JabberwockyJabberwockyThe jaws that biteThe jaws that bite

The claws that catchThe claws that catch

BitesBites

And the great outdoorsAnd the great outdoors

Jim Giesen, M.D.Jim Giesen, M.D.

JabberwockyJabberwockyLewis CarrollLewis Carroll

‘Twas brillig, and the slithey toves‘Twas brillig, and the slithey tovesDid gyre and gimble in the wabe:Did gyre and gimble in the wabe:

All mimsy were the borogoves, All mimsy were the borogoves, And the mome raths outgrabe.And the mome raths outgrabe.

Beware the Jabberwock, my son!Beware the Jabberwock, my son!The jaws that bite, the claws that catch!The jaws that bite, the claws that catch!

Beware the Jubjub bird, Beware the Jubjub bird, and shun the frumious Bandersnatch!and shun the frumious Bandersnatch!

Blood Sucking ArthropodsBlood Sucking Arthropodsand the Joy They Bring Usand the Joy They Bring Us

MosquitoesMosquitoes

Vector to more disease in humans Vector to more disease in humans than any other blood feeding than any other blood feeding arthropodarthropod

Worldwide greater than 3 million Worldwide greater than 3 million deaths per year from malaria alonedeaths per year from malaria alone

Mosquito transmitted disease will be Mosquito transmitted disease will be responsible for the death of one out responsible for the death of one out of seventeen people currently aliveof seventeen people currently alive

Mosquito Borne DiseasesMosquito Borne Diseases Eastern and Western equine encephalitisEastern and Western equine encephalitis St.Louis and La Crosse encephalitisSt.Louis and La Crosse encephalitis West Nile VirusWest Nile Virus MalariaMalaria DengueDengue Bancroftian filariasisBancroftian filariasis Epidemic polyarthritisEpidemic polyarthritis Chikungunya feverChikungunya fever Rift Valley feverRift Valley fever

Mosquito FactsMosquito Facts

Only females suck blood(true Amazons)while Only females suck blood(true Amazons)while wimpy males sip on nectar and plant juices wimpy males sip on nectar and plant juices

Consume up to their own weight in blood every 3-Consume up to their own weight in blood every 3-4 days4 days

Some species are zoophilic some anthropophilicSome species are zoophilic some anthropophilic

and some switch hosts seasonally providing a and some switch hosts seasonally providing a means for transmitting disease from animals to means for transmitting disease from animals to humanshumans

Mosquito AttractantsMosquito Attractants Visual,thermal, and olfactory stimuli attract themVisual,thermal, and olfactory stimuli attract them Visual stimuli important for in flight orientation. Thermal Visual stimuli important for in flight orientation. Thermal

and olfactory more important as the mosquito closes in and olfactory more important as the mosquito closes in Carbon dioxide and lactic acid are two well studied Carbon dioxide and lactic acid are two well studied

attractantsattractants Carbon dioxide can draw mosquitoes from as far away as Carbon dioxide can draw mosquitoes from as far away as

100 feet100 feet Volatile compounds, sweat, and fragrances from lotions, Volatile compounds, sweat, and fragrances from lotions,

soaps, perfumes may be attractantssoaps, perfumes may be attractants Men preferred over women, adults over children, my wife Men preferred over women, adults over children, my wife

over meover me

BlackfliesBlackflies Late Spring Early Summer scourge of the Late Spring Early Summer scourge of the

northwoodsnorthwoods Mouthparts tear the skin surface and Mouthparts tear the skin surface and

produce a pool of blood from which the fly produce a pool of blood from which the fly feedsfeeds

Rare systemic reactions-fever, urticaria, Rare systemic reactions-fever, urticaria, and rarely anaphylaxisand rarely anaphylaxis

Intensely pruritic, painful,and slow to healIntensely pruritic, painful,and slow to heal Tropical species transmit Onchocerca Tropical species transmit Onchocerca

volvulus-the parsitic cause of river volvulus-the parsitic cause of river blindnessblindness

Other Flies and BugsOther Flies and Bugs Tabanids- horseflies, deerflies have been shown capable of Tabanids- horseflies, deerflies have been shown capable of

transmittting tularemiatransmittting tularemia

Sandflies- Tiny flies associated with leishmaniasisSandflies- Tiny flies associated with leishmaniasis Tsetse flies- African trypanosomiasis(sleeping sickness)Tsetse flies- African trypanosomiasis(sleeping sickness) Kissing bugs(Assassin bugs)- Vector for Trypanosoma cruzi Kissing bugs(Assassin bugs)- Vector for Trypanosoma cruzi

the causative agent of Chagas diseasethe causative agent of Chagas disease Fleas- Plague and murine typhusFleas- Plague and murine typhus Chigger mites-Pierce the skin with mouthparts and secrete Chigger mites-Pierce the skin with mouthparts and secrete

a proteolytic saliva that dissolves host tissue creating a a proteolytic saliva that dissolves host tissue creating a porridge which is then lapped up. Transmit scrub typhusporridge which is then lapped up. Transmit scrub typhus

General Treatment of Insect BitesGeneral Treatment of Insect Bites

Oral antihistaminesOral antihistamines Ammonium solution 3.6% (After Bite) Ammonium solution 3.6% (After Bite)

relieves Type1 hypersensitivity relieves Type1 hypersensitivity symptoms dramaticallysymptoms dramatically

Watch for secondary infectionWatch for secondary infection

TicksTicks

Most noted for high nuisance Most noted for high nuisance potentialpotential

Efficient vectors for a large number Efficient vectors for a large number of zoonosesof zoonoses

In the US ticks outrank mosquitoes In the US ticks outrank mosquitoes as vectors and tick-borne illnesses as vectors and tick-borne illnesses constitute an important infectious constitute an important infectious disease problemdisease problem

Tick envenomationTick envenomation

Ticks cause disease by either Ticks cause disease by either transmitting microorganisms or by transmitting microorganisms or by secreting toxins or venomssecreting toxins or venoms

Some trigger potent immune Some trigger potent immune responses others have direct tissue responses others have direct tissue toxicitytoxicity

Clinical effects range from localized Clinical effects range from localized reactions to anaphylaxis, paralysis, reactions to anaphylaxis, paralysis, and deathand death

Pajaroello Tick BitesPajaroello Tick Bites

Desert southwest,California, and Desert southwest,California, and MexicoMexico

Thought to be locally necrotizing Thought to be locally necrotizing toxin resulting in a 2-3 cm toxin resulting in a 2-3 cm

Local erythema, pain, and edema Local erythema, pain, and edema followed by tissue necrosis and followed by tissue necrosis and ulcerationulceration

Rare severe allergic reactionsRare severe allergic reactions

Tick ParalysisTick Paralysis

First reported by Todd in 1912First reported by Todd in 1912 Acute ascending motor paralysis Acute ascending motor paralysis

appearing similar to Guillan Barre, appearing similar to Guillan Barre, botulism,or myesthenia gravisbotulism,or myesthenia gravis

43 different species of tick have been 43 different species of tick have been implicated in the US and Australiaimplicated in the US and Australia

Neurotoxic venom secreted from the Neurotoxic venom secreted from the tick salivary gland causes the tick salivary gland causes the paralysisparalysis

Clinical FeaturesClinical Features

Paralysis develops 5-6 days after a female Paralysis develops 5-6 days after a female tick attaches, usually to the head or necktick attaches, usually to the head or neck

Restlessness, irritability, and paresthesias Restlessness, irritability, and paresthesias followed by ascending, symmetric flaccid followed by ascending, symmetric flaccid paralysisparalysis

Cerebellar dysfunction may occur with Cerebellar dysfunction may occur with incoordination and ataxiaincoordination and ataxia

Resolution of paralysis with tick removal Resolution of paralysis with tick removal establishes the diagnosisestablishes the diagnosis

Ticks as VectorsTicks as Vectors

Lyme DiseaseLyme Disease Rocky Mountain Spotted FeverRocky Mountain Spotted Fever Relapsing FeverRelapsing Fever Colorado Tick FeverColorado Tick Fever EhrlichiosisEhrlichiosis BabesiosisBabesiosis TularemiaTularemia

EhrlichiosisEhrlichiosis Two forms in humans:Human monocytic Two forms in humans:Human monocytic

ehrlichiosis(HME) and human granulocytic ehrlichiosis(HME) and human granulocytic ehrlichiosis(HGE)ehrlichiosis(HGE)

HME is transmitted by the Lone Star Tick HME is transmitted by the Lone Star Tick and is found in the south and eastand is found in the south and east

HGE is found in the upper Midwest and HGE is found in the upper Midwest and Northeast. Range tends to overlap areas Northeast. Range tends to overlap areas where Lyme disease is endemicwhere Lyme disease is endemic

70% occur in May-July70% occur in May-July Broad clinical spectrum of disease from Broad clinical spectrum of disease from

mild viral-like illness to life threatening mild viral-like illness to life threatening neurological complicationsneurological complications

EhrlichiosisEhrlichiosis

HGE only develops rash 10% of the HGE only develops rash 10% of the timetime

Caused by Ehrlichia equi like Caused by Ehrlichia equi like organism with reservoir hosts organism with reservoir hosts including sheep, deer, and rodentsincluding sheep, deer, and rodents

Confirm with serologic testing after Confirm with serologic testing after initiating empiric therapy with initiating empiric therapy with doxycycline 100 mg BID for a doxycycline 100 mg BID for a minimum of 7-10 daysminimum of 7-10 days

Prevention and ProphylaxisPrevention and Prophylaxis Prophylaxis not usually recommended. Even if Prophylaxis not usually recommended. Even if

tick is infected the risk of transmission is low if tick is infected the risk of transmission is low if the tick is found and removed promptlythe tick is found and removed promptly

Proper tick removal technique is imperativeProper tick removal technique is imperative Proper clothing can helpProper clothing can help DEET containing sprays and lotions repel ticks. DEET containing sprays and lotions repel ticks.

Use formulas containing less than 10% DEET for Use formulas containing less than 10% DEET for childrenchildren

Permanone is a tick repellant for use on clothing Permanone is a tick repellant for use on clothing and its active ingredient permethrin kills ticks on and its active ingredient permethrin kills ticks on contact. Field tests have shown permethrin to be contact. Field tests have shown permethrin to be 90% effective in preventing tick bites90% effective in preventing tick bites

Tick PixTick Pix

Case ReportCase Report

20 year old intoxicated college 20 year old intoxicated college student presented to Tucson’s El student presented to Tucson’s El Dorado Hospital ER with severe Dorado Hospital ER with severe cramping back and leg pain. He had cramping back and leg pain. He had stumbled home and plopped himself stumbled home and plopped himself naked into the bath tub. He woke up naked into the bath tub. He woke up sometime later crying out with pain. sometime later crying out with pain. His friend brought the patient and a His friend brought the patient and a flattened black spider to the ERflattened black spider to the ER

The SuspectThe Suspect

Widow SpidersWidow Spiders

Shiny black spider with characteristic Shiny black spider with characteristic red hourglass on the abdomenred hourglass on the abdomen

Latrodectus spiders are worldwide in Latrodectus spiders are worldwide in their distribution and in the US occur their distribution and in the US occur in every state except Alaskain every state except Alaska

Tend to bite defensively when Tend to bite defensively when accidentally crushedaccidentally crushed

Widow Spider VenomWidow Spider Venom

Potent mammalian neurotoxin which Potent mammalian neurotoxin which causes massive neurotransmitter causes massive neurotransmitter release from presynaptic endingsrelease from presynaptic endings

Latrodectism, the syndrome resulting Latrodectism, the syndrome resulting from envenomation, is characterized from envenomation, is characterized by widespread sustained muscle by widespread sustained muscle contraction rather than for local contraction rather than for local tissue injurytissue injury

Clinical PresentationClinical Presentation Involuntary spasm of large muscle groups of Involuntary spasm of large muscle groups of

abdomen, limbs, and lower back can appear abdomen, limbs, and lower back can appear within 30-60 minutes of the envenomationwithin 30-60 minutes of the envenomation

Abdominal symptoms can mimic acute abdomenAbdominal symptoms can mimic acute abdomen Associated signs may include fasciculations, Associated signs may include fasciculations,

weakness, ptosis, priapism, fever, salivation, weakness, ptosis, priapism, fever, salivation, diaphoresis, and bronchorrheadiaphoresis, and bronchorrhea

Symptoms may remain severe for several days. Symptoms may remain severe for several days. Care is largely supportive though an antivenin is Care is largely supportive though an antivenin is available for life threatening casesavailable for life threatening cases

Special care must be taken in Special care must be taken in pregnancy(premature labor) in severe pregnancy(premature labor) in severe hypertension and in childrenhypertension and in children

Recluse SpidersRecluse Spiders

Recluse EnvenomationRecluse Envenomation

Complex venom with at least 8 or 9 Complex venom with at least 8 or 9 major protein bandsmajor protein bands

Components are both dermonecrotic Components are both dermonecrotic and directly hemolyticand directly hemolytic

Clinical spectrum ranges from mild Clinical spectrum ranges from mild and transient skin irritation to severe and transient skin irritation to severe local necrosis and dramatic local necrosis and dramatic hematologic and renal injuryhematologic and renal injury

Recluse BitesRecluse Bites

Another Recluse BiteAnother Recluse Bite

TarantulaTarantula

Urticating HairsUrticating Hairs

Abdominal hairs which are barbed Abdominal hairs which are barbed and may contain an irritant venomand may contain an irritant venom

Type 1,2,3,and4 hairs cause varying Type 1,2,3,and4 hairs cause varying degrees of inflammationdegrees of inflammation

Urticating hairs of Tarantulas can be Urticating hairs of Tarantulas can be transmitted hand to eye and are the transmitted hand to eye and are the cause of potentially severe cause of potentially severe ophthalmic injuryophthalmic injury

Wisconsin Venomous Reptile BitesWisconsin Venomous Reptile Bites

A middle aged fly fisherman was working A middle aged fly fisherman was working the banks of Black Earth Creek a couple of the banks of Black Earth Creek a couple of years ago. He felt a sharp pain in his lower years ago. He felt a sharp pain in his lower leg. Over a period of several hours the leg. Over a period of several hours the pain intensified and the leg became red pain intensified and the leg became red and swollen. A middle aged plastic and swollen. A middle aged plastic surgeon with whom I shared a beer or two surgeon with whom I shared a beer or two in medical school astutely noted the in medical school astutely noted the paired puncture wounds on the leg, paired puncture wounds on the leg, measured the distance between the two measured the distance between the two punctures and arrived at the correct punctures and arrived at the correct diagnosis.diagnosis.

MassasaugaMassasauga

Timber RattlesnakeTimber Rattlesnake

Field Treatment of Pit Viper BitesField Treatment of Pit Viper Bites

Little science and lots of anecdotal Little science and lots of anecdotal recommendationsrecommendations

Weigh benefit against risk of treatmentWeigh benefit against risk of treatment Severe envenomations require antivenom and all Severe envenomations require antivenom and all

due haste should be made to get the victim to a due haste should be made to get the victim to a site for definitive caresite for definitive care

Avoid mechanical suction devicesAvoid mechanical suction devices Avoid tourniquets even simple veno occlusive Avoid tourniquets even simple veno occlusive

band as they may make local tissue necrosis band as they may make local tissue necrosis worseworse

Recognize that defensive bites may be “dry” with Recognize that defensive bites may be “dry” with little or no delivery of venomlittle or no delivery of venom

AntivenomAntivenom Antivenin(Crotalidae)Polyvalent is derived from Antivenin(Crotalidae)Polyvalent is derived from

horse serumhorse serum Derived from horses immunized against two Derived from horses immunized against two

North American and one South American viperNorth American and one South American viper Can be used for treatment of bites by any North Can be used for treatment of bites by any North

American pit viperAmerican pit viper Risk of acute reaction to antivenom itself. Should Risk of acute reaction to antivenom itself. Should

not be used in the field unless full resuscitative not be used in the field unless full resuscitative support is availablesupport is available

Newer sheep derived and purified antivenom, Newer sheep derived and purified antivenom, CroFab has been approved by the FDA for mild to CroFab has been approved by the FDA for mild to moderate envenomationsmoderate envenomations

Other Bites and IssuesOther Bites and Issues

Other envenomations and stingsOther envenomations and stings Mammalian Bites: Local wound Mammalian Bites: Local wound

issues, microbiology of wound issues, microbiology of wound infections, tetanus and rabies infections, tetanus and rabies prophylaxisprophylaxis

Large animal attacks: Bear, mountain Large animal attacks: Bear, mountain lion, muskielion, muskie

Homo horribilus- drunk on a Saturday Homo horribilus- drunk on a Saturday nightnight

‘‘Twas brillig and the slithey tovesTwas brillig and the slithey tovesDid gyre and gimble in the wabe:Did gyre and gimble in the wabe:All mimsy were the borogoves,All mimsy were the borogoves,And the mome raths outgrabe.And the mome raths outgrabe.

The EndThe End

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