Parasitic Infestations, Stings & Bites Part 2

Erik Austin, D.O., M.P.H.

Loaiasis
Aka Loa Loa, Calabar Swelling, Fugitive Swelling, Tropical Swelling Asymptomatic localized subQ swellings, size of a hens egg Prediliction for loose tissues such as eyes, frenulum of tongue, genitalia Transmitted by the Mango fly Chrysops dimidia or silacea Tx: Diethylcarbamazine

Loaiasis worm under the conjunctiva

Onchocerciasis
River Blindness Central & South America, Mexico Pretibial depigmentation: leopard skin Thickened skin: elephant skin May develop into subQ nodules Mazzoti test + if edema, pruritis, fever & arthralgias w/50mg diethylcarbamazine Tx: Ivermectin 150mg single dose

Black fly of the genus Simulium

Leopard skin, Elephant skin

Trichinosis
Inadequately cooked pork, bear or walrus meat Puffy eyelid edema, red conjunctiva and sometimes urticaria, fever, HA, muscle pains, neurologic S&S. 20% have maculopapular rash, very itchy, responsive to corticosteroids. Diagnosis confirmed by muscle biopsy Tx: Albendazole 400mg bid for 2w.

Trichinella spiralis muscle bx

Phylum Arthropoda 3 main classes

Myriapoda
Centipede Millipedes

Insecta
Caterpillar Moth

Arachnida

Myriapoda Centipede Stings

Paired hemorrhagic puncta with erythematous swelling progressing to brawny edema or lymphangitis and lymphadenopathy. U.S. = Scolopendra species, 15-20cm Tx: Rub with garlic or local anesthetic injection.

Scolopendra sp.

Myriapoda Millipede burns

Millipede bodies secrete a toxic liquid that causes brown discoloration, progresses to erythema & vesiculation intense stinging and burning pain Tx: wash site immediately, topical steroids.

Lepidoptera Caterpillar Dermatitis

Nettling hairs contain a toxin that produces local pruritic erythematous macules and wheals. MC campers, children playing in trees and lumberjacks in Fall. Nygmia phoerrhoea (brown-tail moth) Megalopyge opercularis (puss caterpillar) Sibine stimulae (saddleback caterpillar) Megalopyge crispata (crinkled flannel moth) Tx: Antihistamines, resolves 48 hours.

Saddleback

Brown tail moth

Lepidoptera Moth Dermatitis

Hairs of the moth urticating toxin Euproctis chrysorrhoea (brown tail) Cossus cossus (goat) Dicranura vinula (puss) Lymantria dispar (gypsy) Hemenocampa pseudotsugata (Douglas fir tussock) Tx: oral steroids help, lasts 1 week

BROWN TAIL MOTH

GOAT MOTH

GYPSY MOTH

DOUGLAS FIR TUSSOCK

Hemiptera Bedbug Bites

Aka Cimicosis, Cimex lectularis Smelly parasite with non-functioning wings. Hides in crevices by day and feeds on human blood at night. Breakfast-Lunch-Dinner linear bites Sensitivity at site due to saliva Hepatitis B surface antigen has been repeatedly demonstrated in the bugs, but transmission is controversial Tx: Pt: topicals, House: call exterminator.

Hemiptera Reduviid Bug Bites

Aka Kissing Bug, Assasin bug, conenoses Attack face when asleep, bite is painless, bug defecates and rubs feces into wound, spreading Trypanosoma cruzi

Anoplura
Pediculosis (Phthiriasis): Pediculosis Capitis Pediculosis Corporis Pediculosis Pubis (Crabs)

Pediculosis (Phthiriasis)
Pediculus humanus (head & body) Phthirus pubis (pubic or crab louse) Attach and suck blood, saliva is antigenic and creates dermatitis Lice may transmit endemic typhus, relapsing fever or trench fever.

Pediculosis Capitis
MC in children, scalp usually pruritic Diagnosis straightforward. Peripilar hair casts easily differentiated b/c moveable, but the breaks of trichorrhexis nodosum may mimic nits Tx: Apply Permethrin 1% Cream Rinse (Nix) to DRY hair, then rinse out after 3060 minutes. Do not shampoo for 24 hours afterwards.

Pediculosis Capitis

Pediculosis Corporis
Aka: Pediculosis Vestimenti or Vagabonds Dz. Likes pressure areas beneath collar, belt or in bedding. LICE RARELY FOUND ON SKIN. Dx: Generalized itching, parallel scratch marks, hyperpigmentation, LSC & red macules Tx: Laundering clothing and bedding, 1% Malathion powder or 10% DDT may be dusted onto inner surface of underwear Best to discard clothing as lice may live in clothing for 1 month without a blood meal

Pediculosis Pubis (Crabs)

MC Adults, STD, MC genitalia but may invade hypogastrium, axilla or eyelashes. LICE COMMONLY FOUND ON SKIN Pthirus pubis Maculae ceruleae, bluish or slate colored papules, blancheable on sides of trunk or inner thighs. Tx: Permethrin applied for 10 minutes, Repeat in 1 week, Tx Partner as well. Petrolatum for eyelash lice.

Diptera 3 main problems

Mosquito bites Ked itch Myiasis

Mosquito bites Culicinae

Moisture, warmth, carbon dioxide, estrogens and lactic acid in sweat attract the mosquito Pruritic wheal, urticarial reactions. West Nile Virus vector = mosquitoes acquire it from feeding on infected birds. Avoid standing water, wear long sleeves. TX: topical steroids, DEET. Also a vector for filariasis, malaria, dengue, yellow fever.

Ked itch
Sheep ked = Melophagus ovinus Feeds with mouth and sucks blood Woolsorters and sheepherders Pruritic often hemorrhagic papules, nearly always with a central punctum Deer keds attack people in a similar way, MC hips and abdomen, last 12m

Myiasis
Invasion of tissues by fly larvae, eggs hatch, burrow into skin. Furuncle with maggots in the center. Cochliomyia hominivorax (Screw worm) MC cause wound myiasis in USA Phormia regina (Black Blowfly, USA) Dermatobia hominis (botfly, New World) Cordylobia anthropophaga (Tumbu Fly, Africa)

TX: EXCISION OR OCCLUSION W/ PETROLATUM

Blister Beetle Dermatitis

Meloidae, Oedemeridae release the vesicating agent cantharidin Staphylinidae family releases pederin Not biters, vesicant rubs off if beetles brushed against, pressed or crushed on the skin Linear array of vesicle(s), bulla(e) Spanish Fly or Lytta vesicatoria best known for medicinal purposes TX: I&D, Cold compresses, Top CS.

Spanish Fly (Lytta vesicatoria)

Carpet Beetle Dermatitis

Anthrenus scrophulariae Papulovesicular and urticarial involves chest, neck and forearms. Reddish brown, fusiform 6mm long and covered by hairs TX: Fumigate house with sulfuryl fluoride

Carpet beetle note hairs Anthrenus scrophulariae

Bees and Wasps

Bees or APIDS venom contains histamine, mellitin, hyaluronidase, HMW acid phosphatase, phospholipase A Wasps or VESPIDS venom contains phospholipase, hyaluronidase and a protein known as ANTIGEN 5. Honeybee stinger stays in the skin and has a sac you must scrape off, because if you pick it up by the sac, you express more venom into the tissues.

Bee and Wasp Stings

Symptoms vary from a small pruritic wheal to anaphylactic shock. Bee sting anaphylaxis may be first symptom of mastocytosis. Treatment with IL steroids and xylocaine is highly effective. ASA or dilute meat tenderizer compresses. Anaphylaxis 0.3cc epi 1:1,000 SQ Susceptible persons should carry an Ana-Kit with syringe, epinephrine and Antihistamines

Yellow jacket MCC of allergic reaction to insect stings

Nest in the ground or in walls, interrupted by outdoor activity

Ants Fireants most painful

Solenopsis saevissima, invicta, geminata, xyloni S. saevissima is ferocious and vicious: multiple bites in seconds. Intense pain, whealing and eventually sterile pustule with erythematous base, very characteristic lesion. Seizures and mononeuropathy have been reported. Tx: IL steroids oral steroids, SQ epi

Solenopsis saevissima

Pulicosis (Flea Bites)

Human Flea Pulex iritans Cat Flea Ctenocephalides felis Dog Flea Ctenocephalides canis Extraordinary jumpers, no wings Legs and waist MC sites Hemorrhagic puncta surrounded by urticarial patch. zigzag lines or grouped Wells syndrome may occur (eosinophilic cellulitis

Pulex iritans (Human flea) below.

Ctenocephalides felis Cat flea on the right

Fleas as Vectors of Disease

Xenopsylla cheopis and X. brazilensis are vectors of plague and endemic typhus Squirrel flea, Diamanus montanus transmits plague and tularemia

Flea Control
Malathion, Chlordane in kerosene, Lindane dusts or sprays time to call the Orkin man. Insect repellants OFF!, other DEET and pyrethrum preparations.

Tungiasis
Tunga penetrans Aka nigua, chigoe, sand flea, jigger. Reddish brown flea 1mm long Africa, Central & S. America, India, Pakistan Pregnant females burrow into skin of ankles, soles, feet and toes. Lesions become infected and painful

Tunga penetrans

TX: Sx, Abx, Thiabendazole

Tick Bites & Disease Associations

Dermacentor andersoni wood tick (USA) & Amblyomma americanum Lone Star tick (Texas) both transmit Rocky Mountain Spotted Fever, Tularemia & tickborne encephalitis Ixodes transmit Lyme dz in USA Dermacentor variabilis (dog) Tularemia Rhipephalus sanguineus (dog) Rickettsia conorii (Boutonneuse fever) Ticks also transmit Q fever, Babesiosis, Ehrlichiosis, Arbovirus, Viral encephalitis, Hemorrhagic fevers.

Tick Bite Presentations

1) Urticarial wheal 2) Tick Bite Pyrexia 7-12 days of fever, chills, headache, abdom. pain & N/V. 3) Tick Paralysis usually in children, 6 days after attachment, rare, MC head/neck. Flaccid paralysis of legs, then arms, neck, diaphragm, resembles Guillen-Barre syndrome. Tick toxins block NMJs. Tick removal causes rapid recovery, but death may ensue if tick is not removed.

Other Tick Bite Diagnosis

Ornithodorus tholozani may be a vector for Borrelia duttonii, African endemic relapsing fever Bite produces a typical small inflammatory nodule surrounded by a zone of normal skin with a circumferential brownish ring.

Scabies
Distribution: Circle of Hebra Imaginary circle intersecting sites of prediliction areolae, axillae, elbow flexures, wrists, finger webs, umbilicus, lower abdomen, genitalia

Scabies
Papular and burrow-type lesions Face and scalp spared in adults, but not in infants or immunosuppressed. Burrows may be barely visible Dull red nodules persist in groin, called nodular scabies, may persist after cure, histo = pseudolymphoma Norwegian heavy crusting, scaling most common in malnourished, immunosuppressed or pts with neurologic dz.

Sarcoptes scabiei

Mineral oil or AcryMount on a glass slide with cover slip on top

Scybala

Scabies Treatment
Norwegian: Ivermectin 200mg/kg weekly x 3. Permethrin 5% cream from head to toe at night, rinse off in AM x 3. May repeat weekly. Lindane rarely neurotoxic to infants Infants and Pregnant women 6-10% precipitated sulfur in petrolatum applied nightly x 3 nights Treat family members

Animal Scabies
Milder course than human scabies Dogs, cats, poultry, birds, camels or horses Self limited, no burrows or mites found.

Cheyletiella Dermatitis
Non-burrowing mites that are parasitic for dogs, cats, rabbits May bite humans leaving an itchy dermatitis resembling scabies Mites easily seen on pets. Treatment of pet by veterinarian is the only necessary treatment

Demodex mites - Demodicidosis

MC adults > 30 y/o inhabit sebaceous glands of the nose, ala, forehead, chin and scalp Significant only if in large numbers. Readily found in adults without disease pathogenicity controversial Occasionally, recalcitrant rosacea patients may benefit from permethrin Papulonodular eruption may be seen in AIDS patients

Demodex folliculorum found in contents expressed from seb gland

Chigger Bite
Eutrombicula alfreddugesi MC legs and belt line and other sites where clothing causes constriction Grass and bushes typically infested in summer or fall aka Mowers mites Pruritic hemorrhagic puncta surrounded by red swellings TX: TS, Prophylaxis: (DMP) demethylphthalate solution

Gamasoidosis
Persons who handle canaries, pigeons and poultry MC arms & hands, papular, urticarial Diagnosis of urticaria is usually made Ornithonyssus and Dermanyssus mites infest feathers, bite humans Take about 1 week longer to resolve than most bug bites, Tx: malathion

Grocers Itch
Pruritic dermatitis of forearms Carpoglyphus passularum fournd on dates, prunes, figs. Acarus siro and Tyrophagus longior found on cheese.

Grain Itch
Pyemotes tritici Lives in grain, attacks harvesters of wheat, hay, barley, oats and other cereals or other farmhands who work around straw. Urticaria papule with vesicle hemorrhagic punctum TX: malathion Mite may not be demonstrable in skin.

Scorpion Sting
Hide during daytime in closets, shoes, folded blankets, childrens sandboxes. Any sting by a large scorpion should be considered dangerous because venom is hemolytic and neurotoxic MC US is Centruroides sculpturatus Numbness, laryngeal edema, profuse sweating & salivation, cyanosis, nausea and paresthesia of the tongue Tx: tourniquet, antivenin, phentolamine, atropine, barbituates

MC US: Centruroides sculpturatus

Latrodectism Black Widow

Dark dry places under rocks, in cellars, in wood piles. Severe pain in minutes, spreads from bite site to extremities and trunk, severe GI distress, abdominal rigidity delirium, paralysis. S/S last 2 days. Abdominal pain so severe it may be mistaken for appendicitis, colic or food poisoning. Children may die. Opiods, benzodiazepines, antivenin.

Lactrodectus mactans 13mm long, coal black with an orange red hourglass on abdomen

Loxoscelism Brown Recluse

2 types of reactions Localized Necrotic Cutaneous - extensive gangrene, severe edematous painful reaction within the first 8 hours. Starts as bulla with surrounding erythema and ischemia. In one week central dark gangrenous portion may become many cm wide and lasting months before healing. Diffuse Viscerocutaneous - rare

Loxoscelism Therapy
1) Rest, Ice, Compression, Elevation 2) No hot packs or surgery 3) Dapsone 100mg BID 4) Aspirin 5) Surgery, if any should be delayed 4 to 6 weeks. 6) No benefit to surgical excision, actually increases complications.

Sting Ray Injury

Unwitting victim steps on partially buried stingray Puncture wound that ulcerates. Immediate sharp shooting pain with edema and cyanosis, symptoms of shock may occur TX: Venom is detoxified by heat, so soak affected foot in hot water x 1 hr. Pain control.

Snake Bite
Rattlesnake, Cottonmouth, Copperhead Venom = hydrolases, 30 enzymes, anticoagulant, hemolytic, increased capillary permeability If treatment center cannot be reached within 1 hour, tourniquet, incision and suction in first 15 to 30 minutes, antivenin, antibiotics, tetanus toxoid, possibly surgical intervention

UR: Mocassin LR: Copperhead LL: Rattlesnake

Lizard Bite

Heloderma suspectum AZ, NM Paralysis, Dyspnea, Convulsions

Death is rare, Tx= snakebite tx