eMedicine Specialties > Emergency Medicine > Environmental

Bites, Insects: Follow-up

Author: Bo Burns, DO, FACEP, FAAEM, Assistant Professor, Assistant Residency Director, Medical Clerkship Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine; Attending Physician, Department of Emergency Medicine, St Francis Hospital Trauma Emergency Center
Coauthor(s): Kavon Charles Azadi, MD, Resident Physician, Oklahoma Institute for Disaster and Emergency Medicine, University of Oklahoma College of Community Medicine, Department of Emergency Medicine
Contributor Information and Disclosures

Updated: Oct 13, 2009

Follow-up

Further Inpatient Care

  • Patients with true anaphylaxis, particularly if associated with hypotension, often are admitted for monitoring or observation in the ED upon recovery. Accepted definition of "true" anaphylaxis requires the involvement of at least 2 of the following 4 systems: cardiovascular, gastrointestinal, skin, or respiratory. Literature provides no clear direction on who needs admission. Certain patients with a disease transmission (eg, malaria) may require admission.

Further Outpatient Care

  • Follow-up monitoring for infection is advised for individuals bitten by an insect known to transmit a secondary disease, if exposed to the vector in an endemic area (eg, Chagas disease in the case of kissing bugs [Reduviidae]).
  • Individuals who recover from a systemic reaction should consult with an allergist regarding desensitization and prevention measures.

Inpatient & Outpatient Medications

  • Prescribe a bee sting kit with a device for self-administration of epinephrine prior to discharge if the patient had a systemic response to an envenomation (see Hymenoptera Stings).
  • Corticosteroids and antihistamines usually are continued for a few (3-4) days after a systemic response. Serum sickness reactions may require longer therapy (see Serum Sickness).

Deterrence/Prevention

Complications

  • Secondary infection may result from an insect bite.
  • Symptoms of disease transmitted by insect bites may not be evident for days, weeks, or even longer.

Prognosis

  • Prognosis generally is good except in patients with severe untreated anaphylaxis or in those with chronic or invasive infections.

Patient Education

  • Biting insects are ubiquitous in nearly all parts of the world, yet certain measures can be taken to minimize risk of exposure.
    • Periodic pest control may eliminate nests and minimize reproduction of biting insects.
    • Wear protective clothing (ie, long pants, long sleeves), especially when outdoors. Many insects are incapable of biting through clothing. Additionally, light-colored clothing appears to be less attractive to many biting insects, including mosquitos.12 Avoid dark colors or brightly colored floral patterns. Wear protective footwear. Wear gloves when working with soil or in areas of heavy infestation.
    • Avoid use of heavy perfumes, scented soaps, sprays, or lotions that may attract insects.
    • Be aware of surroundings; for example, avoid dense vegetation or animals suspected of carrying fleas, chiggers, or ticks.
    • Prudent use of insect repellent can help minimize exposure to insect bites and stings (See Insect Repellents).13
    • Be aware of the potential for bees or other foraging insects to enter opened soft drink containers that are left idle.
  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education articles Insect Bites, Allergy: Insect Sting, Severe Allergic Reaction (Anaphylactic Shock), Black Widow Spider Bite, Brown Recluse Spider Bite, and Ticks.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize early warning signs of anaphylaxis
  • Failure to obtain a thorough travel or exposure history
  • Failure to consider or recognize exotic diseases or diseases with vague prodromal signs and symptoms
  • Failure to refer questionable cases for reasonable follow-up care
  • Failure to warn patients about possible complications secondary to bites such as infection, serum sickness, and, in atopic individuals, biphasic anaphylaxis
  • Failure to provide a referral to an allergist or to prescribe a bee sting kit to patients with systemic reactions
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Miguel C Fernandez, MD, and Nicolas F Arredondo, MD, to the development and writing of this article.



More on Bites, Insects

Overview: Bites, Insects
Differential Diagnoses & Workup: Bites, Insects
Treatment & Medication: Bites, Insects
Follow-up: Bites, Insects
Multimedia: Bites, Insects
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Ewan PW. ABC of allergies. BMJ. 1998;316:1442,.

  2. Diaz JH. Recognizing and reducing the risks of Chagas disease (American trypanosomiasis) in travelers. J Travel Med. May-Jun 2008;15(3):184-95. [Medline].

  3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  4. Rodriguez M, Perez L, Caicedo JC, et al. Composition and biting activity of Anopheles (Diptera: Culicidae) in the Amazon region of Colombia. J Med Entomol. Mar 2009;46(2):307-15. [Medline].

  5. Anderson AL, Leffler K. Bedbug infestations in the news: a picture of an emerging public health problem in the United States. J Environ Health. May 2008;70(9):24-7, 52-3. [Medline].

  6. Stucki A, Ludwig R. Images in clinical medicine. Bedbug bites. N Engl J Med. Sep 4 2008;359(10):1047. [Medline].

  7. Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clinical consequences of their bites. JAMA. Apr 1 2009;301(13):1358-66. [Medline].

  8. Lane RP, Crosskey RW. Medical Insects and Arachnids. 1993. Chapman & Hall.

  9. [Guideline] Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. Mar 2005;115(3 Suppl 2):S483-523. [Medline].

  10. [Guideline] Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. Dec 15 2006;43(12):1499-539. [Medline].

  11. [Guideline] American Academy of Allergy, Asthma & Immunology. Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help. J Allergy Clin Immunol. Feb 2006;117(2 Suppl Consultation):S495-523. [Medline].

  12. Voigt TF. [Mosquitoes. As carriers of infectious diseases they are increasingly important]. Med Monatsschr Pharm. Aug 2008;31(8):280-9. [Medline].

  13. Karunamoorthi K, Sabesan S. Field trials on the efficacy of DEET-impregnated anklets, wristbands, shoulder, and pocket strips against mosquito vectors of disease. Parasitol Res. Sep 2009;105(3):641-5. [Medline].

  14. Asada H, Miyagawa S, Sumikawa Y, et al. CD4+ T-lymphocyte-induced Epstein-Barr virus reactivation in a patient with severe hypersensitivity to mosquito bites and Epstein-Barr virus-infected NK cell lymphocytosis. Arch Dermatol. Dec 2003;139(12):1601-7. [Medline].

  15. Auerbach PS, ed. Wilderness Medicine. 4th ed. 2001.

  16. Blum J, Beck BR, Brun R, Hatz Ch. Clinical and serologic responses to human 'apathogenic' trypanosomes. Trans R Soc Trop Med Hyg. Oct 2005;99(10):795-7. [Medline].

  17. Busvine JR. Disease Transmission by Insects: Its Discovery and 90 Years of Effort to Prevent it. Springer Verlag; 1993:11-74.

  18. Clark RF, Schneir AB. Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed.

  19. Davis CL. Insects, allergy and disease. In: Allergic and Toxic Responses to Arthropods. 1979:300-9.

  20. Edwards L, Lynch PJ. Anaphylactic reaction to kissing bug bites. Ariz Med. Mar 1984;41(3):159-61. [Medline].

  21. Erbilen E, Gulcan E, Albayrak S, Ozveren O. Acute myocardial infarction due to a bee sting manifested with ST wave elevation after hospital admission. South Med J. Apr 2008;101(4):448. [Medline].

  22. Garcia LS, Bruckner DA. Diagnostic Medical Parasitology. 3rd ed. Amer Society for Microbiology; 1997.

  23. Goddard J. Physician's Guide to Arthropods of Medical Importance. CRC Press; 1996.

  24. Hoffman DR. Allergic reactions to biting insects. In: Levine MI, Lockey RF, eds. Monograph on Insect Allergy. 1981:69-74.

  25. Khamaysi Z, Dodiuk-Gad RP, Weltfriend S, et al. Insect bite-like reaction associated with mantle cell lymphoma: clinicopathological, immunopathological, and molecular studies. Am J Dermatopathol. Aug 2005;27(4):290-5. [Medline].

  26. Krause RS. Immune system disorders, hypersensitivity. In: Aghababian R, ed. Emergency Medicine: The Core Curriculum. Lippincott Williams & Wilkins Publishers; 1998:417-22.

  27. Lynch PJ, Pinnas JL. "Kissing bug" bites. Triatoma species as an important cause of insect bites in the southwest. Cutis. Nov 1978;22(5):585-91. [Medline].

  28. Mieller UR. Insect Sting Allergy: Clinical Picture, Diagnosis, and Treatment. Gustav Fischer; 1990:144-7.

  29. Moffitt JE, Yates AB, Stafford CT. Allergy to insect stings. A need for improved preventive management. Postgrad Med. Jun 1993;93(8):197-9, 203-4, 207-8. [Medline].

  30. Nhachi CF, Kasilo OM. Poisoning due to insect and scorpion stings/bites. Hum Exp Toxicol. Mar 1993;12(2):123-5. [Medline].

  31. Shai A, Halevy S. Direct triggers for ulceration in patients with venous insufficiency. Int J Dermatol. Dec 2005;44(12):1006-9. [Medline].

  32. Soylu A, Kavukcu S, Erdur B, Demir K, Turkmen MA. Multisystemic leukocytoclastic vasculitis affecting the central nervous system. Pediatr Neurol. Oct 2005;33(4):289-91. [Medline].

  33. Ter Poorten MC, Prose NS. The return of the common bedbug. Pediatr Dermatol. 2005;22(3):183-7.

  34. Tokura Y, Ishihara S, Tagawa S, Seo N, Ohshima K, Takigawa M. Hypersensitivity to mosquito bites as the primary clinical manifestation of a juvenile type of Epstein-Barr virus-associated natural killer cell leukemia/lymphoma. J Am Acad Dermatol. Oct 2001;45(4):569-78. [Medline].

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines

 The diagnosis and management of anaphylaxis: an updated practice parameter.
American Academy of Allergy, Asthma and Immunology - Medical Specialty Society
American College of Allergy, Asthma and Immunology - Medical Specialty Society
Joint Council of Allergy, Asthma and Immunology - Medical Specialty Society. 1998 Jun (revised 2005 Mar). 41 pages. NGC:004211

Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help.
American Academy of Allergy, Asthma and Immunology - Medical Specialty Society. 2006 Feb. 29 pages. NGC:005003

The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Infectious Diseases Society of America - Medical Specialty Society. 2006. 96 pages. NGC:005086

Clinical trials

 Cause of Unexplained Anaphylaxis

Population Pharmacokinetics of Benznidazole in Children With Chagas Disease

Immunogenicity, Safety and Interchangeability of Two Tbe Vaccines Administered According to a Conventional Schedule in Children

[ CLOSE WINDOW ]

Keywords

insect bite, bug bites, Insecta, Hymenoptera, Arachnida, anaphylactic shock, Lyme disease, Chagas disease, trypanosomiasis, tick-borne encephalitides, blackflies, Simuliidae, onchocerciasis, river blindness, dermatitis, cellulitis, urticaria, myiasis, fly larvae, human botflies, NewWorld screwworms, Old World screwworms, Wohlfahrtia flies, Tumbu flies, fly maggots, delusional parasitosis, plant-eating phytophagous insects, cockroach bite, earwigs, reduviid bug, horsefly bites, mosquito, malaria, angioedema

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bo Burns, DO, FACEP, FAAEM, Assistant Professor, Assistant Residency Director, Medical Clerkship Director, Department of Emergency Medicine, University of Oklahoma School of Community Medicine; Attending Physician, Department of Emergency Medicine, St Francis Hospital Trauma Emergency Center
Bo Burns, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Kavon Charles Azadi, MD, Resident Physician, Oklahoma Institute for Disaster and Emergency Medicine, University of Oklahoma College of Community Medicine, Department of Emergency Medicine
Kavon Charles Azadi, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, and Oklahoma State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.