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Arthropod Envenomations: Immunologic and Toxicologic Considerations Cyrus Rangan, MD, FAAP, ACMT

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Arthropod Envenomations: Immunologic and Toxicologic Considerations Cyrus Rangan, MD, FAAP, ACMT Emergency Department Evaluation and Treatment for Children With Arthropod Envenomations: Immunologic and Toxicologic Considerations Cyrus Rangan, MD, FAAP, ACMT Arthropod envenomations are a significant cause of environmental injury in children. Bees, wasps, and spiders inflict injury via specialized venoms with a broad range of components, mechanisms, and potential treatments. Immunologic and toxicologic considerations in the evaluation and management of arthropod envenomations are important for the under- standing of the progression of envenomations, prompt diagnosis of severe conditions including anaphylaxis, and the use of antivenom in selected cases. Clin Ped Emerg Med 8:104-109 ª 2007 Published by Elsevier Inc. KEYWORDS envenomation, arthropod, arachnida, hymenoptera rthropod bites and stings accounted for more than ever, clinical symptoms of envenomation and treatment A75000 reports to poison control centers in the are similar. Bees are attracted to carbon dioxide (hence, United States in 2005 [1]. The phylum Arthropoda the predilection for bees to fly around the facial area), includes 2 clinically important classes: Insecta (order: bright colors (ie, clothing), and sweet odors (ie, Hymenoptera—bees, wasps, yellow jackets, and ants), perfumes, fragrances). Children commonly believe that and Arachnida (ticks, scorpions, and spiders). Virtually bees are aggressive insects, but they are mostly docile all arthropods possess some form of venom for immobi- creatures; indeed, the sometimes fearful behavior of lization and digestion of prey, yet only a select few species children around a nearby bee may increase the risk of a have developed venom delivery mechanisms capable of sting. Mass envenomations may occur when a hive is poisoning humans [2]. Pathophysiologic mechanisms of physically disturbed by children throwing rocks or other venom vary considerably among arthropods, and clinical objects at the hive [3]. immunologic considerations in the emergency depart- Bees exist in intricate colonies of thousands, with ment (ED) evaluation and treatment of these injuries are specific duties designated to various colony members to essential to patient management. protect the queen. Guard and soldier bees are tasked to defend the hive against trespassers (animals, humans, and Hymenoptera: Bees and Wasps Childrens Hospital Los Angeles, Los Angeles, CA. Bee and wasp envenomations are the most widely USC/Keck School of Medicine, Los Angeles, CA. documented arthropod exposures, with 4081 pediatric California Poison Control System. exposures and 1 death reported to poison control centers Toxics Epidemiology Program, Los Angeles County Department of in 2005 [1]. Honeybees and bumblebees are part of the Public Health, Los Angeles, CA. Reprint requests and correspondence: Cyrus Rangan, MD, FAAP, Apidae family. Yellow jackets, hornets, and wasps are part ACMT, Los Angeles County Department of Public Health, 313 N of the Vespidae family. Insect structure, behavior, and Figueroa Street, Room 127, Los Angeles, CA 90012. venom components differ between the 2 families; how- (E-mail: [email protected]) 104 1522-8401/$ - see front matter ª 2007 Published by Elsevier Inc. doi:10.1016/j.cpem.2007.04.004 Immunologic and toxicologic considerations 105 other insects); however, less aggressive worker and the release of histamine, leukotrienes, and other cyto- foraging bees may also sting when disturbed [4]. Yellow kines, manifesting with urticaria, dyspnea, hypotension, jackets and hornets may inflict solitary stings more bronchial constriction, and laryngeal edema [9]. The impulsively than the more docile honeybees, whereas allergenic properties of bumblebee venom are similar to Africanized bees are often involved in mass envenoma- honeybee venom [10]. In mass envenomations, severe tions. The barbed surface of the honeybee stinger causes reactions or death may occur from anaphylaxis or directly the insect to eviscerate itself as it attempts to fly away from toxic systemic effects of venom. after stinging, often leaving a detached stinger imbedded Wasp venom contains a number of neurotransmitters, at the site of injury. The venom sac may be visible at the neuromodulators, and immunomodulators, including proximal end of the stinger [5]. Bumblebees possess catecholamines, serotonin, tyramine, bradykinin, and slightly smoother stingers and may be able to sting more mastoparans (histamine-releasing factors), all of which than once [5]. Wasp (hornet and yellow jacket) colonies induce pain and inflammation [11]. Wasp venom also are composed of a few hundred insects. These insects contains allergenic components, including phospholipase deliver venom via nonbarbed stingers, possess more A, phospholipase B, hyaluronidase, and antigen 5, which venom per sting than bees, and may attack singly or en mediate anaphylaxis and delayed hypersensitivity reac- masse [6]. Classically, a retained stinger in the wound tions [12]. indicates a bee sting, whereas the absence of a stinger on Honeybees, bumblebees, Africanized bees, and wasps visual inspection suggests envenomation by a wasp. universally cause painful burning papules at the site of However, bee stingers may extrude after stinging and envenomation, with progression to erythematous wheal- self-evisceration by honeybees, and bumblebees may and-flare reactions that begin to subside within 24 hours. escape without stinger detachment. Therefore, the Up to 50% of cases progress to larger edematous local absence of a stinger at the site of injury does not reactions that may mimic cellulitis or become vesicular or necessarily denote a wasp sting [6]. bullous [13]. Up to 5% of patients experience systemic A limited subset of the US population (1-2 people per reactions, including anaphylaxis. Symptoms of systemic 1000) is allergic or hypersensitive to bee or wasp stings, reactions may include nausea, vomiting, and dizziness in culminating in up to 50 deaths per year. Fatal reactions a dose-response fashion after multiple stings. Rarely do may occur in some patients without previous histories of these systemic reactions occur after solitary stings in the allergic sting reactions [7].Evaluationandtherapy absence of IgE-mediated anaphylaxis. Treatment of local depend upon the nature of the exposure (single vs mass reactions involves symptomatic local wound care with envenomation) and clinical severity. Bee venom can ice, cool compresses, and discretionary use of topical cause injury via immune-mediated mechanisms, includ- corticosteroids. Oral antihistamines may decrease itching. ing local effects and anaphylaxis, or by systemic toxic Efficacy and safety of systemic administration of cortico- effects of venom in mass envenomations. Bee venom steroids have not been validated in controlled trials [13] contains an aqueous solution of 4 primary components: but has been suggested in cases of severe swelling. mellitin, phospholipase A2, hyaluronidase, and mast-cell Imbedded stingers should be removed as early as degranulation protein [8]. Mellitin is the most abundant possible, mostly to alleviate pain but also to potentially component and mediates most of the local pain symp- prevent lingering envenomation. Despite anecdotal pre- toms. Mellitin also causes the formation of pores in red suppositions about various methods of proper stinger blood cell membranes. Phospholipase A2 subsequently removal in the ED setting, controlled trials demonstrate cleaves fatty acids from the lipid side of the cell that the rapid removal of retained stingers may be membranes, resulting in hemolysis. Clinically significant performed via any available method including tweezing, hemolysis occurs in few patients after bee stings. scraping with a credit card, or by applying and removing Hyaluronidase cleaves hyaluronic acid in connective adhesive tape [14]. tissue, allowing other venom components to travel easily Anaphylaxis must be treated promptly with epinephr- to nearby tissues. Mast-cell degranulation protein induces ine 0.01 mg/kg IM (1:1000 aqueous solution), repeated in histamine release from mast cells, resulting in inflamma- 10 to 15 minutes if clinical improvement is not apparent tion and local or systemic vasodilation [8]. Local dermal [9]. Standard treatments of other symptoms of anaphy- reactions typically consist of local edema and spongiosis, laxis, such as airway management, bronchodilators, endothelial cell hyperplasia, and necrosis. Lymphocytes, fluids, and pressors, are indicated based on symptoms. neutrophils, and eosinophils may infiltrate adjacent Signs and symptoms of anaphylaxis in bee envenomation perivascular and reticular tissues [8]. Immunoglobulin may be persistent or recrudescent. Therefore, clinical (Ig) E–mediated type I anaphylaxis, usually in response observation should take place for at least 6 hours after to phospholipase A2 or hyaluronidase, occurs independ- successful treatment. A short course of oral cortico- ently of the number of stings, but may complicate either steroids for 2 to 5 days is often used to prevent late-phase single stings or mass stingings. Cross-linking of IgE allergic reactions. Patients presenting with symptoms of antibodies attached to basophils and mast cells results in systemic IgE-mediated envenomation reactions should be 106 C. Rangan prescribed an epinephrine autoinjector. All patients with 50 bee stings should be observed for at least 24 hours in a a clinical history of anaphylaxis should be referred to an hospital setting [25-27].Fewdataareavailableto allergy specialist for review
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