Insect Bites: Statpearls (Internet) - Treasure Island (FL) : Statpearls Publishing 2019 Jan
Insect Bites: Statpearls (Internet) - Treasure Island (FL) : Statpearls Publishing 2019 Jan
Insect Bites: Statpearls (Internet) - Treasure Island (FL) : Statpearls Publishing 2019 Jan
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Insect Bites
Jim Powers; Rachel H. McDowell.
Author Information
Last Update: June 29, 2019.
Introduction
The term “bug bite” is commonly used to denote both bites and stings inflicted by members of
the phylum Arthropoda. Arthropods make up the largest division of the animal kingdom,
representing approximately 80% of all known animals. Defining characteristics include the
presence of an exoskeleton, jointed appendages, and a body composed of specialized regional
segments.
The four medically significant classes of arthropods are Chilopoda, Diplopoda, Insecta, and
Arachnida. Of these, the insects, which represent more than half of all living organisms, and the
arachnids have the greatest clinical impact on humans.
Erythematous and edematous eruptions along with other dermatological findings such as papules
and urticaria represent the most common clinical manifestations of arthropod bites and stings. In
some cases, the delivery of toxic venom can result in significant systemic reactions including
autonomic instability, neurotoxicity and organ failure. The acute development of anaphylactic
reactions can be rapidly fatal, most commonly due to angioedema or circulatory collapse. In
these cases, rapid recognition and treatment with epinephrine are critical. The most clinically
significant impact of arthropod bites is their ability to serve as vectors for numerous bacterial,
viral, and protozoal diseases.
Etiology
The consequences of arthropod bites are generally due to traumatic injury or local inflammation
and hypersensitivity to arthropod saliva. Even though some arthropods are capable of injecting
venom when biting, most envenomation occurs via a stinger connected to a venom gland.
Notable arthropods possessing stingers include bees, wasps, hornets, fire ants, and scorpions.
Both bites and stings create tissue injury which can serve as a portal of entry for secondary
bacterial infection.
The four classes medically significant arthropods are the chilopods, diplopods, insects, and
arachnids. Members belonging to each class are as follows:
Chilopoda: centipedes
Diplopoda: millipedes
Insecta: Hymenoptera (bees, wasps, hornets and fire ants), mosquitoes, bedbugs, fleas,
lice, beetles, caterpillars and moths, and kissing bugs
Chilopods
Diplopods
Millipedes are members of the class Diplopoda, characterized by the presence of two pairs of
legs per body segment. Millipedes inflict damage through secretion of a toxic liquid from glands
on the sides of their body segments which produces a localized caustic-like effect to tissues.
Clinically this may present with an intense burning sensation accompanied by erythema and
occasionally vesicle formation. The toxic liquid often causes the development of a localized area
of hyperpigmentation, usually brown or black, which may last for months.[1][3] More significant
injury can occur with ocular exposure which can cause chemical conjunctivitis or corneal
ulceration. Treatment of topical exposure is similar to that of a second-degree burn and
includes topical antibiotics and analgesics. Washing the area immediately with soapy water
following exposure may help reduce the effects of the toxin. Treatment of ocular exposure
requires copious irrigation, fluorescein staining to evaluate for ulceration, topical antibiotics,
cycloplegics, and ophthalmology referral.
Insecta
Members of the class Insecta, which comprise approximately 60% of all arthropod species,
include Hymenoptera (bees, wasps, hornets and fire ants), mosquitoes, bed bugs, fleas, lice,
beetles, caterpillars and moths, and kissing bugs.[2]
While most caterpillars and moths are harmless to humans, some cause cutaneous disease when
contact with their protective hairs or spines occurs. The most common clinical manifestations of
exposure are erythema, pruritus, and the development of papules or urticaria at the site of
contact. In the United States, the most serious clinical reactions occur in contact with the Pus
Caterpillar, primarily found in the Southeastern United States. Rather than pruritus, exposure
often results in local burning pain and the development of hemorrhagic, purpuric papules
organized in a grid-like pattern.[3] Treatment of caterpillar and moth induced cutaneous reactions
consists primarily of symptomatic care including local ice application, pruritus control with
topical corticosteroids and systemic antihistamines, and pain control with NSAID’s or
acetaminophen.[2] If hairs or spines are present on the skin, they can be removed with adhesive
tape.[3]
Bedbugs
Cimex lectularius, the human bedbug, is an obligate blood feeder with a worldwide distribution.
It is oval shaped, flat, red-brown in color and about 3 to 6 mm in length. Bedbugs usually live in
crevices in walls, floors, mattresses, cushions, bed frames, and other structures. Bites sometimes
occur linearly and most commonly manifest as a small papule or punctum usually without a
surrounding reaction.[3]Treatment of bites consists primarily of symptomatic care with the use of
topical glucocorticoids and systemic antihistamines to control pruritus.[2] Secondary infections
should be treated with the appropriate antibiotics. Elimination of infestations can be difficult and
requires a combination of professionally applied insecticide and nonchemical controls.
Kissing Bugs
Kissing bugs, or triatome bugs, are a type of reduviid bug that can carry the parasite
Trypanosoma cruzi, the etiologic agent of Chagas disease. Kissing bugs are 1.5 to 2.5 cm long,
brown or black and typically have red or yellow stripes on their abdomen. Triatomes are blood-
sucking insects and nocturnal feeders which transmit Trypanosoma cruzi through their feces.
Their range runs in the southern United States, Mexico, Central America and South America
where they typically live in thatched roofs or cracks and holes of substandard housing. Victims
may sometimes inadvertently scratch or rub the feces into the bite wound or the mucous
membranes, especially the eyes or mouth. Bites are usually painless and present as papules with
hemorrhagic puncta or vesiculobullous lesions.[3] An area of localized swelling, erythema, and
induration corresponding to the site of trypanosome entry is known as a chagoma. The classic
finding in acute Chagas disease is the presence of a chagoma on the eyelid, known as Romana’s
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sign. Following the acute phase of the infection, which can last for several months, patients enter
the chronic phase, during which the infection may remain asymptomatic for decades.
Approximately 20 to 30% of infected patients will develop cardiac or gastrointestinal
complications.
Lice
Lice are parasitic insects that feed on human blood. They have six legs, are tan to grayish-white,
2.5 to 3.5 cm in length, have no wings, and are flat in shape. The three types of lice that feed on
humans are the head louse, Pediculus humanus capitus, the body louse, Pediculus humanus
corporis, and the pubic or crab louse, Pthirus pubis. While head and pubic lice do not have an
association with disease transmission, body lice can transmit typhus and louse-borne relapsing
fever.
Head lice
Head lice occur most frequently in younger children in daycare or elementary school and
typically present on the head, eyebrows, and eyelashes. Head lice exist in one of three forms: the
adult, the nymph, and the egg. Eggs, also known as nits, are yellowish and are cemented to the
hair shafts. The nymph, an immature louse, hatches from the egg in about 8 days, and as the
adult form, is an obligate blood feeder. Common symptoms of head lice infestation include a
sensation of something moving in the hair, itching, or the visualization of nits or lice. Diagnosis
is by identification of nits, nymphs or the adult louse on the scalp or hair. Head lice infestation
treatment is with pediculicides, many of which are available without a prescription. Common
over-the-counter treatments include pyrethrins and permethrin 1% lotion. Oral ivermectin at an
initial dose of 200mcg/kg and repeated 10 days later is often used to treat lice infections but is
not FDA approved for this purpose. Nits removal should be with a fine comb. Since most
treatments do not entirely eradicate the eggs, retreatment is usually necessary seven to ten days
later.
Pubic lice
Pubic lice are smaller than head or body lice, measuring around 1 to 2 mm in length. They have
six legs with two large front legs which resemble the pinchers of a crab. The distribution of pubic
lice is generally limited to areas where the hair is short, such as pubic hair, but may occasionally
be found on eyelashes, eyebrows, and axillary and beard hair. As with head lice, pubic lice have
an egg, nymph and adult form. Transmission is usually through sexual contact, so infestations are
most frequently found in adults. If pubic lice are found, clinicians should consider evaluating for
the presence of other sexually transmitted infections. The symptoms of infestation are similar to
that of head lice, and the finding of lice or nits in the pubic hair establishes the diagnosis. The
treatment of pubic lice infestation is the same as that of head lice. Treatment of lice or nits found
on the eyelashes involves the application of ophthalmic-grade petroleum ointment to the eyelid
margins for 10 days.[3]
Body Lice
Unlike head and pubic lice, body lice do not live on the skin but rather live and lay their eggs in
seams of clothing or bedding, moving to the skin only to feed. Body lice usually spread by direct
contact but can also be transmitted through clothing, bed linens and towels. In the United States,
body lice infestations are most commonly found in homeless populations. While body lice
do share some symptoms with other lice, they produce more severe pruritus secondary to an
allergic response to lice saliva. Areas of pyoderma may be found in areas covered by clothing
such the axilla, trunk, and groin. Unlike head and pubic lice, diagnosis of an infestation is
typically by finding eggs and lice in seams of clothing rather than on the skin. Treatment of body
lice does not usually require the use of a pediculicide because improvements in hygiene,
including showering and access to regular laundered clothing, will often eradicate the infestation.
Wash all clothing, bed linens and towels in hot water and machine dry on the hot cycle. Itching
can be treated with systemic antihistamines and antibiotics may be required for secondary
infection. If pharmacologic treatment is deemed appropriate, it consists of the same agents
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utilized for pubic and head lice. Body lice pose significant health risks because of their ability to
transmit the diseases of epidemic typhus, trench fever, and epidemic relapsing fever.[3]
Mosquitoes
Mosquitoes belong to the family Culicidae and are characterized by compound eyes, delicate
wings, long thin legs, and proboscises which allow for biting and obtaining blood meals. Bites
from mosquitoes produce minimal trauma and are often not felt by the host. The most common
symptom is pruritus, and the most common cutaneous finding is the presence of urticarial
wheals. Treatment of mosquito bites is symptomatic and includes ice application, topical
corticosteroids, and systemic antihistamines. The greatest danger from mosquitos is their ability
to transmit several serious diseases including malaria, filariasis, yellow fever, dengue fever, West
Nile virus, Zika virus, and chikungunya.
Flies
There are a number of medically significant flies that bite humans, most notably the deer fly,
horse fly, sand fly, and tsetse fly. When obtaining a blood meal, flies use their specially designed
mouthparts to lacerate the skin, inject its anticoagulant-containing saliva and then suck up the
resulting bleeding. Some flies can transmit serious diseases such as the Tsetse fly which
transmits trypanosomiasis, the sand fly which transmits bartonellosis and leishmaniasis, and the
deer fly which transmits tularemia. Some flies such as the black fly and horse fly can produce
severe allergic and even anaphylactic reactions. Fly bites are usually quite painful and may
produce significant cutaneous inflammation and the development of large urticarial wheals and
papules. Treatment consists of symptomatic care including ice application, pain control with
acetaminophen or NSAIDs, thorough washing of the wound, and systemic antihistamines for
itching.
Myiasis is a condition that occurs when there is an infestation of fly larvae. Wound myiasis
occurs when flies deposit larvae on or near a wound where they feed on the surrounding tissue.
Copious irrigation will usually remove the larvae, but sometimes debridement is required.[4]
Furuncular myiasis occurs when fly larvae burrow into the skin. The most notable cause of
furuncular myiasis is the human botfly, found in the Caribbean and Central and South America.
Transmission usually occurs when a female fly lays eggs directly on a blood-sucking insect such
as a mosquito.[2] When the insect lands and bites its victim, the eggs get deposited on the skin,
hatch, and the larvae quickly burrow under the skin and emerge fully mature after 5 to 10 weeks.
Clinically, botfly larvae produce an erythematous papule or nodule with a central punctum
representing the larva’s breathing tube [4]While the larvae will emerge spontaneously in 5 to 10
weeks, surgical incision and extraction are usually the treatment. Another treatment option is to
cover the site with a thick layer of petroleum jelly or pork fat which occludes the larva’s
breathing tube and causes it to emerge within 24 hours.[4]Additional treatment includes updating
tetanus immunization, administering antibiotics if secondarily infected, and acetaminophen or
NSAIDs for pain control.
Hymenoptera
The order Hymenoptera includes wasps, bees, yellow jackets, hornets and fire ants. These insects
all have a painful sting delivered by their venom-injecting caudal stinger. The composition of
these venoms are complex, and some have the potential for cross-sensitization. Local reactions to
stings are most common and present with an immediate onset of localized pain, erythema and
edema. Anaphylactic reactions may present with the initial symptoms of pruritus, facial flushing,
and urticaria which can rapidly progress to wheezing, dyspnea, angioedema and stridor,
vomiting, abdominal cramping, and syncope. The Apoidea family of Hymenoptera, consisting of
honeybees and bumblebees, possess a stinger with curved barbs which remains in the victim
following a sting. Africanized, or “killer” bees, are an extremely aggressive bee imported to the
United States from Brazil in the late 1950s. They are most widely distributed in the southwestern
United States, particularly Texas, Arizona, and California but have continued to migrate north
and eastward. Wasps and yellow jackets comprise the Vespidae family which, unlike members of
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the Apoidea family, do not lose their stinger in an attack and have the ability to sting multiple
times.
Treatment of uncomplicated stings includes manual remover of the stinger, application of ice
compresses, and analgesics for pain. Short courses of systemic antihistamines and
corticosteroids are effective for more severe localized reactions.[5]
Fire ants are Hymenoptera belonging to the Formicidae family which live in large ground
colonies in the southeastern United States. They may be red or black, are very aggressive, and
often attack in swarms. Fire ants begin their attack by latching on to their victim with powerful
jaws and then deliver up to 10 stings with their ovipositor. Their venom is composed of alkaloids
and causes intense, burning-like pain. Their venom may produce anaphylaxis and has potential
crossover sensitization with other Hymenoptera venom. As with the Vespidae and Apoidea
families, most reactions consist of localized dermatologic findings. The presence of two central
hemorrhagic puncta from the bite of the ant, surrounded by a ring of erythematous papules
caused by the sting, is a distinctive characteristic.[5] These papules develop into vesicles and
then sterile, pruritic pustules over 6 to 24 hours. Treatment is similar to that of other
Hymenoptera stings.[2]
Fleas
Fleas are wingless ectoparasites that feed on mammals and birds. They are 2 to 4 mm long, thin,
and are red to brown. Flea bites typically present as erythematous papules, often with a
hemorrhagic appearing center. Bites may also manifest as urticarial lesions, vesicles or bullae.
The pruritus can be severe, and scratching of the lesions can result in skin excoriation and
secondary bacterial infection. The primary goal in treating flea bites is to control the intense
itching through the use of topical calamine lotion or corticosteroids, and systemic antihistamines.
The most significant medical impact of fleas is their ability to serve as vectors for several
serious, and potentially fatal diseases including tularemia, endemic typhus, and bubonic plague.
Arachnids
Arachnids are the class of arthropods that include ticks, mites, scorpions, and spiders.
Ticks
Nymphal and adult ticks are characterized by the presence of eight legs tipped with a pair of
claws and an oval-shaped body which becomes engorged during feeding. Most ticks are
categorized as hard ticks, belong to the Ixodidae family, or soft ticks belonging to the Argasidae
family. Ticks feed by cutting a hole in the epidermis and injecting anticoagulants or compounds
which inhibit platelet aggregation. Tick bites are usually painless and can present with a wide
variety of rashes and other dermatologic findings, making diagnosis challenging. Bites often
appear as an erythematous papule with surrounding erythema while others may present as
pruritic urticarial lesions. Tick-borne infectious diseases such as Lyme disease and Rocky
Mountain spotted fever present with characteristic rashes; however, these are not
always identified.
The most significant impact of ticks on humans is their ability to serve as vectors for significant
diseases including Rocky Mountain spotted fever, endemic typhus, ehrlichiosis, Q-fever,
encephalitis, hemorrhagic fever, Lyme disease, relapsing fever, tularemia, babesiosis.
Simple, uncomplicated tick bites are treated with routine wound care, topical corticosteroids and
systemic antihistamines for pruritic lesions and antibiotics if secondary infection is present. Ticks
should be removed with fine-tipped tweezers, grasping the tick as close to the skin as possible
and pulling upward with steady, gentle pressure. Other commonly touted methods of tick
removal such as applying fingernail polish, alcohol or a hot extinguished match are not
recommended as they do not affect detachment and may cause the tick to regurgitate into the
wound, increasing the risk of disease transmission.[6]
Scabies
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Scabies is an infestation of the skin caused by the 8-legged human itch mite, Sarcoptes scabiei.
The mite is small, around 0.4mm, and burrows into the stratum corneum layer of skin where it
lays its eggs. Scabies has a worldwide distribution and usually spread through prolonged direct
contact, often sexual. Initial infections are often asymptomatic for 2 to 6 weeks, and the
development of symptoms is the result of an allergic response to mite proteins deposited under
the skin.[4] The most common manifestations of scabies infestation include intense itching, often
worse at night or with exposure to warm temperatures, and the presence of erythematous papules
or nodules. Tiny burrows created by the tunneling of the female mite under the skin may appear
as raised, linear or curved grayish-white lines on the skin surface, and sometimes contain a black
speck representing the female mite. Cutaneous vesicles may be present but are a more common
presentation of scabies infestation in infants and young children. The dermatologic findings in
scabies infestations most commonly present in the web spaces of the fingers and toes, ventral
surface of the wrist, elbows, back, buttocks and external genitals. The diagnostic basis is on
symptoms of intense pruritis accompanied by the appearance of a corresponding rash or burrows.
Confirmation of the diagnosis can is by microscopic evaluation of a skin scraping revealing the
mite, its eggs or fecal material.[3]
Permethrin, 5% cream, is the drug of choice to treat scabies and is applied from the neck down at
bedtime and then washed off in the morning. The recommendation is for two treatments
administered a week apart.[3] While not FDA approved for the treatment of scabies, the oral
antiparasitic agent Ivermectin is often used, especially in those who have failed other treatments
or cannot tolerate topical medications.[4] Pruritus treatment from scabies infestation is with
systemic antihistamines.
Norwegian scabies, also known as crusted scabies, is a severe form of scabies infestation that can
occur in patients who are elderly, debilitated or immunocompromised. Unlike patients with
typical scabies infection, those with Norwegian scabies manifest with thick hyperkeratotic skin,
sometimes described as “dirty” in appearance. A treatment protocol for crusted scabies is
published by the Centers for Disease Control (CDC) consisting of permethrin cream applied
daily for 1 week then twice-weekly coupled with ivermectin 200 µg/kg on days 1, 2, 8, 9, and 15.
[4]
Scorpions
Scorpions are large arachnids with a pair of anterior legs possessing pinchers. Their tail-like
structure containing a stinger and two venom glands. In the United States, only the bark
scorpion, Centruroides exilicauda, possesses venom with the potential to cause systemic toxicity.
[7]Most stings produce only localized pain similar to that of Hymenoptera stings, and a
diagnostic clue is increased sensitivity to touch or tapping on the area.[5] While systemic
symptoms are uncommon, the venom from the bark scorpion can cause several adverse
autonomic and motor effects such as hypertension, tachycardia, tachydysrhythmias, myoclonus,
and fasciculations.[5] The clinical impacts of these effects can be especially severe in children.
Except in the case of children, most stings manifest similarly to Hymenoptera stings and can be
managed with supportive care including removing the stinger if present, cleaning the site with
soap and water, ice application to the area and acetaminophen for pain. Agitation, muscle spasms
and myoclonus should be managed with benzodiazepines while tachyarrhythmias and
hypertension treatment is with intravenous beta-blockers. An FDA approved centruroides-
specific antivenom is available but is only for cases of severe systemic toxicity.[1]
Spiders
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Spiders are carnivorous arthropods which use venom to immobilize, and in some cases, digest
their prey. In North America, the two spiders that have the greatest potential to cause significant
morbidity are the Black Widow and Brown Recluse.
Brown Recluse spiders (Loxosceles reclusa) are approximately 1 to 1.5 cm in length with a leg
span of greater than 2.5 cm. They have a yellow to brown cephalothorax, a tan abdomen, and
possess a violin-shaped marking on their dorsal cephalothorax which accounts for its nickname,
the “fiddle-back” spider. They are predominantly found in the south and the central United States
and reside in dark, dry places such as woodpiles, sheds, closets, and garages. Bites typically
occur on the extremities when the spider’s dwelling is disturbed, or it feels threatened. Bites may
be perceived as a sharp, stinging sensation but are often painless and cause only minor,
inconsequential reactions, usually presenting as small erythematous lesions. Some bites will
develop an area of cyanosis or pallor, sometimes with the appearance of hemorrhagic blisters,
due to tissue ischemia. The most common complication in serious envenomations is full
thickness skin necrosis which may require significant debridement and skin grafting.[1]
Brown recluse venom is extremely complex and contains hemolytic enzymes which can cause
tissue destruction and necrosis. Diagnosis of uncomplicated brown recluse bites may be difficult
as the initial bite is often painless and the spider may go unseen. Diagnosis is usually based on
the history, especially if the spider was seen, in conjunction with the presence characteristic
dermatologic findings. Treatment of brown recluse envenomation depends on the clinical
presentation. In uncomplicated bites, treatment consists of routine wound care, evaluation of
tetanus status, and local application of ice which may decrease the activity of damaging enzymes
found in the venom. In cases of necrotic ulceration, early excision is not a recommendation as it
can result in recurrent wound breakdown, delayed healing, scarring, and long-term distal
extremity dysfunction.[5]
Black Widows are spiders from the genus Latrodectus, with the most well-known being the
North American black widow, Latrodectus mactans. There are five species of Latrodectus spiders
found in North America, and only three of the five are black. They are approximately 1.5 cm in
length and have up to a 4 cm leg span. Widow spiders are dark brown or black with a rounded,
shiny abdomen and are most widely recognized for the presence of a red or orange hourglass on
the ventral surface of their abdomen. They reside throughout the United States and prefer to spin
their webs in dark, close quarters such as woodpiles, basements, crawl spaces, attics, and stored
boxes. Most bites are defensive, occurring when the female spider perceives a threat to herself or
her eggs, or when the spider is unintentionally disturbed. While the black widow has potentially
dangerous venom, many bites result in only minimal symptoms and produce no severe damage.
Perception of the bite is usually as a sharp pinprick-like sensation which may develop into a dull
ache or numbness at the site. Two red puncta may be visible, and surrounding erythema may
appear within 60 minutes of the bite. Serious reactions may manifest as severe muscle spasms
and pain in the chest, abdomen and lower back. Other clinical manifestations may include
hypertension, sweating, salivation, restlessness, fasciculation, ptosis, nausea, vomiting, and
dyspnea. Severe symptoms usually occur within 1 to 6 hours and last anywhere from 12 to 48
hours.
The venom of the black widow spider is most notable for the potent neurotoxin, alpha-latrotoxin,
which unlike the brown recluse, does not cause local necrosis. Management for those without
systemic symptoms is with supportive care including washing the bite site, application of an ice
pack to the area, updating tetanus immunization, and treatment of pain with acetaminophen.
[5] Muscle spasms, cramping, and pain are usually manageable with benzodiazepines and
opiates.[7] A lactodectus antivenom, derived from horse serum, is available but reserved for
those with significant systemic involvement.
Chiggers
Chiggers are tiny red mite larvae, measuring 0.3 to 1.0 mm in length, belonging to the
Thrombiculidae family. Encounters with chiggers tend to be in tall grasses, weeds, and in
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woodlands. Infestations occur when mite larvae feed on human skin, predominantly in areas
where they reach a constricting area of clothing such as at the ankles, thigh or waist. Bites are
usually not felt initially, but an allergic reaction to the mite saliva causes the development of
extremely pruritic red papules 3 to 14 hours later. Mites are visible on the skin as tiny red dots
that will often crawl until reaching an area of clothing-skin interfaces such as the top of a sock or
the belt-line of pants. If present, chiggers can easily be removed in the shower by scrubbing the
skin with soap and water. The primary treatment is to control the intense itching with topical
calamine lotion or corticosteroids and systemic antihistamines. Chiggers do not transmit any
diseases in the U.S. but are vectors for Scrub Typhus in parts of Asia, Russia, and islands of the
Indian and the Pacific Oceans.
Epidemiology
The incidence of arthropod bites and stings in the United States is difficult to quantify because
most produce only minor symptoms that go unreported. The American Association of Poison
Control Centers reported 28087 cases of arthropod exposures in 2015 which, because of under-
reporting, represents only a small fraction of arthropod encounters.
Pathophysiology
There are four general mechanisms responsible for the pathophysiologic impacts of arthropod
bites and stings. Mechanical injury to tissue during bites and stings results in pain and swelling
and provides a portal of entry for bacteria which can result in secondary infection. Allergic
responses to arthropod salivary antigens are common and contribute to the development of
localized and systemic rashes and cutaneous pruritus. The most significant allergic response to
arthropod bites and stings is the development of anaphylaxis, which can be rapidly fatal. While
some arthropods can deliver toxic venom, the most significant pathophysiologic impact of
arthropod bites is their potential to transmit several clinically important diseases.
Toxicokinetics
Arthropod venom is often a complex mixture of proteins, and other biochemical mediators and
the clinical effects vary significantly depending on its specific composition.
Centipedes
The primary components of centipede venom include histamine, serotonin, enzymes, acid and
alkaline phosphatase, and the amino acid naphthylamidase. Envenomation most commonly
results in intense localized pain, erythema, and edema.
Millipedes
Millipedes secrete a toxin through their body segments which contains hydrogen cyanide,
organic acids, cresols, phenol, benzoquinones, and hydroquinones. The toxin produces a
localized caustic-like effect to the tissues it contacts resulting in an intense burning accompanied
by erythema and occasionally vesicle formation.
Hymenoptera
Scorpions
Bark scorpion venom contains several biologically active substances including serotonin,
acetylcholinesterase, histamine, phospholipase, and hyaluronidase. The venom is neurotoxic and
can open neuronal sodium channels and create prolonged and excessive neuronal depolarization
resulting in neuromuscular and autonomic hyperactivity.
Brown Recluse
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Brown recluse venom causes tissue destruction and necrosis via hemolytic enzymes and
dermonecrotic factors such as Sphingomyelinase D and a levarterenol-like substance that induces
vasoconstriction.[5]
Black Widow
The venom of the black widow spider is most notable for the potent neurotoxin, alpha-latrotoxin
which causes the release of excessive amounts of neurotransmitters, including acetylcholine,
norepinephrine, glutamate, and dopamine from presynaptic nerve terminals. Unlike the brown
recluse, the venom of the black widow does not cause local necrosis.
Patients with vital sign abnormalities, or who present with any evidence of cardiorespiratory
distress must have an immediate assessment of the airway, breathing and circulatory status.
Common findings in anaphylaxis include urticaria, angioedema, tachycardia, respiratory distress,
hypotension, and wheezing. If there is no evidence of anaphylaxis or manifestations of severe
venom toxicity a detailed exam of the area of involvement should be performed.
Bites and stings most commonly present as erythematous, sometimes edematous, papules that
may be solitary, grouped or generalized depending on the arthropod involved. There is usually a
pruritic eruption at the site of the bite or sting and other common findings, including local
erythema, wheals, and urticaria, are often present. Those with intensely pruritic lesions may
develop skin excoriation from scratching, and evidence of secondary bacterial infection may be
present. A detailed exam should be performed to evaluate for the presence of arthropods such as
ticks, lice (including head, body and pubic), myiasis, or scabies. Occasionally an arthropod
stinger, especially following a bee sting, may be found and should be removed.
The clinician should assess for manifestations of vector-borne diseases with the knowledge that
associated clinical findings may not manifest for weeks, months or years following an arthropod
bite.
Evaluation
With uncomplicated arthropod bites or stings resulting in minor localized reactions, no laboratory
or imaging evaluation is indicated. However, additional studies may be necessary in cases of
arthropod envenomation, secondary infection, or if a vector-borne disease is suspected.
Severe envenomations may cause multi-organ dysfunction and require lab studies such as a
complete blood count, basic metabolic panel, liver function, coagulation, creatine kinase, and
urinalysis. An EKG should be included in the evaluation of suspected Lyme disease or the
presence of arrhythmias. Thick and thin blood smears may be helpful in the evaluation of
suspected malaria or early Chagas disease. Serological tests for arthropod-borne diseases may be
required based on clinical presentation and specific arthropod exposure. Diseases associated with
specific arthropods include[3]:
Ticks: Lyme disease, Rocky Mountain spotted fever, relapsing fever, anaplasmosis,
babesiosis, tularemia
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Mosquitoes: malaria, yellow fever, dengue fever, West Nile virus, equine encephalitis,
chikungunya, Zika virus
Treatment / Management
Most arthropod bites and stings can are manageable with simple supportive care measures
consisting of local wound care by cleaning the area with soap and water, updating tetanus status
as needed, applying ice compresses, elevating the area if there is edema present, and treating pain
with acetaminophen or NSAIDs. Pruritus is one of the most common manifestations of bites and
stings and can be treated with calamine lotion or intermediate potency topical corticosteroids.
For moderate or severe pruritus, a short course of systemic corticosteroids and oral
antihistamines, including both H1 and H2 blockers, are often beneficial. If secondary infection is
present, treatment should initiate with appropriate antibiotics. Anaphylaxis must be managed
immediately with intramuscular epinephrine, which may be repeated every 5 to 15 minutes.
Adjunctive treatments such as systemic corticosteroids, albuterol, and antihistamines are often
utilized but should never delay the administration of epinephrine. Antivenom is available for
some arthropod envenomations but should be administered only after consultation with a poison
control center. Poison control centers are staffed 24-hours a day and can be reached at 1-800-
222-1222.
Another important consideration in the management of arthropod bites and stings is to evaluate
for vector-borne diseases and administer appropriate antimicrobial therapy when indicated.
The most important step towards reducing the clinical impacts of arthropod bites and stings is to
prevent them from occurring in the first place. Prevention is especially critical in reducing
a patient's likelihood of contracting serious, and sometimes, life-threatening vector-borne
diseases.
Most available methods focus on the prevention of bites from mosquitoes and ticks, which
transmit the vast majority of vector-borne pathogens to humans. The cornerstone of prevention
efforts involves the use of effective insect repellents which can significantly reduce the
likelihood of bites from mosquitoes and ticks but have no effect on other arthropods such as
bees, spiders, fleas, ants, scorpions, and lice. DEET (N, N-diethyl-meta-toluamide) is the most
well studied, and most effective, broad-spectrum repellent against biting arthropods. The World
Health Organization and the CDC recognize DEET as the gold standard insect repellent and is
the agent against which other repellents are measured.[8] It is considered the first line insect
repellent, especially in areas with heavy mosquito activity. Concentrations of 20 to 50% are
recommended and can provide up to several hours of protection from mosquitoes and ticks.
[8] While the duration of effectiveness does increase up to a concentration of 50%, there is no
further improvement in effectiveness at higher concentrations. Alternatives to DEET include
picaridin and PMD (P-menthane-3,8-diol). Icardin may require more frequent application than
DEET to maintain effectiveness, especially at concentrations below 20%. PMD is a component
of lemon eucalyptus extract that has been shown to have effectiveness and duration of action
similar to DEET. Appropriate clothing such as light colored pants, long-sleeved shirts, and hats
also reduce the likelihood of sustaining insect bites and contracting vector-borne diseases. The
application of permethrin, a synthetic insecticide derived from the chrysanthemum plant, to
clothing greatly improves the deterrence of insect bites. While permethrin application should
never be direct to the skin, it can be applied to articles such as sleeping bags and bed nets.
Studies regarding the use of mosquito nets, especially those impregnated with permethrin,
demonstrate they are highly effective in preventing bites and stings from a variety of arthropods.
[8] These nets are advisable for all travelers visiting areas with endemic arthropod-borne
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diseases. Removal of ticks within 24 hours of their attachment may also decrease the risk of tick-
borne diseases. Thus, the recommendation is for daily checks for any attached ticks when
traveling in tick-endemic habitats.
Differential Diagnosis
The differential diagnosis for suspected arthropod bites and stings presenting with localized
dermatological manifestations is extensive and includes contact dermatitis, drug eruption,
mastocytosis, bullous diseases, dermatitis herpetiformis, tinea, eczema, vasculitis, pityriasis,
erythema multiforme, viral exanthem, cellulitis, abscess, impetigo, folliculitis, erysipelas,
necrotizing fasciitis, and many others.[6][1]
In patients presenting with a necrotic ulcer following suspected brown recluse envenomation,
clinicians should also consider diagnoses such as pyoderma gangrenosum, staphylococcus or
streptococcus skin infection, diabetic ulcers, necrotizing fasciitis, fungal infections,
leishmaniasis, and sporotrichosis.[6]
Prognosis
Most arthropod bites and stings result in uncomplicated localized cutaneous reactions, and
resulting complications are rare. In a small number of cases, fatalities may occur in the first hour
following a bite or sting secondary to the development of anaphylactic shock. The risk of fatal
anaphylaxis decreases significantly with the prompt administration of epinephrine.
The greatest medical impact of arthropod bites is the transmission of infectious diseases. The
prognosis for arthropod-borne infectious diseases depends on the pathophysiologic effects of the
specific organism transmitted.
Prognosis following arthropod envenomation is highly favorable and symptomatic treatment, and
supportive care is often all that is required. Fatalities rarely occur, but an increased risk exists for
children, the elderly, and those with significant underlying cardiovascular disease.
2. Local treatment and symptom management are sufficient in most arthropod bites and
stings.
4. In cases of severe envenomation due to arthropods, such as scorpions and black widow
spiders, the administration of antivenom may be appropriate. Consultation with a
toxicologist is indicated in the management of any severe envenomation and the when the
use of antivenom is a treatment consideration.
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repellents and protective clothing, can significantly reduce the risk of acquiring arthropod-borne
infections. Clinicians play a critical role in assessing a patient’s risk of exposure to arthropod
vectors and providing risk-reduction counseling to at-risk patients.
Questions
To access free multiple choice questions on this topic, click here.
References
1. Haddad V, Cardoso JL, Lupi O, Tyring SK. Tropical dermatology: Venomous arthropods and
human skin: Part II. Diplopoda, Chilopoda, and Arachnida. J. Am. Acad. Dermatol. 2012
Sep;67(3):347.e1-9; quiz 355. [PubMed: 22890735]
2. Haddad V, Cardoso JL, Lupi O, Tyring SK. Tropical dermatology: Venomous arthropods and
human skin: Part I. Insecta. J. Am. Acad. Dermatol. 2012 Sep;67(3):331.e1-14; quiz 345.
[PubMed: 22890734]
3. Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatology. J. Am. Acad. Dermatol.
2004 Jun;50(6):819-42, quiz 842-4. [PubMed: 15153881]
4. Vasievich MP, Villarreal JD, Tomecki KJ. Got the Travel Bug? A Review of Common
Infections, Infestations, Bites, and Stings Among Returning Travelers. Am J Clin Dermatol.
2016 Oct;17(5):451-462. [PubMed: 27344566]
5. Erickson TB, Cheema N. Arthropod Envenomation in North America. Emerg. Med. Clin.
North Am. 2017 May;35(2):355-375. [PubMed: 28411932]
6. Juckett G. Arthropod bites. Am Fam Physician. 2013 Dec 15;88(12):841-7. [PubMed:
24364549]
7. Quan D. North American poisonous bites and stings. Crit Care Clin. 2012 Oct;28(4):633-59.
[PubMed: 22998994]
8. Alpern JD, Dunlop SJ, Dolan BJ, Stauffer WM, Boulware DR. Personal Protection Measures
Against Mosquitoes, Ticks, and Other Arthropods. Med. Clin. North Am. 2016
Mar;100(2):303-16. [PubMed: 26900115]
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