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Bites and stings of uncommon arthropods. 2. Reduviids, fire ants, puss caterpillars, and scorpions.

Arthropod bites and stings may cause intense pain, sometimes out of proportion to the size of the lesion. Severe reactions may arise from prior exposure and buildup of antibodies. Diagnosis often can be made from the clinical presentation if the physician is familiar with the effects of the uncommon bites and stings. Some uncommon bites, such as those of reduviids, can be treated symptomatically, but others, such as those of poisonous scorpions, call for antivenin therapy.

Ants↗

Venomous bites and stings.

Travellers to tropical countries are often extremely concerned about the risk of bites and stings by venomous animals. This fear prompts many enquiries, usually at the last moment before departure, about the possibility of carrying first aid kits and antivenoms. In fact, these accidents are extremely rare because most travellers wear shoes and are far less exposed to venomous animals than indigenous peoples for whom bites and stings may be important causes of death or morbidity.

Animals↗

Penis wound by scorpion sting.

CONTEXT: The majority of scorpion stings are oligosymptomatic, occurring mainly on the hands and feet. Fatality is rare. CASE REPORT: A 33-year old man suffered a severe sting on his penis from a scorpion of the species Tytius trivittatus. Alcohol and salt were used without success in an effort to relieve pain. Medical assistance was sought 4 hours after the event, at which time diffuse erythema, edema and punctiform injury on the glans penis were observed, with no systemic manifestation. Intravenous meperidine was administered with immediate relief of the pain. The local signs disappeared within 48 hours, with the patient remaining asymptomatic.

Adult↗

Venomous bites and stings in the tropical world.

Snakes of the families Viperidae and Elapidae are responsible for the high incidence of morbidity and mortality after snake bites in countries of West Africa, the Indian subcontinent, South-East Asia, New Guinea and Latin America. Envenoming can cause local effects, notably tissue necrosis; and systemic effects, including paralysis, haemostatic disturbances, shock, increased capillary permeability, myocardial damage, rhabdomyolysis and acute renal failure. Specific hyperimmune serum (antivenom) is the mainstay of medical treatment for severe envenoming. Ancillary treatments such as assisted ventilation, repletion of circulating volume, renal dialysis and surgical debridement of necrotic tissues are needed in some cases. Scorpion stings are a common medical problem in middle and southern America, North Africa and the Middle East. Vasodilator drugs are important to counter the effects of massive catecholamine release. Bites by spiders and stings by hymenoptera and marine animals are responsible for deaths and morbidity in some tropical countries.

Animals↗

INSECT STING ANAPHYLAXIS.

Anaphylaxis from insect stings, which is considerably commoner than has been recognized, is a distinct emergency, requiring prompt and energetic treatment. Such reactions require the immediate intramuscular or deep hypodermic injection of 0.5 cc of 1:1000 epinephrine, which may have to be repeated shortly. After the initial critical phase is passed, there may be indication for intramuscular antihistamines and corticosteroids.Persons who have survived insect sting anaphylaxis should be immunized with insect antigens for a minimum period of three years and perhaps indefinitely. The choice between pure venom and extracts of whole insect bodies rests with the physician, although the latter are far more often used.Until immunization has become effective susceptible persons must carry with them at all times a kit containing epinephrine for both injection and aerosol use, and they must be trained by physicians in the proper use of these preparations.

Adrenal Cortex Hormones↗

Insects as allergen injectants, severe reactions to bites and stings of arthropods.

Arthropods capable of penetrating human skin often cause severe local and systemic reactions. Local reactions suggest delayed hypersensitivity while systemic symptoms resemble more the anaphylactic shock in animals. The nature of the antigen remains obscure but predominant evidence suggests its presence throughout the entire organism. Positive history of hypersensitivity to insect injectants was obtained in approximately 20 per cent of persons in the course of routine interviews of 1,078 patients. Repeated bites and stings at long or irregular intervals often induce a state of hypersensitivity, while repeated regular injections of extracts of these insects at shorter intervals may greatly reduce the hypersensitivity. The clinical evidence of allergic sensitivity to insect bites and stings cannot be readily confirmed by skin testing or by other immunological procedures. The history and the character of the lesions as well as certain entomological knowledge of the habits of the insects offer a better basis for specific diagnosis. Treatment with extracts of the whole offending insect generally provides good results but the protection afforded by such treatment varies in degree and duration.

Allergens↗

Scorpion sting envenomation presenting with pulmonary edema in adults: a report of seven cases from Nepal.

Scorpion sting is a common problem in villages of Eastern Nepal. The life-threatening complications of myocarditis and pulmonary edema is known in red scorpion in India but not reported in Nepal. This condition requires urgent attention and ICU care from few hours to days. Delay in recognition and the hypoxemia increase the morbidity and mortality. Illiteracy, ignorance, poverty, traditional faith healers trying treatment in remote areas, lack of transport in difficult terrains and the non availability of ventilation facility in nearby hospital, add to delay in appropriate treatment. Seven young adult patients admitted in a span of two years with history of scorpion sting presenting with pulmonary edema required ICU care. They were successfully managed with the positive pressure ventilation with PEEP, cardiac support with inotropes and fluid balance. Magnitude of problem, clinical presentation and management done is emphasized.

Adolescent↗

Deaths from bites and stings of venomous animals.

Data abstracted from 34 death certificates indicate that the three venomous animal groups most often responsible for human deaths in California from 1960 through 1976 were Hymenoptera (bees, wasps, ants and the like) (56 percent), snakes (35 percent) and spiders (6 percent). An average incidence of 2.0 deaths per year occurred during these 17 years, or an average death rate of 0.01 per 100,000 population per year. Nearly three times more males than females died of venomous animal bites and stings. Half of the deaths from venomous snake bites occurred in children younger than 5 years of age. Susceptible persons 40 years or older appeared to be particularly vulnerable to hymenopterous insect stings and often quickly died of anaphylaxis. Fatal encounters with venomous animals occurred more often around the home than at places of employment or during recreational activities. Deaths resulting from spider bites are rare in California but many bites are reported. Medical practitioners are urged to seek professional assistance in identifying offending animals causing human discomfort and to use these animals' scientific names on death certificates and in journal articles.

Adolescent↗

Parkinsonism after a wasp sting.

A 49-year-old man had mild parkinsonism after being stung by a wasp, a member of the Hymenoptera order. His clinical course was stable for 6 months after which his condition rapidly progressed to a severe akinetic-rigid syndrome with evidence, on a magnetic resonance imaging brain scan, of marked destruction of the basal ganglia. The symptoms did not respond to standard antiparkinsonian medications. Repeated courses of plasmapheresis followed by monthly intravenous infusions of immunoglobulin and long-term administration of azathioprine halted and appeared to partially reverse his deterioration. The literature on the neurologic, particularly the extrapyramidal, manifestations of stings by insects of the Hymenoptera order is reviewed and the possible pathophysiological mechanisms of injury are discussed. Hymenoptera stings should be included in the differential diagnosis of acute and chronic extrapyramidal syndromes.

Animals↗

Enzyme-linked immunosorbent assay of allergen-specific IgG antibodies in bee sting allergic patients hyposensitized with pure bee venom.

An ELISA is presented for detection of IgG antibodies to bee venom. By this method, sera of 11 bee sting allergic patients, who were treated with rapid hyposensitization with pure bee venom, were tested. The highest antibody titers were observed after 30 days of treatment, a maximum rise of 7.4 +/- 1.5 log 2-titer steps. Pure bee venom is shown to be more potent immunologically than whole body bee extract. Prediction of the clinical success, measured by tolerance to a bee sting challenge, is not yet possible using venom specific IgG determinations.

Adolescent↗

[Lung edema and erosive gastroduodenitis as a sequela of inappropriate use of an adrenaline dose aerosol after wasp sting].

Epinephrine (adrenaline) is an important drug in the treatment of severe anaphylactic reactions. Along with other drugs such as H1-antihistamines and glucocorticosteroids, it is found in every first aid kit for at-risk individuals, such as those who are allergic to insect stings. Subcutaneous or intramuscular injections if carried out by an untrained individual or the patient himself might give rise to potential problems. Therefore, it is common to prescribe epinephrine pressure aerosol as a safer alternative. If epinephrine aerosol is overused, it can cause serious problems. A patient developed by self-medication following a wasp sting lung edema as well as an erosive gastroduodenitis. She consumed two aerosol vials each of which contained about 73 mg of adrenaline. In order to avoid such incidents it is crucial that every doctor provides his or her patient with sufficient oral and written information regarding the correct use fo epinephrine inhalers.

Administration, Inhalation↗

Brain infarcts due to scorpion stings in children: MRI.

We report two children with severe neurological complications after having been stung by a scorpion. Clinical and MRI findings suggested brain infarcts. The lesions seen were in pons in one child and the right hemisphere in the other. The latter also showed possible hyperemia in the infarcted area. No vascular occlusions were observed and we therefore think the brain infarcts were a consequence of the scorpion sting. The cause of the infarct may be hypotension, shock or depressed left ventricular function, all of which are frequent in severe poisoning by scorpion sting.

Animals↗

Nephrotic syndrome in a child after a bee sting.

The occurrence of nephrotic syndrome after an insect sting is rarely reported in the literature. A 2-year-old boy developed generalized edema 5 days after a bee sting. The laboratory investigations revealed nephrotic range proteinuria, hypoproteinemia, hypoalbuminemia and hyperlipidemia. The corticosteroid treatment induced prompt remission with resolution of edema and normalization of the laboratory findings. There was no relapse of the disease during the 13-year follow-up. Although spontaneous remission might occur, corticosteroid treatment induced prompt remission and shortened the hospital stay.

Adrenal Cortex Hormones↗

Acute disseminated encephalomyelitis after bee sting.

Acute disseminated encephalomyelitis (ADEM) usually follows a viral infection or an immunization and is thought to be an immunomediated disease. We describe a patient with ADEM after multiple yellow jacket bee stings. The patient recovered after treatment with a high dose of methylprednisolone. Although the pathologic mechanism exact remains unclear, potential cross-reactivity between bee toxins and the central nervous system myelin could induce demyelination. ADEM should be considered a rare complication of bee stings.

Animals↗

High incidence of bites and stings by snakes and other animals among rubber tappers and Amazonian Indians of the Juruá Valley, Acre State, Brazil.

Among forest-dwelling Amazonian Indians and rubber tappers (seringueiros) of the Juruá valley in Acre State, north-western Brazil, snakebite is an important cause of morbidity and death. Overall, 13% of a surveyed population had been bitten during their lifetime. Seventeen per cent of Katukina Indians, but only 8% of Ashaninkas, had been bitten by snakes reflecting, perhaps, different levels of traditional knowledge of the forest and its dangers. Most bites occurred in the jungle or on jungle trails (56%), while people were working (41%) or walking (26%), and were inflicted on the feet (54%). Ninety per cent of bite victims received treatment, usually traditional (93%); the majority (80%) recovered fully. Mortality was estimated at about 400 deaths per 100,000 population per lifetime. Bites and stings from other venomous forest and river animals, especially the freshwater sting ray (Potamotrygon sp.), were also extremely common. One death from an ant bite was recorded.

Animals↗

Stinging insect allergy: detection and clinical significance of venom IgE antibodies.

Venom-specific IgE antibodies in 109 sera from patients who had had immediate systemic allergic reactions following insect stings were measured by the radioallergosorbent (RAST) procedure. The majority of sera contained IgE antibodies to either bee, yellow jacket, or hornet venoms. Some sera had positive RAST reactions with 2 or 3 venoms, but others contained single venom-specific IgE antibodies. Of 24 patients who had large local reactions, the sera of 12 contained venom IgE antibodies. The RAST procedure provides an accurate means of documenting IgE-mediated allergic sensitivity to stinging insects.

Antibodies↗

Antibodies to purified bee venom proteins and peptides. I. Development of a highly specific RAST for bee venom antigens and its application to bee sting allergy.

IgE antibodies to purified proteins and peptides from honeybee venom have been measured by the RAST. Trace amounts (less than 0.1%) of the major venom protein phospholipase A2 (PLA2) grossly distorted the measurement of IgE antibody to the other venom proteins, acid phosphatase (Acid P) and hyaluronidase (HYAL), and overemphasized their importance. Reduction of antigen coupled to the cellulose paper discs, which were used in the assay, diluted out the contaminating PLA2 without apparent loss in sensitivity. The reduction of disc-bound antigen increased the competition between IgE and IgG antibodies but did not affect measurement of IgE antibodies in sera taken from 35 untreated patients who had a history of general allergic reactions to bee stings. In 54% of sera from bee venom--allergic patients, the greatest IgE antibody response was to PLA2. In all, IgE antibodies to PLA2 were present in 91% of these sera. IgE antibodies to Acid P, HYAL, or melittin were present in 60%, 51%, and 31% of sera, respectively, and accounted for the highest level of binding in 17%, 17%, and 6% of these. Only 6% of sera were positive for whole venom but negative for the isolated antigens. A low level of IgE antibody was found to peptide 401 in 6% of sera. No IgE antibodies were found to apamin. While confirming the central role played by PLA2 in bee sting allergy, these results show that other venom components are also important in some patients.

Acid Phosphatase↗