​Kembara Xtra - Medicine - Arthropods bites and stings

​Kembara Xtra - Medicine - Arthropods bites and stings 
ESSENTIAL DESCRIPTION
The largest group of animals in the animal kingdom are arthropods.
The greatest threat to human health comes from two classes: insects and arachnids.
Arthropods can infect humans by biting or stinging them, entering their tissue, or by causing contact allergies to their skin, hairs, or secretions. Transmission of pathogenic microbes during feeding is of the utmost concern.
● Following bites, stings, or contact, common aftereffects include localized redness, itching, and swelling that are often mild and temporary.
- Severe local reactions that worsen over the course of 24 to 48 hours - Systemic reactions characterized by anaphylaxis, neurotoxicity, organ damage, or other symptoms of systemic toxins - Tissue necrosis or secondary infection
- Transmission of contagious diseases: Presentation can be weeks to years away.

INCIDENCE OF EPIDEMIOLOGY
33,671 incidents of exposure to arthropods were reported in 2016. Only a small portion of arthropod encounters are like this.
0.5–3.3% of people get systemic reactions to hymenoptera venom, and the majority of fatalities are people who had never had an allergic reaction.
Widespread prevalence with seasonal and regional variations

Arthropods: four key classes with significant medicinal implications
Hymenoptera (bees, wasps, hornets, and fire ants), mosquitoes, bed bugs, flies, lice, fleas, beetles, caterpillars, and moths are among the insects.
- Arachnids, including ticks, mites, spiders, and scorpions
- Centipedes, or chilopods
Diplopods include millipedes.

● Pathophysiologic effects can be divided into four categories: toxic, allergic, infectious, and traumatic.
- Local (tissue inflammation or destruction) versus systemic (neurotoxic or organ damage) impacts of venom's toxic effects.
- Allergic: Venom or salivary antigens may result in localized inflammation. Anaphylaxis or serum sickness may be the outcome of exaggerated immunological reactions.
- Trauma: Mechanical injuries from biting or stinging result in discomfort, edema, and a gateway for secondary infection and bacterial growth. An arthropod retention reaction may result in a granulomatous reaction.
Arthropods are capable of spreading bacterial, viral, and protozoal illnesses.
Atopy in the family pedigree may play a role in the emergence of more severe allergy reactions.


RISK FACTORS Previous sensitization Risk is raised by a number of outdoor activities, jobs, and travel exposures.
Individuals who are young, old, immunosuppressed, have a chronic or poorly controlled respiratory or cardiac condition are more likely to experience a negative outcome.
Mastocytosis individuals are more likely to experience anaphylaxis

DURATIONAL PREVENTION

Avoid areas where common arthropods live.

 Insect repellents (ineffective against ants, bed bugs, spiders, scorpions, caterpillars, or bees)
- DEET, or N,N-diethyl-meta-toluamide
 The most powerful all-purpose insect repellant against biting arthropods○ In regions with endemic arthropod-borne illnesses, formulations with higher concentrations (20–50%) are the preferred option.
Concentrations greater than 30% last longer.
DEET doses greater than 50% offer no appreciable protective advantages.
Picaridin (icaridin) is safe for children older than six months old, as well as for pregnant and nursing women.
P-menthane-3,8-diol (PMD; lemon eucalyptus extract), a 20% spray equivalent to 20% DEET, provides mosquito protection.
 30% doses provide 4 to 5 hours of tick and mosquito protection.
Not advised for children under the age of three.
- IR3535: less effective in the majority of studies; inappropriate for areas where malaria is prevalent

 Bed netting and clothing are effective barriers.
- Don long pants, shirts with long sleeves, and caps.
The synthetic pesticide permethrin is generated from the chrysanthemum plant. Avoid applying to the skin directly.
Clothing treated with permethrin is safe for pregnant women and children of all ages, and it offers effective protection against insects.
All travelers to disease-endemic areas who face a risk of being bitten by arthropods are encouraged to use mosquito nets.
Nets that have been permethrin-treated may provide additional security.
Desensitization for Hymenoptera-specific venom is 75–95% successful; skin tests are used to gauge sensitivity; allergists and immunologists should be consulted.
Baits, sprays, dusts, aerosols, and biologic treatments can control (but not completely eradicate) fire ants.
By removing ticks as soon as possible—within 24 hours of attachment—the risk of infections brought on by ticks may be reduced.

DISEASE HISTORY
With the visualization of an arthropod, there is a sudden beginning of pain or itching. Many cases (bed bugs, lice, scabies, ticks) are either unknown to the patient or first asymptomatic. Take into account when treating patients who have wheals, papules, urticaria, localized erythema, pruritus, or bullae.
Determine the insect by its habitat or any remnants the patient provided.
While useful, prior exposure history is not always accessible or trustworthy.

 Travel, employment, social, and leisure history

If the stinger is still embedded in the flesh, remove it by flicking or scraping it. A clinical diagnosis of anaphylaxis exists. Erythema, urticaria, and angioedema are some of the symptoms.
- Drooling and itching of the lips, tongue, and uvula. - Chest pain, wheezing, a persistent cough, stridor, and dysphonia
If anaphylaxis is not present, the examination concentrates on the sting or bite itself. - Hypotension, dysrhythmia, syncope, and chest pain. Common symptoms include localized erythema, edema, wheals, urticaria, papules, or bullae; in addition, there may be excoriations from scratching. Check for tick attachments or arthropod infestations (lice, scabies). Skin scraping can detect scabies; body lice are typically discovered in clothing seams; signs of secondary bacterial infection after 24 to 48 hours include increased erythema, discomfort, fever, lymphangitis, or abscess.

Differential diagnoses for urticaria and localized dermatologic reactions include: - Contact dermatitis, drug eruption, mastocytosis, bullous diseases, erythema multiforme, viral exanthem, impetigo, folliculitis, erysipelas, necrotizing fasciitis, tinea, and eczema.
Anaphylactic-type reactions include cardiac, hemorrhagic, or septic shock; acute respiratory failure; asthma; angioedema; urticarial vasculitis; flushing syndromes (catecholamines, vasoactive peptides); syncope; and a black widow spider bite should be considered in the differential diagnosis of the acute abdomen.

DETECTION & INTERPRETATION OF DIAGNOSIS
Initial examinations (lab, imaging)
Rarely required; basic lab results are often normal

Tests in the Future & Special Considerations
Serious envenomations may impair organ performance and necessitate laboratory monitoring (CBC, full metabolic panel, prothrombin time/international normalized ratio).
Potential diseases carried by arthropods
- Ticks: ehrlichiosis, Powassan illness, Heartland virus (HRTV), Bourbon virus, relapsing fever, anaplasmosis, babesiosis, tularemia, Rocky Mountain spotted fever (RMSF),
- Flies: bartonellosis, loiasis, tularemia, leishmaniasis, and African trypanosomiasis
- Fleas: tularemia, murine typhus, plague
- Scrub typhus caused by chigger mites
- Body lice: relapsing fever and pandemic typhus
- Kissing bug disease: Chagas
- Malaria, dengue fever, West Nile virus, equine encephalitis, chikungunya, and Zika virus are all transmitted by mosquitoes.
Refer to an allergist for official testing if you have a history of anaphylaxis, major systemic symptoms, or more severe reactions (3)[B].
Other Skin and immunologic testing are available for diagnosing specific allergies.

CARE/ ALERT Rapid anaphylaxis is a serious condition that can be fatal.
The majority of anaphylaxis-related deaths take place 30 to 60 minutes after a sting.
Epinephrine should be administered as soon as anaphylaxis is suspected. Increased lethality is linked to delay.
Antihistamines and steroids never serve as the first line of treatment for anaphylaxis and do not replace epinephrine; there is no direct evidence of their efficacy in this condition. Airway care is crucial for angioedema.
UNSPECIFED MEASURES
Reduce itch, pain, and swelling with analgesics, cold packs, and local wound care.

First Line: MEDICATION

 For insect bites/stings accompanied by anaphylaxis, unanimity among experts
Most importantly, administer epinephrine intramuscularly (IM) in the midanterolateral thigh at a dose of 0.3 to 0.5 mg per dose for adults and 0.01 mg/kg to a maximum dose of 0.3 mg per dose for children. Repeat this procedure every 5 to 15 minutes for a total of three injections.
- 100% oxygen as required
- IV liquids Create one or two large-bore IV lines. Pediatrics: 20 to 30 mL/kg normal saline bolus, 1 to 2 L IV; repeat as necessary.
- Diphenhydramine 25 to 50 mg IV (pediatrics 1 to 2 mg/kg): an H1 antagonist- H2 antihistamines: 50 mg IV ranitidine- Two agonists: nebulized albuterol for bronchospasm Despite being routinely used, corticosteroids (2.5 to 5.0 mg in 3 mL) had no effect on acute anaphylaxis and may have some value in avoiding biphasic allergic responses.
Insect stings or bites without anaphylaxis: Tetanus booster as needed
Antihistamines taken orally
Adults should take 25 to 50 mg of diphenhydramine PO/IV/IM every 4 to 6 hours. Pediatrics: 50 mg PO, IV, or IM maximum dose; daily maximum dose of 300 mg for both adults and children.
 H2 blockers: ranitidine adults: 150 mg PO 1 to 2 times day as needed; pediatrics: 2 to 4 mg PO. Cetirizine adults: 5 to 10 mg PO daily; pediatrics: 6 to 23 months—2.5 mg PO daily; 2 to 5 years—5 mg PO daily; 6 years and older—5 to 10 mg PO daily. 1-2 times per day, as necessary
- Topical steroid cream or ointment for 3 to 5 days; oral steroids; short course for severe pruritus or local responses; prednisone or prednisolone 1 to 2 mg/kg once daily.
1% Hydrocortisone OTC
 Might take into account stronger doses like triamcinolone 0.1% and fluocinolone 0.025%
- Wound care: only use antibiotics in cases of infection
– Other particular therapies
Scorpion stings: Use nitroprusside, prazosin, or -blockers to treat excessive catecholamine release. (4) Atropine for excessive salivation. There is only one scorpion venom with FDA approval. Utilize only after consulting a toxicologist.
Black widow bites: Use benzodiazepines and narcotic analgesics to treat muscle spasms (4).
Antivenom is available, however it should only be used in cooperation with a toxicologist for severe symptoms (5)[B].
For questions about management, call the poison control hotline at 1-800-222-1222.
- Fire ants: sterile pustules are typically caused by them; leave intact; do not open or drain.
- Pain management and supportive care for brown recluse spiders; surgical consultation if débridement is required. - Early tick removal. associated with ehrlichiosis, RMSF, babesiosis, and Lyme disease.
- Head, pubic, and body lice (Pediculosis)
Permethrin 1% topical lotion, first line
Alternatives include pyrethrins and ivermectin, which has been demonstrated to be helpful for pediculosis but is not FDA-approved.
 Repeat the procedure in seven to ten days.
- Scabies, Sarcoptes scabiei
 The preferred medication is 5% permethrin cream: Apply all over the body. After 8 to 14 hours, wash off. Recur in a week.
 Ivermectin: FDA-unapproved treatment for scabies, 200 g/kg PO once; repeat in 2 weeks
A 2018 Cochrane review discovered no distinction between permethrin's efficacy and that of systemic or topical ivermectin.


QUESTIONS FOR REFERENCE
Consultation with allergy/immunology is beneficial for patients with a history of anaphylaxis, severe systemic symptoms, or progressively worsening reactions.

SURGICAL AND OTHER PROCEDURE
For severe brown recluse spider bites and other bites, débridement and delayed skin grafting may be required.

ALTERNATIVE & COMPLEMENTARY MEDICINE

Calamine lotion has not been proved to be beneficial.
Bites may be soothed with a paste made of 3 teaspoons baking soda and 1 teaspoon water.

Anaphylaxis, vascular instability, neuromuscular events, discomfort, GI symptoms, and renal damage or failure are only a few of the considerations for admission, patients, and nurses.
After the symptoms of anaphylaxis subside, all patients should be monitored for an additional hour. Extended observation is advised for those who have severe anaphylaxis or who need more than one dosage of epinephrine.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
Venom immunotherapy, which is 80-98% successful, is the cornerstone of treatment for Hymenoptera.
If the patient has a history of anaphylaxis, offer epinephrine for self-administration. Think of "med-alert" designations.

patient observation

Serum sickness responses, vasculitis (rare), and other delayed consequences, such as infectious infections from insect bites, should be monitored.

EDUCATION OF PATIENTS
Arthropod prevention and avoidance strategies

Excellent prognosis for local responses; greatest prognosis for systemic reactions with early management to prevent cardiorespiratory collapse

Arthropod-associated infectious illnesses, secondary bacterial infections, and scarring are complications.
Phobias and psychological effects