Loxosceles, Ticks, and Bed Bugs, Oh My!

Loxosceles, Ticks and
Bed Bugs, Oh My!
Identifying, Treating and Preventing
Arthropod Bites and Stings
Jill Cochran, PhD, APRN, CFNP
Assistant Professor, Clinical Sciences, WVSOM
[email protected]
Christine Plaugher, MS
Clinical Research Coordinator, CRCH, WVSOM
[email protected]
Objectives
By the end of this lecture, you should be able to:

Describe arthropods and how they transmit pathogens

Visually recognize several medically important arthropods and
the types of injury or illness they cause

Understand how to treat and prevent arthropod borne illness,
bites and stings
Please be aware, some images included in this presentation are graphic

arthropod - any of the phylum Arthropoda - invertebrate
animals (such as insects, arachnids, and crustaceans) that have
a segmented body and jointed appendages, a usually chitinous
(tough semitransparent substance) exoskeleton molted at
intervals, and a dorsal anterior brain connected to a ventral
chain of ganglia.

The class Insecta, or insects, are the Arthropoda that have
three pairs of legs, a segmented body divided into three regions
(head, thorax, and abdomen), one pair of antennae and,
usually, wings. Other Arthropoda classes have more than three
pairs of legs and only one or two body regions, and they never
have wings. Other common classes of Arthropoda are Crustacea
(such as sowbugs, crayfish, crabs), Diplopoda (millipedes),
Chilopoda (centipedes), and Arachnida (such as spiders, ticks,
mites, scorpions).

vector – living organisms that can transmit infectious diseases
between humans or from animals to humans.
Anatomy of an Insect
Culex adult
Source: Mariana Ruiz Villarreal LadyofHats, PD
https://commons.wikimedia.org/w/index.php?title=File:Culex_pipiens_diagr
am_en.svg&oldid=192310963
Culex larva
Source: LadyofHats, PD
https://commons.Wikimedia.org/w/index.php?title=File:Culex_restuans_larv
a_diagram_en.svg&oldid=192311713
Insects & Entomology
Putting things into Perspective

There are 7,000 people registered as members of the Entomological
Society of America who work in entomology and closely related
professions.

More than 1 million species of insects have been identified in the
world. The total number of documented species of all creatures is 2.5
million. Insects represent 40% of all species. 1 in 4 of all creatures
are thought to be beetles.

It is believed that there could be as many as 30 million species of
insects in the world. Currently sorted into 30 Orders, which breaks
down into 234 Families, ? Genera, ? Species. These counts may
change if new species are discovered.

It is estimated that roughly 10 quintillion insects live in the world. In
comparison, there are roughly 7.5 billion humans.

When an entomologist medicates a plant they have to take into
consideration how this will affect the entire food chain.
Arthropod Borne Illness
Sources: WHO & CDC web pages for particular illnesses

Dengue virus alone infects as many as 400 million people worldwide each year.
Half of the world’s population is at risk for this mosquito borne illness (tropical
and sub tropical climates). It is the leading cause of serious illness and death
among children in some Asian and Latin American countries.

Plague - Yersinia pestis although rare in the US is significant in Africa. Plague is
transmitted via fleas (Xenospsylla cheopis) that infest rats. Humans are infected
when bitten by a flea that has been biting a rodent that itself has been infected
with the disease.

Yellow Fever – a mosquito borne RNA virus that belongs to the genus Flavivirus.
About 15% of people who get yellow fever develop serious illness that can lead to
death. Picked up by mosquitoes from monkeys and transmitted to humans.

Onchocerciasis – River Blindness caused by a parasitic worm, Onchocerca volvulus,
transmitted by black flies. Worldwide it is the second major cause of infectious
blindness. Long term missionaries, Peace Corps and other long term volunteers or
researchers are at highest risk in the US because multiple bites are required for
infection. Need to be near streams and fast moving waters since this is where black
flies reside.

Chikungunya – Currently no vaccine. Transmitted by same mosquitoes that transmit
Zika and Dengue. Daytime biters. Fever and joint pain – similar symptoms to Dengue
and Zika. Most people feel better within a week, but can have persistent joint pain
for months.

Trypanosomiasis – sleeping sickness. Protozoan parasite (Trypanosoma) transmitted by
the tsetse fly in sub-Saharan Africa. Usually fatal without treatment. Can take from
weeks to years for symptoms to develop, therefore making diagnosis difficult.
Disturbance of the sleep cycle is what gives the disease its name, and is an important
feature in diagnosis.

Chagas – About 6-7 million people worldwide are infected with
the parasite, Trypanosoma cruzi. Transmitted by the
triatomine bug (“kissing bugs”). This is an assassin bug of the
family Reduviidae. Termed the American trypansomiasis. Feed
on human blood at night, and usually bite on the face near the
eyes or mouth, defecates close to the bite and the parasite is
transmitted from the feces into the bite wound when a person
smears it in by rubbing over the area in their sleep. Vector
control is the current control method. Long term infection
causes cardiac disorders and enlargement of the esophagus and
colon. Has been increasingly detected in the US and Canada in
the last decade.

Malaria – in 2015 438,000 people died from malaria, a mosquito
borne disease caused by the parasite, Plasmodium. Malaria was
eliminated from the US in 1951 via the use of a combination of
pesticides and water drainage practices. The primary chemical
used was DDT dichloro-diphenyl-trichloroethane). DDT was
canceled from use by 1991 in many countries primarily due to
Silent Spring written by Rachel Carson (published in 1962). DDT
bioaccumulates in fat and is spread through the food chain.
In this presentation, we will focus on
arthropod related clinical manifestations
that we expect you to potentially come
into contact with multiple times in your
career.
Pick a critter - what caused this?
Bed Bugs
Source: Piotr Naskrecki, CC-PD
http://phil.cdc.gov/phil/details.asp?pid=9820
Ants
Mosquitoes
Source: James Gathany, CC-PD
http://phil.cdc.gov/phil/details.asp?pid=8932
Source: 1. Servasbemal, CC-BY-SA-3.0
Source: Agriculture Research Service, Scott Bauer, CC-PD
https://commons.wikimedia.org/w/index.php?title=
File:Fire_ants02.jpg&oldid=142115054
Mosquitoes
after a blood meal
Mosquitoes are responsible for 400,000 to 600,000 deaths from malaria alone
worldwide each year. They kill more people than any other animal.
La Crosse Encephalitis
Bunyavirus transmitted by
Aedes triseriatus Say - American tree-hole mosquito
Mosquito Life Cycle
Source: LadyofHats, CC-PD
http://entomology.ucdavis.edu/
news/images/mosquitoleayingeggslarge.jpg
American tree-hole mosquito
Source: Monsieur.sploosh, CC-BY-3.0
https://commons.wikimedia.org/w/index.php?title=:File:Ochle
rotatus_triseriatus_F0007_recolor_resize.jpg&oldid=159215894
Quick Facts

La Crosse was isolated in 1963 in La Crosse, Wisconsin. Occurs in upper mid-western, midAtlantic and southeastern states.

It is transmitted primarily by Aedes triseriatus (tree-hole mosquito) and occasionally by
Aedes albopictus Skuse (Asian tiger mosquito).

Aedes triseriatus is a day feeder. Therefore they choose active daytime rodents for feeding.
These include chipmunks and squirrels who happen to be reservoirs for La Crosse.

The tree-hole mosquito female can pass the virus transovarially into her eggs, and therefore
larvae can hatch out already infected with the virus.

Since a male mosquito can hatch out of an egg already infected with the virus, he can then
sexually transmit it to a female mosquito upon mating, thus amplifying the disease.

Females can eat nectar, but they must take a blood meal after mating in order to fertilize
their eggs. Males only eat nectar. Therefore, a male will only spread it to other female
mosquitoes.

A female will normally mate once and only needs one blood meal to mature her eggs.
Research has shown that mosquitoes infected with La Crosse are less efficient feeders, and
therefore will potentially bite more than once to obtain a complete blood meal increasing
the chances of the disease being spread.
La Crosse virus (LAC) circulates in chipmunks, rabbits and squirrels among
which it is transmitted by Aedes triseriatus. It was the first arbovirus (viruses
transmitted by arthropod vectors) to be shown to be transovarially transmitted
in mosquitoes. This mosquito has many generations per year (multivoltine),
and populations can reach numbers of 60,000 per acre in mid-summer.
In this cycle, the mosquitoes
can sexually transmit the disease
and the females can lay eggs
Already infected with the virus.
Source: CDC, PD
http://www.cdc.gov/lac/tech/transmission.html
WV Department of Health &
Human Resources has a
Mosquito Surveillance Plan
http://www.dhhr.wv.gov/oeps/disease/Zoonosis/Mosquito/Pages/default.aspx
you can search online to find out how your state controls mosquitoes
Source: James Gathany, CDC, CC-BY-2.5,
https://commons.wikimedia.org/w/
index.php?title=File:Culex_sp_larvae.png&oldid=164231417
La Crosse Virus Cases by State
Source: CDC, PD
http://www.cdc.gov/lac/tech/epi.html
La Crosse Virus Cases by State
Cases Per 100,000 population
Source: CDC, PD
http://www.cdc.gov/lac/tech/epi.html
Diagnosis of LaCrosse Virus

Preliminary diagnosis is often based on the patient's clinical
features: fever (usually lasting 2-3 days), headache, nausea,
vomiting, fatigue (tiredness), and lethargy (reduced activity or
alertness). Severe neuroinvasive disease (disease affecting the
nervous system) occurs most frequently in children under the
age of 16.

Places and dates of travel.

Laboratory diagnosis of arboviral infections is generally
accomplished by testing of serum or cerebrospinal fluid (CSF) to
detect virus-specific IgM and neutralizing antibodies.

Patients with suspected LAC encephalitis should be
hospitalized, appropriate serologic and other diagnostic tests
ordered, and supportive treatment (including seizure control)
provided.
http://www.cdc.gov/lac/tech/diag.html (Accessed 2016-5-27)
What disease has this transmission cycle?
Source: CDC, PD
http://www.cdc.gov/ncidod/dvbid/westnile/cycle.htm
Transmitted by Culex spp. and others
isolated in 65 species of mosquitoes and 332 species of birds
 Can be found in blood donations because people may not be
symptomatic when donating.
 Symptoms are neurologic illness that can include high
fever, neck stiffness, disorientation, tremors, seizures,
paralysis or coma.
 Recovery can take months and some neurologic effects
may be permanent.
 About 10% of people who develop neurologic infection
will die.
 Hard to control because so many species can vector it.
 Encourage patients to never handle dead birds, and to report
them to the county sanitarian when they find them.
Source: Alvesgaspar, CC-BY-SA-3.0/GFDL
https://commons.Wikimedia.org/w/index/php?
Title=File:Mosquito_September_2010-I.jpg&oldid
=61211337
West Nile Virus Activity by State – 2015
Source: CDC, PD
http://www.cdc.gov/westnile/statsmaps/preliminarymapsdata/activitystatedate.html
Diagnosis of West Nile Virus

An estimated 70-80% of human WNV infections are subclinical or
asymptomatic. Most symptomatic persons experience an acute
systemic febrile illness that often includes headache, weakness,
myalgia, or arthralgia; gastrointestinal symptoms and a transient
maculopapular rash also are commonly reported. Less than 1% of
infected persons develop neuroinvasive disease, which typically
manifests as meningitis, encephalitis, or acute flaccid paralysis.

Laboratory diagnosis is generally accomplished by testing of serum or
cerebrospinal fluid (CSF) to detect WNV-specific IgM antibodies.
Immunoassays for WNV-specific IgM are available commercially and
through state public health laboratories.
http://www.cdc.gov/westnile/healthcareproviders/healthcareproviders-diagnostic.html (Accessed 2016-5-27)
Treatment for Encephalitis

There is no specific treatment for WNV or La Crosse disease; clinical
management is supportive.

Patients with severe meningeal symptoms often require pain control
for headaches and antiemetic therapy and rehydration for associated
nausea and vomiting.

Patients with encephalitis require close monitoring for the
development of elevated intracranial pressure and seizures. Patients
with encephalitis or poliomyelitis should be monitored for inability to
protect their airway. Acute neuromuscular respiratory failure may
develop rapidly and prolonged ventilatory support may be required.
http://www.cdc.gov/westnile/healthcareproviders/healthcareproviders-treatmentprevention.html (Accessed
2016-5-27)
Control Measures & Monitoring

Make sure that there is no standing water around the patient’s home. Have them
dump all buckets, barrels, bins, tires, etc. that can hold standing water for any
period of time.

Mosquitoes are not attracted to bug zappers. They prefer warm, carbon dioxide
emitting objects.

Have patients wear products containing Deet (use caution with children – avoid
hands, eyes, mouth and use a lower concentration) or Avon Skin So Soft (contains
Coumarin) if spending long periods of time in wooded or wet areas. Spraying Deet
on a hat keeps it off your skin and the insects out of your face.

In urban situations, tree holes are being filled with sand. This is not an acceptable
solution, for example in WV, where the state is around 75% forested. You could
never fill all of the tree holes.

Pellet or granular pesticides can be used in standing water situations where the
water cannot be removed to control mosquitoes in the larval stage. Oils and films
can also be effective, however one must always consider water quality
requirements/issues.
Pick a critter – what caused this?
Spider
Source: Wikimedia Commons, CDC
http://phil.cdc.gov/phil/detail.asp?ide=1125
Tick
Source: Scott Bauer, CC-PD
http://www.ars.usda.gov/is/graphics/photos/mar98/k8002-3.htm
Lice
Source: 2. Denys Williams, CC-BY-SA-3.0/GFDL
Source: S.E. Thorpe, CC-PD
https://commons.wikimedia.org/w/index.php?title
=File:Pediculus_humanus.jpg&oldid=149945723
Tick
Lyme Disease
Borrelia burgdorferi transmitted by
Ixodes scapularis Say (Eastern US)
& Ixodes pacificus Cooley & Kohls (Western US)
Blood Engorged Tick
Ixodes scapularis Deer Tick or
Blacklegged Tick
Source: Luvitsa, CC-PD
https://commons.wikimedia.org/w/index.php?
title=File:Dog-ticks5.jpg&oldid=161141825
Ixodes pacificus
Western Black-Legged Tick
Source: James Gathany, CDC, CC-PD
http://phil.cdc.gov/phil/detail.asp?ide=8686
Actual Size of Life Stages
Source: CDC
http://www.cdc.gov/ticks/life_cycle_and_hosts.html
Quick Facts

Lyme disease is caused by Borrelia burgdorferi, a gramnegative spirochete bacterium, and was first recognized in the
US in 1975. The primary US vector Ixodes scapularis (also
known as Ixodes dammini) was not isolated until 1979. The
causative agent, B. burgdorferi was isolated in 1981. It is the
most common vector-borne bacterial disease in the world.

Lyme disease occurs primarily in the northeast in the US, but
according to the Lyme Disease Association, in 2013, it had been
reported in 80+ countries. Several species of Ixodes can
actually vector Lyme disease.
Borrelia burgdorferi
Source: CDC, CC-PD
http://phil.cdc.gov/phil/details.asp?pid=6631

The bullseye rash is not always present in infection.
Life Cycle

Stage 1: Egg - Blood-fed females lay eggs on the ground typically in late spring near a site
where they detached from their host.

Stage 2: Larva – Summer of yr 1, eggs hatch and 6 legged larvae feed on small mammals or
birds. Engorged larvae drop from host to ground where they overwinter and molt. Can pick
up B. burgdorferi during this first blood meal.

Stage 3: Nymph – Spring of yr 2, larvae emerge as 8 legged nymphs. Feed from May through
July typically. Can transmit disease at this time. Become infected from feeding on whitefooted mice, chipmunks, or certain species of birds. The white-footed mouse is the principal
reservoir. This nymphal stage is when Lyme disease is most likely spread to humans due to
their small size and being difficult to detect and remove from the human body.

Stage 4: Adult – Fall of yr 2, nymphs molt into adults. Adults seek medium to large
mammalian hosts, particularly white-tailed deer. The females feed on large mammals,
mate, lay eggs (up to 3000) in the soil, and die. If they don’t feed in the fall, they try to
find a large mammal host the following spring (yr 3). Ticks can be active any time it is
warm. Adult male ticks are not thought to take a blood meal and therefore are not known to
transmit tick-borne pathogens. They can be infected, however from their 2nd meal. Females
will take 3 meals.

White tailed deer are not competent reservoirs for Lyme disease. However, the disease rate
is linked to the abundance of deer in a given year.
Ixodes scapularis Say
life cycle
Source: CDC, PD
http://www.cdc.gov/ticks/life_cycle_and_hosts.html
Note: Adults are
present when nymphs
are present because
the cycle overlaps
due to it being
a multi-year cycle.
Disease Transmission

It is thought that if tick removal occurs within 24-48 hours that
there is no risk of transmission. However, a 2014 study by
Michael Cook in the UK stated that a literature review in animal
models found that transmission can occur in <16 hours and that
the minimum attachment time for transmission of infection has
never truly been established.

The CDC web page on Lyme Disease states that, “In most cases,
the tick must be attached for 36 to 48 hours or more before the
Lyme disease bacterium can be transmitted.”
Tick mouthparts
They use chelicerae to “saw” into the skin and then insert the central
hypostome.
Source: Kevin Broady, CC-BY-3.0
https://commons.wikimedia.org/w/index.php?
title=File:Ixodholcapitulum.jpg&oldid=52852047
Source: Moorhouse DE, CC-BY-3.0
https://commons.wikimedia.org/w/index.php?
Title=File:Ixodholhypost.jpg&oldid=186537774
Proper Tick Removal
Ticks may be frozen and kept for later identification.
They secrete a cementing substance that assists in
their attachment and can make removing them
especially difficult.
Source: CDC, PD
http://www.cdc.gov/ticks/removing_a_tick.html
Testing of Ticks
Contact your local health department or extension office to assist with tick
identification.
In general, testing of individual ticks is not useful because:
If the test shows that the tick contained disease-causing organisms, that
does not mean that the patient has been infected.
 If the patient has been infected, then they will probably develop
symptoms before the results of the tick test are available. Do not wait
on tick testing results before beginning appropriate treatment.
 Negative results can lead to false assurance. The patient may have been
bitten by a second tick that was not captured, but carried the disease.

For more information on where you can get tick testing completed visit:
http://www.lymediseaseassociation.org/index.php/about-lyme/preventiontick-removal/tick-testing
http://www.cdc.gov/lyme/removal/index.html (Accessed 2016-5-27)
Erythema migrans – rash in Lyme disease
obvious bulls-eye presentation
Source: James Gathany, CDC, CC-PD
http://phil.cdc.gov/phil/details.asp?pid=9875
less obvious bulls-eye presentation
Source: Lamiot, CC-BY-SA-3.0;CC-BY-1.0-2.0-2.5/GFDL
https://commons.wikimedia.org/w/index.php?title
=File:LymeYoungBoy14Oct2009.JPG&oldid=187402363
Source: CDC
http://www.cdc.gov/lyme/resources/reportedcasesoflymedisease_2014.pdf
Diagnosis of Lyme Disease
Untreated Lyme disease can produce a wide range of symptoms,
depending on the stage of infection. These include fever, rash,
facial paralysis, and arthritis. A patient should seek medical
attention if they have observed any of these symptoms and have
had a tick bite, live in an area known for Lyme disease, or have
recently traveled to an area where Lyme disease occurs.
http://www.cdc.gov/lyme/stats/index.html
Early Signs and Symptoms (3 to 30 days after
tick bite)


Later Signs and Symptoms (days to months
after tick bite)
Fever, chills, headache, fatigue, muscle and
joint aches, and swollen lymph nodes

Severe headaches and neck stiffness

Additional EM rashes on other areas of the body
Erythema migrans (EM) rash:

Occurs in approximately 70 to 80 percent of
infected persons
Arthritis with severe joint pain and swelling,
particularly the knees and other large joints.

Begins at the site of a tick bite after a delay
of 3 to 30 days (average is about 7 days)
Facial or Bell's palsy (loss of muscle tone or
droop on one or both sides of the face)

Intermittent pain in tendons, muscles, joints,
and bones

Heart palpitations or an irregular heart beat

Episodes of dizziness or shortness of breath

Inflammation of the brain and spinal cord

Nerve pain

Shooting pains, numbness, or tingling in the
hands or feet

Problems with short-term memory





Expands gradually over a period of days
reaching up to 12 inches or more (30 cm)
across
May feel warm to the touch but is rarely
itchy or painful
Sometimes clears as it enlarges, resulting in
a target or “bull's-eye” appearance

May appear on any area of the body

See examples of EM
rashes(http://www.cdc.gov/lyme/signs_symptoms
/rashes.html)
Lyme carditis
http://www.cdc.gov/lyme/signs_symptoms/lymecard
itis.html
Source: CDC, PD
http://www.cdc.gov/lyme/diagnostictesting/labtest/twostep/index.html
Testing and Treatment for Lyme Disease

Laboratory blood tests are helpful if used correctly and performed with
validated methods. Laboratory tests are not recommended for patients who do
not have symptoms typical of Lyme disease. Just as it is important to correctly
diagnose Lyme disease when a patient has it, it is important to avoid
misdiagnosis and treatment of Lyme disease when the true cause of the illness
is something else.

Patients treated with appropriate antibiotics in the early stages of Lyme disease
usually recover rapidly and completely. Antibiotics commonly used for oral
treatment include doxycycline, amoxicillin, or cefuroxime axetil. Patients with
certain neurological or cardiac forms of illness may require intravenous
treatment with drugs such as ceftriaxone or penicillin.

For detailed recommendations on treatment, consult the
2006 Guidelines for treatment developed by the
Infectious Diseases Society of America
http://cid.oxfordjournals.org/content/43/9/1089.full

In a small percentage of cases, these symptoms can last
for more than 6 months. Although sometimes called
"chronic Lyme disease," this condition is properly known as
"Post-treatment Lyme Disease Syndrome
(http://www.cdc.gov/lyme/postlds/index.html)" (PTLDS).

Mobile App!

http://www.cdc.gov/mobile/applications/mobileframewo
rk/tickborne-diseases.html
http://www.cdc.gov/lyme/treatment/index.html
Pick a critter – who caused this?
Ants
Mosquitoes
Source: 3. CDC, CC-PD
Tick
Source: Jerry Kirkhart, CC-BY-2.0
http://www.flickr.com/photos/jkirkhart35/3514239511/
Tick
Dermacenter andersoni Stiles
Rocky Mountain wood tick
Source: CDC, PD
http://www.cdc.gov/ncidod/dvrd/rmsf/Natural_Hx.htm
Dermacenter variabilis (Say)
dog tick
Life Cycle of the Dog Tick
Source: Larvalmadness, CC-BY-SA-4.0-I
https://commons.wikimedia.org/w/index.php?title=File:Life_Cycle.gif&oldid=195232930
Rocky Mountain Spotted Fever
(tick-borne typhus fever)
Rickettsia rickettsii transmitted by
Dermacenter variabilis (Say) (East) &
Dermacenter andersoni Stiles (West)
Tick hemolymph cells infected
with Rickettsia rickettsii
Source: CDC, CC-PD
http://www.cdc.gov/ncidod/dvrd/rmsf/Organism.htm
 Symptoms typically begin 2-14 days after the bite of an infected tick.
 About half of the infected people do not remember being bitten.
10% of people never develop the rash.
 Disease begins with sudden onset of fever and headache. Most people
will visit their doctor during this time-frame, and several visits may
occur before the patient is diagnosed due to the non-specific symptoms.
 RMSF can be fatal in the first eight days of symptoms if not treated correctly,
even in previously healthy people. Once the red to purple petechial rash is seen
(generally not until the 6th day or later), it is a sign that the illness has progressed to
severe disease. Every attempt should be made to begin treatment before petechiae develop.
Symptoms

Fever

Rash (occurs 2-5 days after fever, but can be absent)

Headache

Nausea

Vomiting

Abdominal Pain (may mimic appendicitis or other causes of acute
abdominal pain)

Muscle Pain

Lack of Appetite

Conjunctival infection

Patients with severe infection requiring prolonged hospitalization may
have long-term health problems. It infects the endothelial cells that
line the blood vessels and causes vasculitis, therefore bleeding or
clotting in the brain and other vital organs may occur.
Cases of Rocky Mountain Spotted Fever per million persons 2010
Source: CDC, PD
http://www.cdc.gov/rmsf/stats/index.html
Diagnosis of RMSF

The gold standard serologic test for diagnosis of RMSF is the indirect
immunofluorescence assay (IFA) with R. rickettsii antigen, performed
on two paired serum samples to demonstrate a significant (four-fold)
rise in antibody titers.

two paired samples taken weeks apart demonstrating a significant
(four-fold) rise in antibody titer provide the best evidence for a
correct diagnosis of RMSF. For more in-depth information about
testing, please visit
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5504a1.htm

The diagnosis of RMSF must be made based on clinical signs and
symptoms, and can later be confirmed using specialized
confirmatory laboratory tests. Treatment should never be
delayed pending the receipt of laboratory test results, or be
withheld on the basis of an initial negative finding for R.
rickettsii. is the first line treatment for adults and children of all
ages and should be initiated immediately whenever RMSF is
suspected.
http://www.cdc.gov/rmsf/symptoms/index.html (Accessed 2016-5-27)
Testing and Treatment for RMSF

Use of antibiotics other than doxycycline is associated with a higher risk of fatal outcome. Treatment is
most effective at preventing death if doxycycline is started in the first 5 days of symptoms. Therefore,
treatment must be based on clinical suspicion alone and should always begin before laboratory results
return or symptoms of severe disease, such as petechiae, develop.

If the patient is treated within the first 5 days of the disease, fever generally subsides within 24-72 hours.
In fact, failure to respond to doxycycline suggests that the patient’s condition might not be RMSF. Severely
ill patients may require longer periods before their fever resolves, especially if they have experienced
damage to multiple organ systems. Resistance to doxcycline or relapses in symptoms after the completion
of the recommended course of treatment have not been documented.

Recommended Dosage
Doxycycline is the first line treatment for adults and children of all ages:

Adults: 100 mg every 12 hours

Children under 45 kg (100 lbs): 2.2 mg/kg body weight given twice a day

Patients should be treated for at least 3 days after the fever subsides and until there is evidence of
clinical improvement. Standard duration of treatment is 7-14 days.
Treating Children

The use of doxycycline to treat suspected RMSF in children is standard practice recommended by both CDC
and the AAP Committee on Infectious Diseases. Use of antibiotics other than doxycycline increases the risk
of patient death.
Control Measures & Monitoring for Patients

Have patients check their pets for ticks, and check themselves for ticks every six
hours or so when spending time outdoors, especially after walking through tall
grasses. Especially in the hair, under their arms, and in their groin area.

If they hunt animals, have them check themselves thoroughly after the deceased
animal cools. The ticks will exit the carcass and attach to them for warmth.

Keep the grass mown around their homes, and tuck pants into socks anytime they
wade through long grasses. Have them wear light colored clothing so they can find
ticks easily on themselves.

Suggest they launder their clothes immediately upon entering their home if they
noticed a tick on their person.

Have them vacuum the interior of their vehicle if they have been out in areas where
they know ticks are present. A tick requires one meal per year (and sometimes less
often) and can survive without drinking for many months so potential is present for
them to hang out in a car/home for a long time waiting for a meal to show up.

Vacuum the home thoroughly and often if the patient goes
outdoors a lot or has a pet that is in and out of the home.

Have them keep rodent and bird populations down around their
homes by not providing areas where nesting can occur.

Insecticides can be useful if heavy populations of ticks exist in
close proximity to your home. They can be used on your pet
and/or on your yard. If a patient spends a lot of time outdoors,
they can use Permethrin on their clothing. Always spray the
clothing and allow it to dry, before putting it on the body. Then
wash that clothing separately from other household clothing.
Pick a critter – what caused this?
Assassin Bug
Source: Nmspec, CC-BY-SA-4.0-I
https://commons.wikimedia.org/w/index.php?
title=File:Yokozuna_assassin_bug_with
WhiteCompoundEyes06.jpg&oldid=195766221
Source: Jeffrey Rowland, CC-BY-2.0
http://www.flickr.com/people/34255754@N00
Spider
Yellow Jacket
Source: Wikimedia, Bombman356
https://commons.Wikimedia.org/w/index.php?title=
File:Yellow_jacket_wasp.jpg&oldid=72652920
Source: CDC, CC-PD
http://phil.cdc.gov/phil/details.asp?pid=1125
Spider
Brown Recluse Spider
Loxosceles reclusa Gertsch and Mulaik

The brown recluse has 6 eyes
instead of the typical 8 found on
a spider. They are arranged in
pairs of two in a semicircle
around the front of the
cephalothorax.

It has a fiddle shape on it’s
carapace.
Source: Br-recluse-guy, CC-PD
https://commons.wikimedia.org/w/index/php?title=
File:Brown-recluse-coin-edit.jpg&oldid=179764639
Notice shape of fiddle on carapace and three
pairs of eyes in semi-circle shape
Source: mattb/pennywisdom2099, CC-PD
https://commons.wikimedia.org/w/index.php?title=File:Loxosceles_reclusa_adult_male_4.
jpg&oldid=142680841
Fast Facts

There must be a counter pressure on the spider for you to be bitten by a brown
recluse. People often do not feel the bite of a brown recluse when it occurs.

The brown recluse venom causes severe lesions by necrosing the tissue surrounding
the bite area—it basically digests you so that you can be devoured like it would its
prey. The blister will develop within about 7 hours after being bitten.

Brown recluse have a lifespan of 2 to 4 years, and females produce up to 5 egg sacs
in a lifetime which can contain 50 eggs each. Potentially producing 250 progeny in
their lifetime.

The brown recluse is not native to WV and northern states, and would most likely be
found indoors because the outdoor climate is not acceptable for it to persist in
nature there. Therefore, if you have a patient exhibiting symptoms of a bite
consider they have an infestation in their home, or they have traveled to a warmer
region recently.

Brown recluse spiders are exactly that – reclusive. Females do not move far from
their retreat, and males and older juveniles are who are more likely to bite due to
getting into shoes or bedding. They are very rarely seen during daylight.
Diagnosis for Brown Recluse Bite
https://www.nlm.nih.gov/medlineplus/ency/article/002859.htm (Accessed 2016-5-27)

Will begin as a small, raised red bump.

There may be no pain during the bite, and the patient will not know what bit them.
Some very toxic creatures have painless bites. This is because the mouthparts they use
to inject the venom are very sharp and specialized for this purpose. More immediately
painful venoms are generally for “stunning” the victim long enough for the creature to
get it in a position to potentially devour it—such as wrapping it in a web for safekeeping until they are ready to feed, or to give them time to escape the danger.

Pain will develop within a few hours after being bitten, and can become severe.
•
May have chills, itching, general ill-feeling or discomfort, fever, nausea, reddish or
purplish color around bite, sweating.
•
The wound may eventually be characterized by necrotic tissue and that area will grow
in size daily. This may lead you to believe the patient has MRSA.
Medline recommends the patient call poison control and keep a specimen of the spider for
identification.
Treatment for Brown Recluse Bites








Clean the bite area with soap and water/apply ice to the bite area
Elevate and immobilize
Administer pain medication as needed
Administer tetanus prophylaxis if indicated
Resolving bites should be monitored for the development of secondary bacterial infection
For patients with bites that have a dusky center or other signs of developing necrosis, we
suggest administration of dapsone (Grade 2C). After screening for glucose-6-phosphate
dehydrogenase deficiency.
Early surgical excision and/or curettage of a necrotic lesion (Grade 2C). However, once
the lesion is demarcated and clinically stable, debridement and wound care may assist
healing.
Grade 2C defined:
http://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=EM/6485
https://www.osha.gov/OshDoc/data_Hurricane_Facts/brown_recluse_spider.pdf (Accessed 2016-5-27)
http://www.uptodate.com/contents/bites-ofreclusespiders?source=machineLearning&search=brown+recluse+spider+bite&selectedTitle=1%7E150&sectionRank=1&anchor=H21#H21
(Accessed 2016-5-27)
Control Measures & Monitoring

Population levels in your home can be monitored by placing sticky
traps, known as glue boards, throughout the home. Along with
detecting their presence, these will serve to kill the pest as well.

If you have an infestation, move beds away from walls and drapes.

Reduce clutter in your home, and vacuum thoroughly. They can
however, reside between the walls and above ceiling tiles which
makes them difficult to eradicate.

Move firewood and debris away from the home perimeter.

An infestation will warrant a use of an insecticide. Often a
combination of spray and dust insecticides are utilized. Also, many,
many sticky traps should be placed around the home to catch them.

Due to the spider’s reclusiveness, bites are rare even in infested
homes.
Pick a critter – what did this?
Spider
Earwig
Ants
Source: David˜O, CC
https://www.flickr.com/photos/8106459@N07/495658264
Source: Luis Miguel Bugallo Sánchez, CC-BY-SA-3.0;
CC-BY-1.0-2.0-2.5
https://commons.wikimedia.org/w/index.php?title=File:
Forficula_Auricularia_en_Bastavales,_Galiza_090818_002.
jpg&oldid=142134493
Black Widow Bite
You can differentiate a spider
bite from a mosquito bite by
looking at the number of
holes that are present in the
wound. A spider bite would
have two holes, and a
mosquito bite would have
one—if undisturbed from
scratching by the human.
Black Widow Spider
Latrodectus mactans Fabricius
Female Eastern Black Widow
Source: Chuck Evans, CC-BY-2.5
https://commons.wikimedia.org/w/index.php?title=
File:Black_Widow_Spider_07-04-20.jpg&oldid=186668422
Male Black Widow
Source: Tanthals39, CC-BY-3.0
https://commons.wkimedia.org/w/index.php?title=File:Latrodect
us_mactans_-_male_black_widow.JPG&oldid=140800184
Fast Facts

Only adult female black widows bite humans. Male and
juvenile widows do not bite because they have weaker biting
muscles.

Egg masses typically hold 300 eggs. She can produce more than
10 egg sacs without subsequent mating because she stores
sperm. Therefore, she does not need to repetitively mate.
That’s potentially 3,000 babies!

She constructs a haphazardly built web.

She can live for 3 years.

She is only known to kill the male after mating in cages where
the male cannot escape.

Many bites used to occur in outhouses, and indoor plumbing has
reduced this incidence. If you have an outhouse, brush under
the rim of the seat with a toilet brush before sitting to void
spiders from the area.
Fast Facts

Her bright colors on her underside are a warning to predators.
It means “do not eat”. Eating her can cause the predator to
become quite ill.

Her venom is 15x more potent than that of the rattlesnakes,
and is much more potent than the venom of cobras and coral
snakes. However, the mortality rate is low with reports ranging
from 0.2% to 5%.

As with brown recluse spiders, juvenile black widow spiders are
a smaller version of the adult. They start out very light in color
and darken with molts. It may be hard to determine whether
you have an infestation until an adult female is located.
Diagnosis of Black Widow Bite
https://www.nlm.nih.gov/medlineplus/ency/article/002858.htm (Accessed 2016-5-27)

The bite may feel like a pin prick if felt at all. Local swelling may occur. Pain can
become intense in 1 to 3 hours and continues for up to 72. The muscle pain spreads
from the bite area to the entire body. If the bite is on the upper body, most pain
will be felt in upper body. If bite is on lower body, most pain will be felt in the
abdomen.

Symptoms can include nausea, tremors, vomiting, leg cramps, abdominal pains, rigid
stomach muscles (which can be confused with appendicitis), profuse perspiration,
and a rise in blood pressure. Occasionally breathing difficulties, paralysis, and fever
can occur.

Contractions can begin in pregnant women.

Seizures are usually seen right before death in children.

Death in a healthy person is rare.
Medline recommends the patient call Poison Control and keep the spider for
identification.
Treatment for Black Widow Bites
MILD ENVENOMATION - Clean the bite area with soap and water • ice to the bite area
• Elevate and immobilize
• Administer pain medication as needed.
• Administer tetanus prophylaxis if indicated
MODERATE TO SEVERE ENVENOMATION — characterized by intermittent muscle pain extending up
the bitten extremity, sometimes involving the chest, abdomen, or back; regional or diffuse
diaphoresis; nausea and vomiting; and headache.
● Local wound care and tetanus prophylaxis as for mild envenomation
● Parenteral opioids for pain
● Parenteral benzodiazepines to reduce the frequency and severity of muscle spasms
● Antiemetic therapy (eg, sublingual or intravenous ondansetron) for nausea and vomiting

In one observational study of 148 patients with moderate or severe American black widow spider
envenomation (Latrodectus mactans), the duration of symptoms was 24 to 48 hours with
symptomatic treatment alone and approximately 50 percent of patients required hospitalization
for pain control.
http://www.uptodate.com/contents/management-of-widow-spiderbites?source=search_result&search=black+widows+brown+recluse+spider+bite&selectedTitle=5%7E150 (Accessed 2016-5-27)
Control Measures & Monitoring

Remove wood piles and debris away from the perimeter of the home.

Always use a shovel or gloved hand to move a piece of wood that has been lying on the
ground for an extended period of time. They love to rest under rocks, wood rails,
doghouses, or anything that has sat outside long enough for them to build a home
under. They are also often found in gardens.

Eliminate clutter inside and outside of the home.

Keep your grass trimmed around your home.

Seal openings and install screens.

Vacuum your home thoroughly. However, they are not commonly found inside homes.

Manually kill any you find—search them out around the exterior of your home and kill
them. They can be found in garages as well. Shortly after dark is a good time to do
this.

Pesticides can be used to control the black widow where large infestations occur.
Concentrates are most effective, and would be used monthly until the infestation has
resolved itself.
If this showed up in your office
would you know what caused it?
A generally healthy 57 year old male
presented in the office with an enlarging skin
lesion on the lateral mid-calf area of his right
leg, present for the past 7-10 days.
Occasionally experienced lancinating pain in
the area, followed by several minutes of
intense pruritus. There was no associated
fever, chills or other skin manifestation or
any other systemic symptoms.
Photo and case presentation courtesy of Andrea Nazar, DO
Professor of Clinical Science, WVSOM
The patient worked in a hospital radiology
department and denied any history of drug or
alcohol use. He regularly worked out in a
local gym. There was no history of trauma.
He and his wife had vacationed in Costa Rica
one month prior and had returned healthy.
Insect Family Oestridae
Dermatobia hominis (Linneaus, Jr.)
Human Bot Fly
Photos courtesy of Andrea Nazar, DO, Professor of Clinical Science, WVSOM
Life Cycle of the Bot Fly
the incredible complexity of nature

The egg of the bot fly is deposited on a blood-feeding arthropod, usually a mosquito or
a tick that is captured by the adult bot fly in flight. This behavior is known as phoresy (a
non-parasitic relationship in which one species is carried around by another).

The tick or mosquito vector then takes a blood meal and the bot fly eggs react to the
temperature of the blood feeding host and hatch.

The bot fly larva then enters the skin through the bite wound created by the tick or
mosquito or through hair follicles, where it burrows deeper into the skin. The larva
breathes through two posterior spiracles (breathing holes at the rear end of the larva’s
body) which lie flush with the skin of the host, and this hole will remain uncovered by
skin. In general, the life of the larva in the host is five to 12 weeks where it feeds on its
host’s tissue.

The larva will cut its way out of the host when it is ready to pupate, drop to the ground,
form a hard case around itself, and in two to three weeks will emerge as an adult. Once
the adult fly emerges, it uses its antennae to locate another fly for mating, and the
cycle continues. The adult does not feed.
Symptoms and Treatment for Bot Fly Myiasis

Patient typically notes an insect bite that enlarges over time, fluid
may drain from the lesion, patient may feel irritation, crawling or
episodic lancinating pain

Removal of the larva is the cure, but secondary infection can occur.

Can cover the hole with petroleum jelly or tape and when the larva
attempts to get air, extract it with tweezers (it can take 24 hours for
the larva to attempt for air). Be careful not to break the larva, use
tweezers that are not too sharp. May want to numb the area.
https://www.youtube.com/watch?v=HFSfYpwgSoA

May also numb the area and make a small slit to remove the larva.
You may want to treat with antibiotics to prevent infection.

One home remedy states that putting camphor (Tiger Balm and
Campho-Phenique have camphor as an ingredient) on a cotton ball and
taping it to the skin over the wound will bring the larvae completely
out on it’s own—this generally takes 8 hours.
Saddleback Caterpillar
Pick a critter – what did this?
Source: thatredhead4, CC-BY-2.0
http://flickr.com/photo/408504089@N03/3784952879
Ants
Bed Bugs
Source: 4. Oliver Arend, CC-BY-SA-3.0
Bed Bugs
Cimex lectularius Linnaeus (temperate climates)
& Cimex hemipterus Fabricius (tropical climates)
Bed Bug Nymph
Source: CDC, CC-PD
https://commons.wikimedia.org/w/index.php?title=File:Bed_bug_nymph,_Cimex_lectularius.jpg&oldid=118663085
Bed Bugs Quick Facts

Feed at night for about 5 to 10 minutes while you sleep, then
retreat back to their hiding place.

Will hide behind baseboards, in pictures, behind headboards,
inside mattresses, between mattresses, behind wallpaper, etc.

Inject saliva when feed, and human skin reacts to the protein in
it.

Require a blood meal to molt to the next life stage.

Are not known to transmit disease. Can cause itching and swelling
at site of bites. Infection can occur from scratching the bites.

Evidence of presence would be blood colored droplets (excrement)
on your bedding, and you may notice the actual insects on your
mattress.

Can live for more than a year without food and are very good at
hiding in tight places therefore difficult to exterminate.

Sometimes there is a sweet odor where there is a large
infestation.
Bed Bug Control

It is not advisable for homeowners to treat bed bugs on their own. The necessary
pesticides require a pesticide applicator license to purchase. Most people would not know
how to appropriately apply the pesticides. Fumigation is often necessary to resolve an
infestation.

When you travel, take the giant zip locks and zip your suitcases into them (or garbage bags)
while in the hotel. Keep your suitcase off of the floor and on top of desks/counters.

Carry a small flashlight with you. You can use this to inspect behind hotel headboards,
around trim (often hotels have sealed trim to help prevent insect infestations), and under
mattresses to look for signs of an infestation before you settle into your room.

When you return home, leave your suitcase in your garage or an area not attached to your
home until you have time to unpack. Wash all of your clothing and inspect other items for
signs of insects. Vacuum your suitcase thoroughly before bringing it into your home. This
works well for roach control as well.

If you live in an apartment building—good luck!!
Diagnosis of Bed Bug Bites
May notice an itchy hive-like bump at the site of the bite the next
morning. May disappear over the course of the day.
•
There may or may not be a visible bite mark in the center of
the bump.
•
After that, small bruise-like areas can turn into red, intensely
itchy bumps
•
There may be a clustered configuration – bites in a line
(breakfast, lunch & dinner)
Resolution can take 2 weeks and may leave a darkening of the
skin.
http://www.skinsight.com/info/resource_center/bed-bugs-and-bug-bites?Imiw9cApl#lookfor
(Accessed 2016-5-26)
Treatment for Bed Bug Bites
If they are in the home, the patient must get
control of them

A low-strength topical corticosteroid cream or ointment, such
as hydrocortisone can help with itching.

Diphenhydramine (Benadryl) can also be used to control the
itch.

May need to treat secondary infection from scratching.

Sometimes bites may blister, and in rare cases a person can
have a severe allergic reaction resulting in anaphylaxis.
Pick a critter – what caused this?
Flies
Source: USDA, CC-PD
http://www.sel.barc.usda.gov/diptera/dips
/simuli.htm
Ants
Source: 5. Agriculture Research Service, Daniel Wojcik, CC-PD
Yellow Jackets
Fire Ants
genus Solenopsis, but in particular the
Red Imported Fire Ant – Solenopsis invicta Buren
Swarming Fire Ants
Source: Pollinator, CC-BY-SA-3.0/GFDL
https://commons.wikimedia.org/w/index.php?title=File:
Fire_ant_queens_3589.jpg&oldid=176319881
Fire Ant Mound
Source: Alex Wild, University of Texas “Insects
Unlocked” Program, CC0-BY-1.0/UP
https://www.flickr.com/photos/131104726@N02/
16371103174
Fast Facts

The red imported fire ant was first introduced into either Mobile, AL or Pensacola,
FL between 1933 and 1945 from Brazil.

As of 2008, the ant was established in AL, AR, CA, FL, GA, LA, MD, MS, NM, NC, SC,
OK, TN, TX, and VA.

Ants will develop reproductive progeny (alates) after a colony reaches 1 year in age.
These alates will be winged, and will conduct mating flights. Once the female alate
has mated, she will snap her wings off at the basal suture and find a suitable spot to
begin her new colony.

Colonies will occasionally have multiple queens, and these types of colonies can
build closer to each other. It is estimated that up to 40 million ants can live on an
acre.

A queen can live 7 years, but a worker will only live about 5 weeks.

Fire ants are in the same insect family as bees and wasps. The females are the
“stingers”.

Fire ants are a big agricultural pest. They damage land and machinery and injure
livestock.
Source: USDA, PD
https://www.aphis.usda.gov/plant_health/plant_pest_info/fireants/downloads/ifa-potential-range.pdf
Fire Ant Control

Quarantines are in place to control the spread of fire ants by
checking plants, hay, and sod that are being transported out of
the quarantined areas.

Homeowners can work to effectively control fire ant
populations. Keep your property cleaned up of garbage and do
not throw out food scraps.

When treating for fire ants, you want to consider the type of
treatment you are using. You must kill the queen to kill a
mound. Therefore, treatments that allow for a chemical (a
bait) to be fed to the queen are the most effective in home
use.

Biological control of a creature is more difficult once it has
been removed from its native region. Promoting the critters
that kill fire ants, such as competitive ant species, is important
in their control. Therefore, broadcast pesticide applications
may hinder biological control.
Diagnosis of Fire Ant Stings

The chemical they inject is composed of alkaloids derived
from piperidine (gives black pepper its spicy taste).

About 24 hours after a person is stung, a pustule-like sore
forms at the sting site, which usually itches intensively.

Scratching the pustule may rupture the skin, leading to
secondary infection and scarring.

Some people are highly allergic and may require
immediate medical attention for anaphylaxis.
Treatment for Ant Stings

Management of local reactions. Wheal and flare reactions and sterile pustules - application of
topical anti-itch preparations with hydrocortisone acetate (1 percent) cream, and/or a topical
antihistamine and/or oral antihistamine treatment, kept clean with soap and water. Infected
lesions require appropriate antimicrobial therapy.

●Large local reactions –Pruritus can be treated with the topical agents listed above or
immediate application of high potency topical corticosteroids and administration of a single
dose of 20 mg of prednisone attenuates the response.

●Extreme local reactions – Extreme local reactions may merit skin testing and venom
immunotherapy for the prevention of recurrent extreme local reactions. This approach is similar
to that used for large local reactions to winged hymenoptera stings

In some patients with large or extreme local reactions, there may be enough induration, pain,
and heat at the site to suggest cellulitis. However, fire ant venom alkaloids have both
antibacterial and antifungal properties, and cellulitis rarely occurs in nondiabetic patients. The
presence of a sterile pustule is a clear indicator that these are late-phase reactions to imported
fire ant (IFA). However, if the clinician is unsure, a course of oral antibiotics may be
appropriate.
http://www.uptodate.com/contents/stings-of-imported-fire-ants-clinical-manifestations-diagnosis-andtreatment?source=machineLearning&search=ant+stings&selectedTitle=2%7E72&sectionRank=1&anchor=H22#H22 (Accessed 2016-5-27)
What should you do when you see this?
Source: Famartin, CC-BY-SA-4.0-I
https://commons.wikimedia.org/w/index.php?title=File:2015-10-21_14_54_35_Yellow-jackets_at_the_entrance_to_a_below-ground_nest_along_Terrace_Boulevard_in_Ewing_New_Jersey.jpg&oldid=181038762
Fast Facts Vespula spp.
Source: Bombman356, CC-BY-SA-3.0
https://commons.wikimedia.org/w/
index.php?title=File:Yellow_jacket
_wasp.jpg&oldid=72652920

If it is daylight outside, do not bother it!!

This is a yellow jacket nest. It could have 5,000
yellow jackets in it. Yellow jackets will kill.

If you see wasps flying up and down from the ground in your yard—do not mow over
that area. If you look, you will find an entrance hole to a yellow jacket nest. Storms
irritate bees and wasps. Mowing over their nest is like creating a giant storm, and thus
giant irritation in the wasp.

Yellow jackets are predatory and like meat. Keep your garbage cleaned up to help
prevent them around your home. If you have holes in your yard created by other
critters, fill them so that yellow jackets cannot utilize them to build a nest.

Yellow jackets are only minor pollinators. They are good predators. They have their
place in the cycle of life, however they can be extremely dangerous to humans. I do
believe there are circumstances when they need to be exterminated, and that you
need to maintain your property in a way where you can avoid contact with them.
Fast Facts

Yellow jackets have a smooth stinger and can sting repeatedly. Only females sting
(ovipositor).

They release an alarm pheromone when they sting. This alerts the other yellow
jackets to the present danger and this results in the aggressive, defensive behavior
form other members of the colony—and multiple stings.

Nearly 100 people per year die from bee/wasp stings in the US. This number is likely
underreported. It is estimated that over 2 million Americans have allergies to insect
stings.

Treatments – locate the nest and treat it with a registered insecticide – aerosol wasp
sprays will work. Baits on the outside edge of the nest are recommended also. You
must do this after dark. If you attempt to do this during the day, all of the wasps will
not be in the nest and they will not all be killed. Also, they cannot navigate in the
dark therefore you will be protected from being stung in the process of trying to
destroy the nest.

If you prefer natural methods, you can hang meat on a string over a 5 gallon bucket
with soapy water in it. When the yellow jackets cut off a piece of meat, it will be
heavy and they will fall into the water and the soap will assist in killing them. The
queen however, does not leave the nest, and to effectively kill a nest, you must kill the
queen.
What should you do when you see this?
Source: USGS Bee Inventory and Monitoring Lab, CC-BY-2.0
https://www.flickr.com/photos/usgsbiml/14283379287/
Apis mellifera Linnaeus

Leave it alone! It is a honeybee drone and it cannot sting
you.

Even if it had been a female. Leave it alone! We depend on
honey bees for our survival. We do not try to control for
honey bees. We try to promote their existence.

Honey bees have a barbed stinger (ovipositor), and it will
tear off when she stings, therefore killing her. It will
continue to pump venom so you want to scrape it out quickly
with a fingernail or credit card if possible. Do not squeeze it
because that will pump more venom into the wound.

The average person can tolerate 10 stings per pound of body
weight. 500 stings may kill a child, but the average adult
should be able to withstand 1100 stings.

Avoid honey bees when a storm is coming. They are sensitive
to pressure drops and can sense storms from a longer
distance away than a human. They become irritable in
stormy weather.
Worker Bee
Source: CSIRO, CC-BY-3.0
http://www.scienceimage.csiro.au/image/2317
Hornet/Wasp/Bee Sting Diagnosis

A painful, itchy bump will arise after the sting

May be accompanied by swelling of the area.

Symptoms of anaphylaxis:
swelling of the throat, lips, and mouth
abdominal cramping
diarrhea
nausea and vomiting
severe decrease in blood pressure
collapse
difficulty breathing
hives and itching
Treatment for Stings and Anaphylaxis

Remove any insects or stingers still attached to the skin or entrapped in the patient's clothing.

Uncomplicated local reactions usually do not require treatment beyond application of cold compresses.
Make a paste of baking soda and water and apply it to the stung area to help with pain and itching.

Large local reactions (LLRs) control itching or minimize swelling. The affected part should be elevated if
possible. For severe swelling, we suggest administration of oral prednisone (Grade 2C). A dose of 20 to 60
mg given once or tapered rapidly over two to five days is sufficient.

Anaphylaxis occurs in up to 3 percent of stings.

The initial treatment of choice for anaphylaxis is epinephrine injected intramuscularly into the
anterolateral thigh.

Upon discharge, any patient with symptoms of a systemic allergic reaction or anaphylaxis should receive
both of the following:
1) An epinephrine autoinjector and instructions about how and when to use it.
2) Referral to an allergy specialist to determine if he/she is a candidate for venom immunotherapy.

A tetanus booster is not necessary following a sting unless there was a concomitant soil-contaminated
injury.
http://www.uptodate.com/contents/bee-yellow-jacket-wasp-and-other-hymenoptera-stings-reaction-types-and-acutemanagement?source=machineLearning&search=sting&selectedTitle=1%7E77&sectionRank=3&anchor=H22#H22 (Accessed 2016-5-27)
Lice Prevention & Treatment
Pediculus humanus Linnaeus

If you have a school with repeated lice infestation, suggest the children keep
their jackets on their desk chairs and their book bags at their desks with them
(especially elementary age children who do not switch classes). This prevents
lice from crawling from coat to coat and bag to bag while on coat racks.

Lockers are very effective at keeping lice from spreading—perhaps why we see
more lice in elementary age children as compared to high school age children.

Combing is the most effective method for lice removal. If the hair is difficult to
comb, have the parent coat it in cooking oil (any kind should work). This will
allow the lice comb to go through smoothly while at the same time smothering
adult lice. The comb can be dipped in a cup of rubbing alcohol and wiped off
with a tissue in between swipes through the hair to remove and kill the eggs and
live lice so they aren’t reintroduced to the hair.

Treat with lice treatment on day 1 (would generally
recommend doing this for everyone in household), comb
hair daily with lice comb/oil combo for next 5-6 days,
apply 2nd lice treatment to the afflicted people in the
household only. Don’t apply a second pesticide treatment
if lice and eggs were not found in the hair at all in the 7
days since the first treatment. Hair can be washed after
oil combing. Permethrin has staying power and is used
due to its residual properties (really should not wash right
after using it). However, the oil and combing are what
are key to removal since permethrin does not kill eggs.
Therefore, it is give and take…combing daily is essential
and if you need oil to get the comb through the kid’s hair,
then use it. It also really seems to help to get the eggs
off.

Wash bedding thoroughly at first and second scalp
treatments. Bag up, and tie off tightly, stuffed animals
and things that cannot be washed easily for several weeks
(think about how long a bed bug can go without food!).
Vacuum cars, carpets, mattresses, and furniture
thoroughly and dispose of vacuum bag appropriately.
Chemical sprays are not necessary if the hair is
consistently combed and bedding is washed multiple
times. If you can’t wash something, pop the item in the
freezer for a few weeks then vacuum it. Cleaning up is
required to end an infestation. If a child is maintaining
head lice it is most likely because the family isn’t
effectively cleaning and combing.
“Super Lice”

Took quite a few searches and a fair amount of looking to find
an actual entomological article on the internet that was not
“media hype” about this.

Resistant to Permethrin – this can happen with any arthropod or
bacterium as you well know. Over time only those lice resistant
to permethrin reproduce, passing this resistance on to their
progeny.

Nix ultra claims to kill both “Super” and regular lice (like they
are different species…), including eggs. It also claims to be
pesticide free. The ingredients are listed as mineral oil and
dimethicone (surprise! A smothering agent and a slickening
agent). When all else fails –and insects become resistant we
revert to less harmful, manual methods—which have worked all
along. Humans like a quick fix, and sometimes that is not the
best method.
Match the critter to the wound
B.
6. Source: Jack Poland, CDC, PD
A.
7. Source: Nzfooty, CC-BY-U
Flea
Source: Josef Reischig, CC-BY-SA-3.0
https://commons.Wikimedia.org/w/index.php?title
=File:Flea_(251_01)_Aphaniptera:_total_preparation.
jpg&oldid=147284582
Left: multiple flea bites – probably from a cat or dog flea
Right: ulceration of a flea bite by Yersinia pestis, carrier of
the plague
Family Siphonaptera Bite Diagnosis

Inflict bites that are usually papules arranged in a nonfollicular pattern.

Bites generally occur on the calves and ankles.

They induce papular urticaria.

Flea allergy may cause respiratory symptoms in humans, particularly in
patients allergic to cats, although anaphylaxis has not been reported.
Fleas can transmit plague, bartonellosis, typhus and tungiasis. However,
they are generally just a nuisance and most people are bitten by cat and
dog fleas.
Fleas also carry tapeworms. The child (or pet) must ingest the flea to get
the tapeworm.
Flea Control

Check to see if the patient has indoor/outdoor pets or if this is an
isolated incident where they have stayed in another location.

If caused by their pets and pet is indoor only- have them talk to their
veterinarian about how to control the flea on their pet. There are
chemical and mechanical controls (combing and bathing).

If their pet is outdoor and indoor, then they may need to talk to their
local extension agent about what types of products are safe to apply
to their yard for flea control.

Vacuum, vacuum, vacuum! Especially around baseboards. If it is
really out of hand, an indoor bug bomb (spray fumigant) may be the
answer. Make sure they remove pets and themselves from home when
doing this and to wash dishes, cups, and silverware afterwards.

Fleas cannot live and breed on human blood alone. They have to be
able to feed freely for hours to reproduce and this can’t happen on a
human. Therefore, if a family has moved into a new single standing
residence with an existing infestation and they do not have pets—rest
assured, the population will eventually die out.
Flea Bite Treatment

Treat urticarial with antihistamine/or steroid cream to
reduce itching

Treat if secondary infection

Fleas play a role in the transmission of several infectious
diseases as a component of epidemiologic cycles that also
include animals and humans. Examples, as stated earlier,
include plague (Yersinia pestis), bartonellosis, typhus, and
tungiasis
Generalized urticaria - thorough history is important…could you tell the difference
if only one of these showed up in your office?
Have you been outdoors a lot? Have you been camping? Have you been out of the country?
Do you have pets? Have you stayed in a hotel or another home recently?
Did you see what bit you? What did the critter look like, and what time of day did it happen?
Part of treating insect harm is making sure the human is not re-exposed repeatedly.
Mosquito Bites
Flea Bites
Bed Bug Bites
Example of a successful insect control
program: black fly suppression
Source: The WV Daily News, Lewisburg, WV April 20, 2016

Program was started in 1986 in WV in response to the inability of
residents to spend time outdoors due to the high black fly
population.

This is a suppression effort – not an eradication effort – if it were
stopped, the population numbers would rise again. These fly larva
serve as fish food as well, so it is a balancing act.

Helicopters drop VectoBac® (Valent Biosciences) bacterial
suspension into the rivers every 7 to 14 days once the water
temperatures start to rise. It is designed to allow the particles lie
at a level where the larva can have an opportunity to feed on it.

VectoBac® contains Bacillus thuringiensis subsp. israelensis (Bti) a
natural soil bacterium which kills black fly and mosquito larvae.
This bacterium is specific to these insects and has a low toxicity to
other organisms. It is a gram-positive spore-forming subspecies
that works as an endotoxin.
Example of a successful insect control
program: eradication of screwworm fly
Screwworm Cochliomyia hominivorax (Coquerel)
Source: National Agricultural Library of the USDA’s Agricultural
Research Service: Edward F. Knipling Papers Screwworm
Eradication Collection, CC-PD
https://commons.wikimedia.org/w/index.php?title=File:Cobalt000
1.jpg&oldid=165511220

The screwworm is the only insect known to consume
the living flesh of warm-blooded animals, and has
caused immeasurable suffering and losses of
mammals throughout the world.

One of the least well-known peaceful uses of atomic
energy—using x-radiation to sterilize insects
originally in the form of Cobalt 60.

Screwworm pupae were sterilized using an x-ray
exposure at a level that would not disrupt the fly’s
mating behavior.
In the 1930’s ARS scientists Edward Knipling and
Raymond Bushland began working on developing
alternative screwworm control measures. Once the
x-ray technique was perfected in 1957, it only took 9
years (1966) to completely eradicate the screwworm
from the U.S. Since 1991, Mexico and several
Central American countries have been declared free
of screwworm.
A sterilization plant located in Mexico had been in
continuous operation 24 hours per day, 365 days per
year from 1976 through the 1990’s sterilizing
screwworm pupae. In the late 1990’s they had plans
to close the facility to move it closer to the
infestation border in Panama.
Dispersal rates of sterilized flies had been as high as
120 million per week in Nicaragua alone in the 1990’s
allowing for a major reduction in fly incidence in
just two years in that country.
Screwworm larvae in a Belgian Sheepdog
Source: Astridlorena, CC-BY-3.0/GFDL
https://commons.wikimedia.org/w/index.php?title=File:Cochliomyia_hominivorax.jp
g&oldid=191697172
Screwworm Adult
Source: The Mexican-American Commission for the Eradication
of the Screwworm, CC-PD
https://commons.Wikimedia.org/w/index.php?title=File:Cochli
omyia_hominivorax_(Coquerel,_1858).jpg&oldid=129671173

Successful trials of irradiation have also been conducted
on the Tsetse fly which transmits sleeping sickness

Targeted insects for irradiation include Anopheles
mosquito (malaria) and Aedes mosquitoes (Zika, fliariasis,
dengue, yellow fever)
Important Points to Remember

Sometimes it is necessary to think outside of the box – where has your patient been in the
weeks prior to their symptoms? If they have been spending a lot of time outdoors or out of
the country, an arthropod vectored illnesses could be highly likely. Do they have bite marks,
a welt, or rash on their body?

If an insect or spider is brought to you by a patient, you can seek identification assistance
through your local extension office. You can freeze hard-bodied arthropods, and this is best
if you wish to have them tested. Soft-bodied arthropods can be stored in alcohol (70% or
higher is best). Your extension agent can send the critter to a nearby university to obtain
identification. Veterinarians could possibly even provide assistance with identifying
ticks/worms because they see a lot of these critters in their offices.

Very few critters in the US are truly toxic, so always be suspicious as to whether the person
has identified their attacker correctly. Everyone thinks the snake/spider that bit them was
a copperhead/rattlesnake/cottonmouth/brown recluse.

Warm winters followed by wet spring/summers will generally increase arthropod vectored
illness possibilities.

Tell your patients to always swipe an arthropod from their skin—never smack them.
Sometimes pressure is required for an arthropod to bite, and this keeps your patient from
applying pressure.
References

Animal Diversity Web. Aedes triseriatus. 2014. http://animaldiversity.org/accounts/Aedes_triseriatus/ (Accessed 2016-518).

Apperson, Charles and Michael Waldvogel, Department of Entomology North Carolina Cooperative Extension. Red Imported
Fire Ant in North Carolina. http://www.ces.ncsu.edu/depts./ent/notes/Urban/ifa.htm (Accessed 2016-5-13)

Auburn University Department of Entomology and Plant Pathology. Fire Ant Biology. 2013.
http://www.ag.auburn.edu/enpl/fireants/biology.php (Accessed 2016-5-13).

Bayer Companion Vector-Borne Diseases. Deer Tick. http://www.cvbd.org/en/tick-borne-diseases/about-ticks/tickspecies/deer-tick/life-cycle/ (Accessed 2016-5-18).

Ben-Dov, Elton. Baciullus thuringiensis subsp israelensis and Its Dipteran-Specific Toxins. 2014 Apr; 6(4): 1222-1243. doi:
10.3390/toxins6041222. [PMC free article] [PubMed] (Accessed 2016-5-11).

Centers for Disease Control and Prevention. Rocky Mountain Spotted Fever. 2015.
http://www.cdc.gov/rmsf/symptoms/index.html (Accessed 2016-5-12).

Centers for Disease Control and Prevention. West Nile Virus. 2015.
http://www.cdc.gov/westnile/healthcareproviders/healthcareproviders-diagnostic.html (Accessed 2016-5-23)

Collins, Laura and Rudolf H. Scheffrahn, University of Florida. Red Imported Fire Ant. 2013.
http://entnemdept.ufl.edu/creatures/urban/ants/red_imported_fire_ant.htm (Accessed 2016-5-13).

Cook, Michael J. Lyme borreliosis: a review of data on transmission time after tick attachment. International Journal of
General Medicine (2015):8 1-8.

Entomological Society of America. Frequently Asked Questions on Entomology. 2010. http://www.entsoc.org/print/6962
(Accessed 2016-5-20).

Entomology Collection. Dermacenter andersoni.
http://www.entomology.ualberta.ca/searching_species_details.php?b=Acari&c=7&s=31507 (Accessed 2016-5-13).

Entomology at the University of Kentucky. Brown Recluse Spider. 2005.
http://www2.ca.uky.edu/entomology/entfacts/ef631.asp (Accessed 2016-5-18).
References
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Grissell, E.E., Florida Department of Agriculture and Consumer Services, Division of Plant Industry and Thomas R. Fasulo,
University of Florida. Yellowjackets and hornets. 2013.
http://entnemdept.ifas.ufl.edu/creatures/urban/occas/hornet_yellowjacket.htm (Accessed 2016-5-17).

Jackson, Bryan, Carlyle Brewster, and Sally Paulson. La Crosse virus infection alters blood feeding behavior in Aedes triseriatus
and Aedes albopictus (Diptera: Culicidae). Journal of Medical Entomology. 2012. Nov; 49(6) 1424-1429.

Jacobs, Steve, Penn State Extension. Bed Bugs. 2015. http://ento.psu.edu/extension/factsheets/bed-bugs (Accessed 2016-513).

Jiordano, Angelo. State coordinator says spray used in area black fly control program is non-toxic. 2014.
http://www.alleghenymountainradio.org/state-coordinator-says-spray-used-in-area-black-fly-control-program-is-non-toxic/
(Accessed 2016-5-11).

Galvin, Thomas J. and John H. Wyss. “Screwworm Eradication Program in Central America (Benefit/Cost Study).” In Emmanuel
Camus, James A. House, and Gerrit Uilenberg, eds. Vector-Borne Pathogens: International Trade and Tropical Animal Diseases.
New York: New York Academy of Sciences, 1996.

Gunderman, Richard. America’s most lethal animal. The Conversation. 2015. http://theconversation.com/Americas-mostlethal-animal-45989 (Accessed 2016-5-17).

Kettle, D.S. Medical and Veterinary Entomology. 2nd Ed. Cambridge: University press, 1995.

Merriam-Webster. Definition of arthropod. http://www.merriam-webster.com/dictionary/arthropod (Accessed 2016-5-18).

Nazar, Andrea. A Growing Irritation: Careful History Makes the Diagnosis. Osteopathic Family Physician. 2014; 6(6): 31-33.

Minnesota Dept. of Health. Blacklegged Ticks. 2014. http://www.health.state.mn.us/divs/idepc/dtopics/tickborne/ticks.html
(Accessed 2016-5-18).

New World Encyclopedia. Black Widow Spider. 2013. http://www.newworldencyclopedia.org/entry/Black_widow_spider
(Accessed 2016-5-18).

PA Department of Environmental Protection Division of Vector Management. Use of Bacillus thuringiensis israelensis (Bti) by the
Pennsylvania Black Fly Suppression Program. http://fishandboat.com/pafish/bass_black/smb2006/reebuck.pdf (Accessed 2016-511).
References

Perdue University. Fleas. 2008. https://extension.entm.purdue.edu/publichealth/insects/flea.html

Penn State Extension. Brown Recluse Spiders. 2015. http://ento.psu.edu/extension/factsheets/brown-recluse-spiders
(Accessed 2016-5-18).

UC IPM, University of California Agriculture & Natural Resources. Black Widow and Other Widow Spiders. 2009.
http://www.ipm.ucdavis.edu/PMG/PESTNOTES/pn74149.html (Accessed 2016-5-18).

University of Wisconsin Dept. of Entomology. Wisconsin Ticks and Tick-borne Diseases. (Accessed 2015-8-18).
http://labs.russell.wisc.edu/wisconsin-ticks/ (Accessed 2016-5-18)

United States Department of Agriculture, Agriculture Research Service. Bee Stings / Safety. 2012.
http://www.ars.usda.gov/Research/docs.htm?docid=11067 (Accessed 2016-5-17).

United States Department of Agriculture, Agriculture Research Service. Subduing the Screwworm. 1992.
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
University of Kentucky Entomology. Definition of Insect.
https://www.uky.edu/Ag/Entomology/ythfacts/4h/unit1/intro.htm (Accessed 2016-5-18).

UpToDate. Insect Bites. http://www.uptodate.com/contents/insectbites?source=machineLearning&search=insect+bites&selectedTitle=1%7E150&sectionRank=1&anchor=H2#H2 (Accessed
2016-5-24)

Walker, Ned. 1992. The eastern treehole mosquito Aedes triseriatus. Wing Beats. Vol. 3(2):17.

West Virginia Daily News. Black Fly Spray Set Thursday. Lewisburg, WV. April 20, 2016.

West Virginia DHHR. Mosquito-borne diseases. 2015.
http://www.dhhr.wv.gov/oeps/disease/Zoonosis/Mosquito/Pages/default.aspx (Accessed 2016-5-18)

West Virginia University Extension Service. Bed Bugs. 2015. http://anr.ext.wvu.edu/pests/insects/bed_bugs (Accessed
2016-3-18)

World Health Organization. Definition of vector. http://www.who.int/mediacentre/factsheets/fs387/en/ (Accessed 20165-18).
Additional Photo Sources
1. Servasbemal, CC-BY-SA-3.0
https://commons.wikimedia.org/w/index.php?title=File:Mosquito_back.jpg&oldid=172361188
2. Denys Williams, CC-BY-SA-3.0/GFDL
https://commons.wikimedia.org/w/index.php?title=File:Site_of_tick_removal.jpg&oldid=154837551
3. CDC, Public Domain
https://commons.wikimedia.org/w/index.php?title=File:Rocky_mountain_spotted_fever.jpg&oldid=1783
68321
4. Oliver Arend, CC-BY-3.0
https://commons.Wikimedia.org/w/index.php?title=File:Bed_bug_bites_around_left_wrist.jpg&oldid=18
3806544
5. USDA, Agriculture Research Service: Daniel Wojcik, Public Domain
https://commons.wikimedia.org/w/index.php?title=File:FireAntBite.jpg&oldid=176319875
6. Jack Poland, PhD, CDC, Public Domain
https://commons.wikimedia.org/w/index.php?title=File:Ulceration_of_flea_bite_cause_by_Yersinia_pest
is.jpg&oldid=120379673
7. Nzfooty, CC-BY-Unrestricted
https://commons.wikimedia.org/w/index.php?title=File:Fleabite.JPG&oldid=174014092
Additional Resources

The General Approaches to Insect Control: An Overview. Adapted from Mahr,
D.L., and N.M. Ridgway. 1993. Biological control of insects and mites: An
introduction to beneficial natural enemies and their use in pest
management. N. Central Reg. Ext. Publ. 481.
http://www.entomology.wisc.edu/mbcn/fea102.html (Accessed 2016-5-25)