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OUCH!● Insect bites & stings can be mild, but they also have the
ability to transmit insect-borne illnesses and cause severe allergic reactions
● Bites vs. Stings○ Bites consist of punctures made by the mouthparts of the organism○ Stings involve the injection of venom and may cause reactions ranging
from local irritation to life-threatening allergic reactions
● Lesions from arthropod bites (mosquitoes, ticks, kissing bugs, bed bugs, black flies, etc.) usually result from the host's immune reactions to the insect’s salivary secretions or venom
LOCAL REACTIONS● Normal reaction to an insect bite is an
inflammatory reaction at the site, appearing within minutes, and usually involves pruritic erythema and edema
● Treatment○ Wash with soap and water○ Ice or cold packs may help with swelling○ Topical creams, gels, and lotions (Calamine
or Pramoxine) may help with itching○ Oral antihistamines (Cetirizine or
Fexofenadine) preferred in small children to help with troublesome itching
PAPULAR URTICARIA● Hypersensitivity disorder in
which insect bites (most commonly fleas, mosquitoes, or bed bugs) lead to recurrent and sometimes chrony itchy papules on exposed areas of skin
● Reported predominantly in young children (typically 2-10 years old)○ Diaper area, genital, perianal, and
axillary areas are spared
PAPULAR URTICARIA● There may be a delay between the inciting bite and the onset
of lesions, and new lesions may appear sporadically● Renewed itching may reactivate older lesions, and the
disorder may last from months to years● Treatment
○ Selective and limited use of non-sedating antihistamines for itching○ Mid-potency corticosteroids
● Resolves spontaneously
SYSTEMIC ALLERGIC REACTIONS● Uncommon, widespread activation of mast cells with
prominent flushing and hypotension● Treatment
○ Rapid administration of Epinephrine
MOSQUITOES● Most commonly occurring insect bites● Results in local pain, pruritus, and
erythema● Immediate “wheal-and-flare” response that
peaks at about 20 minutes and/or an indurated pruritic papule that peaks at 2-3 days and resolves over days-weeks
● “Skeeter syndrome”: Dramatic swelling surrounding the bite, heat, redness, itching and pain, which may be accompanied by low-grade fever occurring particularly in young children○ Managed prophylactically with antihistamines
● In rare cases, patients can develop anaphylaxis
MOSQUITOES● Disease Transmission
○ United States - West Nile virus, St. Louis encephalitis, Eastern equine encephalitis, and La Crosse encephalitis
○ Worldwide - Malaria, Yellow fever, Dengue fever, etc.
● Prevention○ Apply insect repellents that contain ingredients such as DEET○ Wear long sleeves and pants when in an environment where mosquitoes
are prevalent
WEST NILE VIRUS● Mosquito-borne illness that can lead to a wide range of
clinical symptoms ranging from asymptomatic disease to severe meningitis and encephalitis
● Seasonal epidemic, with peak around mid-August to early September
● ~1 in 4 people who become infected will become ill and only ~1 in 230 who become infected develops severe symptoms
● Risk factors include advancing age, malignancy, organ transplantation, and genetic factors
WEST NILE VIRUS - CLINICAL MANIFESTATIONS● Most commonly asymptomatic● West Nile fever
○ Self-limited illness, which is indistinguishable from dengue fever and other viral syndromes
○ Abrupt onset of fever, headache, malaise, back pain, myalgias and anorexia
○ Occasionally rash found on chest, back and arms
● Neuroinvasive disease○ Fever in conjunction with meningitis, encephalitis, flaccid
paralysis, or mixed pattern○ Encephalitis more common in older age groups and meningitis more
common in children
TICKS● Primary concern is disease transmission
○ Lyme disease■ Tick-borne illness caused primarily by the
Borrelia burgdorferi species transmitted by ticks in the U.S.
■ Broad spectrum of clinical manifestations which depend on the stage of the illness
○ Rocky Mountain spotted fever (RMSF)● Rarely, tick paralysis and allergic reactions may
occur○ Tick paralysis occurs after a tick has been attached
for 4-7 days. Symptoms include paresthesias, fatigue, and weakness.
○ Some tick bites can sensitize patients to allergens that are found in certain foods such as red meat
LYME DISEASE - EARLY LOCALIZED DISEASE IN CHILDREN● Occurs within the first 2-3 weeks of
infection● Erythema migrans
○ Rash that appears as a red macule at the site of the tick bite, usually within 7-14 days after the bite
○ Most likely to occur on the head or neck in younger children and on the extremities in older children
○ May be pruritic or burning, but rarely painful
LYME DISEASE - EARLY DISSEMINATED & LATE DISEASE● Early Disseminated Disease
○ Occurs weeks to several months after the tick bite
○ Multiple erythema migrans○ Cranial nerve palsy (especially facial nerve
palsy)○ Meningitis○ Carditis○ Fever, fatigue, headache and arthralgia common
● Late Disease○ Occurs weeks to months after the initial
infection if not treated effectively○ Arthritis - usually monoarticular or
oligoarticular, affecting primarily the knee
ROCKY MOUNTAIN SPOTTED FEVER● Caused by infection with Rickettsia rickettsii via
tick-bite● More common in rural and suburban locations● Infected patients become symptomatic 2-14 days after
being bitten
ROCKY MOUNTAIN SPOTTED FEVER - CLINICAL MANIFESTATIONS● Classic symptoms include fever, severe
headache, and rash● Rash usually develops between the third
and fifth days of illness○ Blanching erythematous rash with macules
that become petechial over time ○ Usually begins on the ankles and wrists and
spreads to the trunk○ Rash that appears on the palms and soles is
highly characteristic of RMSF, but usually occurs in later-stage disease
● Other symptoms may include flu-like illness, muscle and joint pain, nausea and vomiting, and abdominal pain
PREVENTION OF TICK BITES & DISEASE● Transmission most likely to occur from May
through October, with a peak in June in northeastern states
● Wear protective clothing● Use repellents that contain DEET or
permethrin● Avoid areas of high vegetation with tall
grass● Carefully examine gear and pets for ticks● Place dry clothes in dryers on high heat for
short period of time after outdoor activities
BEES● Generally sting people in self-defense
or protection of their nests● Acutely painful● Uncomplicated local reactions
○ Redness and an area of painful swelling at the site of the sting that develops within minutes and resolves within a few hours
○ Treatment: Cold compresses● Large local reactions
○ Exaggerated redness and swelling at the site of the sting that gradually enlarges over one to two days
○ Treatment: Cold compresses, NSAIDs, oral antihistamines, oral prednisone
BEES● Systemic allergic
reactions/Anaphylaxis○ Can develop at any age, but more
severe in adults○ Develops rapidly○ Generalized urticaria, flushing,
angioedema○ Respiratory symptoms (hoarse
voice, upper airway obstruction)○ Cardiovascular symptoms
(lightheadedness, hypotension)○ Management: IM Epinephrine
● Prevention
LICE● Tiny parasitic insects that can infest
the skin, and live on people’s head● Head lice are very contagious -
spreading by close body contact and shared clothes and other personal items
● Seen mostly in child-care settings and among school-aged children
● Most common symptom is itching, especially at night
● Lice or their eggs (nits) can typically be seen on the hair, behind the ears, or on the neck
LICE● Treatment depends on the symptoms and severity of the
condition● Very treatable - includes applying a medicated cream
rinse or shampoo to your child's hair ● Treatment may also include removing nits from wet hair
with a comb, soaking combs and brushes in hot water and the shampoo, and checking other household members
● Children can return to school or daycare the day after their first treatment for head lice
REFERENCES● Eisen, R. Prevention of Lyme Disease. In: UpToDate, Waltham, MA, 2020.● Freeman, T. Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and
acute management. In: UpToDate, Waltham, MA, 2020.● Freeman, T. Patient education: Bee and insect stings (Beyond the Basics). In:
UpToDate, Waltham, MA, 2020.● Goddard, J. Insect and other arthropod bits. In: UpToDate, Waltham, MA, 2020.● Head Lice in Children - Stanford Children's Health. (n.d.). Retrieved from
https://www.stanfordchildrens.org/en/topic/default?id=lice-90-P01908● Petersen, LR. Clinical manifestations and diagnosis of West Nile virus infection. In:
UpToDate, Waltham, MA, 2020.● Petersen, LR. Patient education: West Nile virus infection (Beyond the Basics). In:
UpToDate, Waltham, MA, 2020.● Sexton, DJ. Clinical manifestations and diagnosis of Rocky Mountain spotted fever. In:
UpToDate, Waltham, MA, 2020.● Shapiro, ED. Lyme disease: Clinical manifestations in children. In: UpToDate, Waltham,
MA, 2020.