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Insect Bite

Insect bites may be inflicted by mosquitos, fleas, bugs, lice and a plethora of other species pertaining to distinct families of the order insects. While they are of little medical interest in the vast majority of cases, immunocompromised or allergic patients may suffer from severe reactions to an insect bite.


Presentation

Most insect bites are presented in form of puncture wounds, papule formation, localized urticaria and pruritus. These symptoms typically subside within a few hours or days. Both immunodeficiency and secondary infection after scratching may provoke more severe local symptoms. Patients infected with HIV, those suffering from mast cell disorders or lymphoproliferative diseases may present with tissue necrosis due to insect bites. Lymphadenopathy and fever may be observed. Scratching may lead to secondary bacterial infection or allow transmission of trypanosoma.

Systemic reactions are very rare, but may consist in:

Patients currently treated with beta-sympatholytics and angiotensin-converting enzyme inhibitors seem to be at higher risks of systemic reactions.

Localized Pain
  • Most cause only transient local pain and/or itching, but about 1 percent of Americans experience severe allergic reactions to insect venom; about fifty die each year. Furthermore, these pests can transmit diseases.[motherearthliving.com]
  • For intense local pain, injection of local anesthetic may be required. Systemic medication may be needed for generalized pain. Individuals who have had an allergic reaction to an insect bite may benefit from venom immunotherapy.[medical-dictionary.thefreedictionary.com]
  • Some insect bites are associated with papule formation, transient pruritus and/or localized pain, others are not even noticed by the person who got bitten. However, certain patient groups have high risks of severe, possibly lethal complications.[symptoma.com]
  • The use of cold compresses may help reduce local pain, swelling and itching. Oral antihistamines such as chlorphenamine (sedating) or topical corticosteroids (such as hydrocortisone 1%) may help reduce itching.[fitfortravel.nhs.uk]
  • Other spider bites usually cause local pain, which may be relieved by ice packs or simple analgesics and antihistamines may help swelling and itching.[anaesthesia.med.usyd.edu.au]
Veterinarian
  • Have pets checked by a veterinarian for possible mite or scabies infestations. Consult with a pest control professional or Board Certified Entomologist concerning identification of suspected insect or mite infestations.[citybugs.tamu.edu]
  • Treat and suggest having animals treated by a veterinarian. Expect relief from symptoms within 24 hours. If no improvement or symptoms worsen, consult pharmacist or physician. Assess Benenfit: No follow-up usually required.[medsask.usask.ca]
  • You can pick up a flea medication at your local veterinarian office. Bites from lice will appear in your hair. You may not be able to see them, so have a friend or family member check for you. They are red and itchy.[wikihow.com]
Lymphadenopathy
  • Characteristic symptoms are malaise, fever, chills, lymphadenopathy, arthalgia and abdominal pain. Papular urticaria.[symptoma.com]
  • A condition mainly seen in Japanese children, in which a mosquito bite is followed by local skin necrosis combined with fever, lymphadenopathy, and hepatosplenomegaly ( 21 ), is thought to represent reactivation of a latent Epstein-Barr virus infection[doi.org]
Plethora
  • Insect bites may be inflicted by mosquitos, fleas, bugs, lice and a plethora of other species pertaining to distinct families of the order insects.[symptoma.com]
Dentist
  • With this report, the authors, as dentists, emphasize the significance of recognition, early diagnosis, and referral of such patients with bleeding disorders to specialized centers, for prompt treatment.[ncbi.nlm.nih.gov]
Pharyngitis
  • A case of Kaposi's sarcoma with oral, pharyngeal and extremity lesions is reported. The first lesion appeared on the spot of an insect bite on the left leg during a stay in the Mediterranean area.[ncbi.nlm.nih.gov]
Nausea
  • The black widow spider may cause only a mild local reaction at the bite site, but pain, stiffness, chills, fever, nausea, and abdominal pain may follow within a few hours.[skinsight.com]
  • There may be nausea, vomiting, severe headache, and loss of appetite, pain in the abdomen, muscle aches and diarrhoea. After initial 2 to 5 days there may be a red rash on the wrists, forearms, palms, soles and ankles.[news-medical.net]
  • Difficulty swallowing or breathing Chest tightness Widespread hives Swelling of the lips, tongue or throat Nausea, vomiting, diarrhea Fatigue, significant increase[wm.edu]
  • Spiders Black widow spider bites cause muscle cramp, seizure, nausea, vomiting and rise in blood pressure. These spiders are roughly 1/3 inch wide and 1.5 inches long, counting their long legs.[firstderm.com]
Abdominal Pain
  • The black widow spider may cause only a mild local reaction at the bite site, but pain, stiffness, chills, fever, nausea, and abdominal pain may follow within a few hours.[skinsight.com]
  • Call a doctor if: You have a fever, severe headache, muscle and joint pain, nausea and vomiting, abdominal pain or a red, blotchy rash that starts on your ankles and wrists and spreads across your body within a week of being bitten. 4 / 6 Bees and Wasps[sharecare.com]
  • They include: Chest pain Face or mouth swelling Difficulty swallowing Difficulty breathing Fainting or lightheadedness Abdominal pain or vomiting Rash or flushing For severe reactions, first check the person's airways and breathing.[nlm.nih.gov]
  • Description For those allergic to bites and stings, their skin breaks out in hives, the eyes itch, the chest and throat feel constricted, a dry cough comes on, and there is often nausea, abdominal pain, vomiting, and dizziness.[healthcentral.com]
Urticaria
  • Papular urticaria. Patients suffering from papular urticaria typically present with chronic skin lesions and pruritus that tend to disappear in winter but that often reappear next summer.[symptoma.com]
  • Insect bites and the associated hypersensitivity reactions known as papular urticaria account for a significant number of all referrals from pediatricians and dermatologists to our pediatric dermatology clinic.[ncbi.nlm.nih.gov]
  • […] urticated papules - there may be a central punctum; they may be excoriated; occasionally blisters are associated bites often occur in groups; often asymmetrical more than one family member may be affected may be secondary bacterial infection papular urticaria[gpnotebook.co.uk]
  • Abstract Insect bites and the associated hypersensitivity reactions known as papular urticaria account for a significant number of all referrals from pediatricians and dermatologists to our pediatric dermatology clinic.[pediatrics.aappublications.org]
Eczema
  • The rash may resemble other conditions such as hives or eczema. Bed bug infestations can be hard to identify. Bed bugs may leave reddish stains, dark spots, or pale yellow eggs on bedding and infested materials.[emedicinehealth.com]
  • Occasionally, an insect bite can lead to complications which may need treatment, including infection and eczema. In a small number of cases, an insect bite can result in a dangerous reaction called anaphylactic shock.[nhs.uk]
  • 'Your immune system is more likely to over-react to bites if you have other allergies, eczema or hay fever,' explains Sultan Dajani, of the Royal Pharmaceutical Society.[dailymail.co.uk]
  • Neem oil : Effective against fungal conditions, boils, eczema, and ringworm, and it would undoubtedly help an insect bite as well. Tea Tree oil : Helpful for healing cuts, burns, infections and a multitude of other skin afflictions.[articles.mercola.com]
  • Arthropods can infest human skin, especially scabies and head lice They can inflict bites and stings They can carry diseases such as malaria, yellow fever and filariasis They can give rise to allergic conditions such as hay fever, asthma and atopic eczema[dermnetnz.org]
Pruritus
  • Most insect bites are presented in form of puncture wounds, papule formation, localized urticaria and pruritus. These symptoms typically subside within a few hours or days.[symptoma.com]
  • Pruritus is also variable. open bite upper and lower incisors fail to meet when the mouth is closed. pincer bite upper and lower incisors make contact on their edges rather than overlapping when the mouth is closed. reverse scissor bite the labial surface[medical-dictionary.thefreedictionary.com]
  • Testing another medical device called Bite Away, they concluded that: "Locally administrated concentrated heat leads to fast amelioration of symptoms [swelling, pruritus and pain].[articles.mercola.com]
  • Double blind, placebo-controlled trials have shown that cetirizine, levocetirizine, and loratadine decrease wheal diameter and pruritus scores due to mosquito bites.[clinicaladvisor.com]
  • […] mycosis 真菌症 n necrotizing fasciitis 壊死性筋膜炎 nevus 母斑 nodule 結節 o ointment 軟膏 ophiasis 蛇行状脱毛症 p papule 丘疹(きゅうしん) paste 軟膏 pemphigus 天疱瘡(てんぽうそう) pernio 凍瘡(とうそう) photosensitivity 光線過敏症 phototest 光線テスト phototherapy 光線療法 pityriasis 粃糠疹(ひこうしん) primary lesion 原発疹 pruritus[tokyo-med.ac.jp]
Exanthema
  • […] crust 痂皮(かひ) cryosurgery 凍結外科 cutaneous candidiasis 皮膚カンジダ症 d decubitus 1.褥瘡(じょくそう) 2.臥位 dermatitis 皮膚炎 dermis 真皮 diascopy 硝子圧法 drug eruption 薬疹 e eczema 湿疹 epidermis 表皮 erosion びらん eruption 発疹 erysipelas 丹毒(たんどく) erythema 紅斑(こうはん) erythroderma 紅皮症 exanthema[tokyo-med.ac.jp]
  • Common causes are immunological and non-immunological cutaneous drug eruption 1– 4 —particularly secondary to antibacterials 5– 7 (fig 3), urticarial reactions, 8, 9 viral exanthema, infestation, and insect bites.[doi.org]
Headache
  • Other symptoms include fever, significant fatigue, body aches, stiff neck and headache. Early treatment frequently has a positive outcome. 3 / 6 Dog Tick Where: All states, but mainly North Carolina, Oklahoma, Arkansas, Tennessee and Missouri.[sharecare.com]
  • Symptoms of Rocky Mountain Spotted Fever Initial symptoms may include fever, nausea, vomiting, severe headache, severe neck pain, muscle pain, and lack of appetite.[nextcare.com]
  • In addition to the classic bull’s-eye rash of Lyme disease, tick-borne illnesses can cause chills, fever, fatigue, headaches, and muscle or joint pain.[consumerreports.org]
  • Symptoms of Lyme disease include fever, rash, headache and fatigue. If caught early enough, the disease can be treated with antibiotics.[cbsnews.com]
  • There may be nausea, vomiting, severe headache, and loss of appetite, pain in the abdomen, muscle aches and diarrhoea. After initial 2 to 5 days there may be a red rash on the wrists, forearms, palms, soles and ankles.[news-medical.net]

Workup

Most insect bites don't require any additional diagnostic measures.

If patients present uncommon symptoms like tissue necrosis, these should guide the physician's decision regarding further diagnostic measures. They may be carried out to identify potentially underlying immunodeficiency.

Thorough anamnesis and query for possible exposure to insects may be of great help to identify the etiological agent in patients presenting with serum sickness or papular urticaria.

With regards to anaphylaxis, immediate treatment takes priority over diagnostic workup. However, patients that show severe adverse reactions to insect bites are considered to have higher risks of anaphylaxis upon getting bitten again. Therefore, the causative species and/or allergen should be identified if possible. Significant advances have been made regarding diagnostic measures such as skin tests to prove hypersensitivity to determined proteins [4] [11].

Trypanosoma Cruzi
  • While bed bugs are not known to transmit infectious diseases, assassin bugs serve as vectors for Trypanosoma cruzi.[symptoma.com]
Bartonella Quintana
  • Lice may also serve as vectors for Borrelia recurrentis and Bartonella quintana, etiological agents of relapsing fever and trench fever, respectively. Insect bites may be prevented by minimizing exposure.[symptoma.com]
Dirofilaria Immitis
  • ., Dirofilaria immitis, Leishmania spp., Plasmodium spp.).[symptoma.com]
Nocardia Brasiliensis
  • Analysis of the purulent exudate obtained from the nodule revealed Nocardia brasiliensis. The initial therapy with trimethoprim-sulfamethoxazole had to be stopped due to a drug eruption.[ncbi.nlm.nih.gov]

Treatment

Local application of ice and possibly antihistamines may help to reduce inflammation and pruritus. The latter is of major importance to avoid scratching and subsequent secondary infection, particularly in children. Systemic treatment is not necessary in uncomplicated cases of insect bites.

In contrast, tissue necrosis and systemic symptoms do require special treatment, possibly even surgery. While antihistamines and corticosteroids is occasionally used to treat serum sickness and papular urticaria, they are routinely administered to patients suffering from anaphylaxis. Additionally, these patients may require application of adrenaline. Depending on adrenaline-mediated effects, aggressive intravenous fluid therapy to compensate for hypotension and administration of beta-sympathomimetics to induce bronchodilation may be necessary. Early intubation and oxygen supply is recommended to avoid asphyxia due to bronchospasm.

Prognosis

Prognosis is generally excellent. Most insect bites are little more than transient nuisances; however, severe reactions to insect bites may be associated with significant morbidity and mortality. Anaphylaxis, tissue necrosis and secondary bacterial infection may pose serious threats to human health and require immediate medical attention. The risk of an anaphylactic reaction is significantly increased in patients presenting underlying mast cell disorders [8].

Etiology

As has been mentioned above, mosquitos, fleas, bugs and lice shall serve as examples for insects that may inflict bites in this article.

  • Mosquitos pertain to the order of Diptera and constitute the family Culicidae. Female mosquitos dispose of mouthparts forming a proboscis that allows for penetration of human skin and sucking of blood.
  • Fleas form a rather small order within the insect class, the Siphonaptera. Similar to mosquitos, they are able to pierce human skin and feed on blood.
  • Bugs, or true bugs, pertain to the order Hemiptera. Of medical importance are bed bugs (family Cimicidae) and assassin bugs (family Reduviidae). They pierce and suck using their proboscis.
  • Lice form the order Phthiraptera and have retractable mouthparts that are also adapted to piercing and sucking.

Epidemiology

With the exception of the oceans, there is no place on earth that's free from insects. They can be found on every continent, even in Antarctica. However, insect populations are generally larger in hot and humid climate zones. In temperate climates, the risk of insect bites is higher during the warm summer months.

Many insect species inhabit certain geographic regions and thus, only locals and travelers may be bitten by a particular type of insect. While this also limits exposure to pathogens transmitted by insects, expansion of vectors may put additional human populations at risk. Such phenomena have been observed in mosquitos transmitting malaria and leishmaniasis, for instance [2] [3].

People pertaining to any race, gender and age group may be bitten by insects. Overall morbidity and mortality are very low, but serious complications may be observed even in patients who haven't been diagnosed with hypersensitivity previously. Such reactions may be fatal [4].

Sex distribution
Age distribution

Pathophysiology

Insects either bite to access possible food sources or to defend themselves and their offspring. While biting, they expose their host or enemy to proteins contained in their saliva [5], to anticoagulants injected in order to feed more easily on blood, to local anesthetics to avoid being removed while feeding, and possibly to pathogens they serve as vectors for. With regards to the former, all kind of proteins may act as allergens and severe reactions to insect bites are almost exclusively mediated by the immune system of the patient. Usual reactions to insect bites are also evoked by the immune system and mainly comprise urticaria and pruritus as characteristic symptoms of a type I hypersensitivity reaction. This may cause the patient to scratch, which, in turn, may lead to secondary infections.

If healthy individuals are bitten by insects, the main risk for complications rests in transmission of pathogens. A plethora of viruses, bacteria and protozoa may be transmitted by biting insects. Some pathogens use distinct insect species as an unspecific carrier, while others have to complete developmental stages within determined insects.

  • Mosquitos are known to transmit all kinds of pathogens. They serve as vectors for viruses (e.g., those viruses causing yellow fever, Dengue fever, West Nile fever), bacteria (mainly Enterobacteriaceae) and protozoa (e.g., Dirofilaria immitis [6], Leishmania spp., Plasmodium spp.).
  • Although fleas are rarely considered when talking about vector-borne diseases today, they are of major historical importance as vectors of Yersinia pestis, causative agent of the bubonic plague. Of note, this disease is still not eradicated [7], but antibiotics have considerably reduced its dreadfulness. Fleas may also transmit Rickettsia spp. that cause typhus.
  • While bed bugs are not known to transmit infectious diseases, assassin bugs serve as vectors for Trypanosoma cruzi. This protozoan parasite causes Chagas disease and is actually transmitted via the feces of the bug, but infection is largely facilitated if the patient scratches bite sites.
  • Similar to fleas, presence of lice has been associated with bouts of typhus. Lice may also serve as vectors for Borrelia recurrentis and Bartonella quintana, etiological agents of relapsing fever and trench fever, respectively.

Prevention

Insect bites may be prevented by minimizing exposure. Appropriate measures are particularly recommended to people living in or traveling to geographical regions where insects transmit diseases like malaria and Chagas disease. Preventive measure comprise:

  • Wearing of long-sleeved clothes.
  • Use of window screens and/or mosquito nets.
  • Use of repellents. Insect species may be resistant to certain formulations. Up-to-date information should be consulted before deciding for any particular repellent.
  • Prolonged stays in high-risk areas such as those close to stagnant waters should be avoided. This restriction may apply only to certain times of the day and year.

In order to avoid secondary infections of insect bites, patients should refrain from scratching.

Patients with a medical history of adverse reactions to insect bites should carry adrenaline pens to allow for immediate countermeasures in case of anaphylaxis. In severe cases, desensitization should be considered [12]. Spontaneous desensitization may occur while growing up [5].

Summary

Insects constitute a huge class of animals that may comprise as much as ten million species - some experts estimate even higher numbers. Animals as distinct as beetles, flies, wasps, bees, ants, moths and butterflies are all insects. They pertain to the phylum of arthropods, like arachnids do, but both classes can easily be distinguished by counting legs: Insects have six legs, arachnids have eight. Of course, there are many other morphologic and functional differences between insects and arachnids, but this method should suffice for non-zoologists.

An insect's body consists of head, thorax and abdomen, and is sustained by a hard exoskeleton. Upon closer inspection, antennae, eyes or ocelli and mouthparts may be recognized on the head. The insect's mouthparts are often used to illustrate evolution: While most insect species dispose of labrum, mandibles, maxillae, labium and hypopharynx, these organs have been largely modified to adapt to distinct forms of nutrition. Insects may chew, bite, suck, sponge, lick and pierce with their mouthparts.

Any damage inflicted with an insect's mouthparts may be referred to as an insect bite. Because mosquitos pierce and suck with their mouthparts, they cause insect bites. Other insects that may invoke lesions by using their mouthparts are fleas, bugs and lice. Insects may bite to access food sources or to defend themselves.

On the other hand, evolution brought forward a wide variety of insects that dispose of specialized organs to inject venom into the body of a potential enemy, e.g., the sting of bees and wasps. These organs are usually supported by an insect's abdomen. Although insect bite and insect sting are often used interchangeably, they are clearly different entities from a zoological point of view. Of note, some species, like wasps may bite and sting. Most humans who encounter wasps are stung, not bitten, though.

Some insect bites are associated with papule formation, transient pruritus and/or localized pain, others are not even noticed by the person who got bitten [1]. However, certain patient groups have high risks of severe, possibly lethal complications. These patient groups comprise people who present hypersensitivity reactions after exposure to insect allergens as well as immunocompromised patients who may develop local reactions or systemic symptoms.

Patient Information

Insects constitute a huge class of animals that comprises several millions of species. In general, an insect's body consists of head, thorax and abdomen, whereby three pairs of legs can be observed on the thorax. Indeed, the fact that insects have six legs and arachnids have eight may be used to distinguish animals pertaining to either one taxonomic class.

The insect's head carries antennae, primitive eyes and mouthparts. Evolution brought forward a wide variety of species whose mouthparts are adapted to pierce human (or other species') skin and to suck blood. From a zoological point of view, this is an insect bite. Considering that definition, mosquitos, fleas, bugs and lice bite.

In contrast, other insects have a sting which is typically located towards the rear end of the animal and which has evolved to inject venom into the body of a possible enemy. These insects sting. While there is a clear difference between an insect bite and an insect sting, some species - wasps, for instance - may bite and sting.

In most cases, insect bites are minor nuisances that cause urticaria and pruritus, symptoms that usually subside within a few hours or days. However, biting insects may also transmit serious diseases, e.g., malaria, leishmaniasis and Chagas disease. Thus, prevention of insect bites does not only aim at avoiding formation of itchy papules but is of major importance for anyone living in or traveling to geographical regions where the aforementioned diseases are endemic.

Severe adverse reactions to insect bites are rarely observed. Immunodeficient individuals may present with tissue necrosis due to an insect bite. Other patients may suffer an allergic reaction and develop life-threatening anaphylaxis, though insect stings are much more likely to induce anaphylaxis than insect bites.

References

Article

  1. Morsy TA. Insect bites and what is eating you? J Egypt Soc Parasitol. 2012; 42(2):291-308.
  2. Laporta GZ, Linton YM, Wilkerson RC, et al. Malaria vectors in South America: current and future scenarios. Parasit Vectors. 2015; 8:426.
  3. Maia C, Cardoso L. Spread of Leishmania infantum in Europe with dog travelling. Vet Parasitol. 2015; 213(1-2):2-11.
  4. Engler RJ. Mosquito bite pathogenesis in necrotic skin reactors. Curr Opin Allergy Clin Immunol. 2001; 1(4):349-352.
  5. Peng Z, Ho MK, Li C, Simons FE. Evidence for natural desensitization to mosquito salivary allergens: mosquito saliva specific IgE and IgG levels in children. Ann Allergy Asthma Immunol. 2004; 93(6):553-556.
  6. Diaz JH. Increasing risks of human dirofilariasis in travelers. J Travel Med. 2015; 22(2):116-123.
  7. World Health Organization. Plague around the world, 2010-2015. Wkly Epidemiol Rec. 2016; 91(8):89-93.
  8. Reiter N, Reiter M, Altrichter S, et al. Anaphylaxis caused by mosquito allergy in systemic mastocytosis. Lancet. 2013; 382(9901):1380.
  9. Gaig P, Garcia-Ortega P, Enrique E, Benet A, Bartolome B, Palacios R. Serum sickness-like syndrome due to mosquito bite. J Investig Allergol Clin Immunol. 1999; 9(3):190-192.
  10. Demain JG. Papular urticaria and things that bite in the night. Curr Allergy Asthma Rep. 2003; 3(4):291-303.
  11. Peng Z, Simons FE. Advances in mosquito allergy. Curr Opin Allergy Clin Immunol. 2007; 7(4):350-354.
  12. Ariano R, Panzani RC. Efficacy and safety of specific immunotherapy to mosquito bites. Eur Ann Allergy Clin Immunol. 2004; 36(4):131-138.

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Last updated: 2019-07-11 22:30