease pain at the site of the bite. Larger reactions can be treated with oral corticosteroids, antihistamines, and analgesics. Systemic reactions should be treated with intramuscular epinephrine.[7] Fire ant bites initially lead to the formation of a wheal, followed by the development of sterile pustules; additional reactions can range from a small burning itch to painful swelling, tissue edema, and anaphylaxis.
Image courtesy of Medscape | BM Drees, Texas Imported Fire Ant Project Coordinator, Texas A&M University, College Station, Texas.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Fire ants (genus Solenopsis) are named for the burning pain that develops after exposure. The chief troublemaking species is S invicta, the red imported fire ant (shown). It lives in grassy areas and garden sites and near sources of water, and it is very difficult to eradicate.[20] The 3-6 mm ants are not always conspicuous, so people and pets often inadvertently trespass on their territory. If disturbed, the ants swarm up the intruder's leg and then sting all at once. Fire ants firmly grasp the skin with their mandibles and can repeatedly inject venom from a retractile stinger at the end of the abdomen. The venom is 95% insoluble alkaloid, with a small aqueous fraction that contains soluble proteins. Inhibiting the muscle cell membrane's Na1-K1-ATPase pump, the alkaloids (methyl-n-piperidines) prompt a postsynaptic neuromuscular blockade.[21] The stings produce a pustule and pain, whereas the aqueous portion of the venom is responsible for its allergenic activity.[7]
Image courtesy of Wikipedia | Strongbad1982 (talk).
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
This map shows the current distribution of the red imported fire ant (S invicta) in the United States. Fire ants are characterized by their tendency to swarm when provoked and may attack in great numbers. Hypersensitivity to fire ant venom from a single bite occurs in 0.6-6% of individuals who have been stung. There is significant crossover with persons sensitized to other members of Hymenoptera.[7] There is a potential for anaphylaxis associated with fire ant stings, but promising research using whole-body extracts has curtailed systemic reactions in laboratory conditions.[22]
Image courtesy of Wikimedia Commons | DLdoubleE.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
A 32-year-old man is brought by his friends to the ED with a generalized urticarial rash (similar to that shown here) and audible stridor. He appears to have altered mental status and is not responsive to questioning. His friends report that they were playing lacrosse in the local field when he started complaining of trouble breathing and shortly after fainted. His pulse is 150 bpm, his blood pressure is 78/35 mm Hg, his respiratory rate is 32 breaths/minute, and his oxygen saturation is 85% (room air). Along with preparing for emergent intubation, what medication should you immediately administer?
0.01 mg/kg intramuscular (IM) epinephrine, and start normal saline boluses
Parenteral diphenhydramine, ranitidine, and steroids
0.3-0.5 mg IM (1:1000 concentration) epinephrine
1 L normal saline bolus
Image courtesy of Wikimedia Commons | Muhammad Mahdi Karim.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
Answer: C. 0.3-0.5 mg IM (1:1000 concentration) epinephrine
This patient is in anaphylactic shock from a bee sting. The first medication administered should be epinephrine, 0.3-0.5 mg IM. Parenteral administration of standard antihistamines and steroids is recommended. The patient should be observed for several hours to ensure that symptoms do not intensify or relapse. Bronchospasm can be treated with beta-agonist nebulization. Hypotension may require massive crystalloid infusion. If hypotension persists, an IV infusion of epinephrine at 2-10 mcg/min can be started. Dopamine has also been used for persistent hypotension. Antivenin is not yet commercially available to treat bee stings.
In this image, a honeybee (Apis mellifera) carries pollen back to its hive.
Image courtesy of Wikimedia Commons | Waugsberg.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
In this image, a honeybee's stinger has been torn off of the insect and remains in the wound, continuing to pump venom into the victim.
A bee sting usually causes immediate pain, a wheal-and-flare reaction, and localized edema, without a systemic reaction. Toxic reactions occur with multiple stings and include gastrointestinal symptoms (eg, vomiting and diarrhea), headache, fever, syncope, and, rarely, rhabdomyolysis, renal failure, and seizure.[23] Hypersensitivity reactions, including anaphylaxis, are immunoglobulin E (IgE)–mediated and are not dependent on the number of stings.[7] Honeybees sting only in self-defense or in defense of the hive. Many wasp and hornet species are much more aggressive; their stings usually have a similar presentation.[24]
Image courtesy of Wikimedia Commons | Waugsberg.
5 Arthropod Envenomations: From Benign Bites to Serious Stings
Nima Sarani, MD; Bo Burns, DO, FACEP, FAAEM | September 3, 2019 | Contributor Information
This image demonstrates a bee sting wound after the stinger has been removed.
Application of an ice pack to the bee sting site diminishes swelling and can halt discomfort in local reactions. The stinger should be removed by scraping to avoid squeezing remaining venom from the retained venom gland. Following evisceration, the gland continues to undergo involuntary muscle contraction, so prompt removal of the stinger prevents a greater volume of venom from being introduced. NSAIDs and other analgesics, in addition to antihistamines, can relieve discomfort.[7]
Components of honeybee venom include melittin, apamin, and peptide 401. Cell membrane hydrolysis by melittin alters membrane permeability, with this polypeptide being the primary source of sting-related pain. Peptide 401 prompts an inflammatory reaction by causing mast cells to release histamine as they degranulate. Enzymatic components include phospholipase A2, which, though nontoxic by itself, plays a major hemolytic role when working in tandem with melittin.[25]
What some schoolchildren did on their summer vacation was to contract infections or infestations that they can pass on to their classmates. Do you know how to recognize and treat them?Slideshows, August 2019
Scorpion stings are a major public health problem in many underdeveloped tropical and subtropical countries, especially Sahelian Africa, South India, the Middle East, Mexico, and South Latin America. The estimated annual number of scorpion stings is 1.2 million leading to 3250 deaths (0.27%).Diseases/Conditions, November 2018
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Contributor Information
Authors
Nima Sarani, MD
Emergency Medicine
Disclosure: Nima Sarani, MD, has disclosed no relevant financial relationships.
Bo Burns, DO, FACEP, FAAEM
George Kaiser Family Foundation Chair in Emergency Medicine
Associate Professor & Program Director
Department of Emergency Medicine
University of Oklahoma School of Community Medicine
Tulsa, OK
Disclosure: Bo Burns, DO, FACEP, FAAEM, has disclosed no relevant financial relationships.
Editor
Mark P Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P Brady, PA-C, has disclosed no relevant financial relationships.
Reviewer
Arlo Pelegrin, MSc
Professor of Biology
Community College of Aurora
Aurora, CO
Disclosure: Arlo Pelegrin, MSc, has disclosed no relevant financial relationships.
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References
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