3. This presentation is designed to present an overview of this
topic. This presentation is for informational and
educational purposes only.
Those involved in the creation of this presentation,
including Nathan Hare, M.D. and Allergy Partners, PA,
will not be held responsible for any treatment taken by
viewers as a result of their interpretations of the
information provided.
4. • Arthropods: Insects vs. arachnids
• What is an allergy?
• What is anaphylaxis?
• What symptoms are consistent with an
allergic reaction?
• Management of anaphylaxis
• Routes of exposure for an allergic reaction
• Review of arthropod reactions
• Route of exposure
• Types of reactions
• Management
5. • “an organism with … three body regions– head, thorax,
and abdomen.”
• It has 6 legs
• It has “a pair of antennae and external mouthparts.”
http://insects.about.com/od/insects101/p/whatisaninsect.htm
8. • They have “two distinct regions, the cephalothorax and
the abdomen.”
• They have 8 legs.
• They “lack wings and antennae.”
http://insects.about.com/od/noninsectarthropods/p/arachnida.htm
10. • The immune system reacts to something
harmless (allergen)
• It thinks that the allergen is dangerous
• Symptoms are caused by the immune system
trying to defend the body
• “Hypersensitivity”
11. • Irritation
• Tarantula hairs
• Envenomation (poison)
• Caterpillars with poisonous spines
• Saddleback caterpillar
• Puss Caterpillar
• Spider bites
Black widow
Brown recluse
http://goo.gl/XzLTw4
Puss Caterpillar
12. • A rapid, sudden onset, life-threatening, allergic reaction.
13. • Mouth: Itchy, swelling of tongue and/or lips
• Throat: Itchy, tightness/closure, hoarseness,
trouble breathing/swallowing
• Skin: Itchy, hives, redness, swelling, red watery
eyes
• Gut: Nausea, vomiting, cramps, diarrhea
• Lung: Short of breath, wheeze, repetitive cough
• Heart: Pale or blue skin color, dizzy/faint, weak
pulse
• Neurological: Sense of “impending doom,”
irritability, change in alertness, mood change,
http://goo.gl/Fp12Sp
15. • Epinephrine (repeat in 5 minutes if no
improvement)
• ~25% of the time a second dose is needed
• “If there is any doubt, it is generally better to
administer epinephrine.”
• Benadryl
• “H1 antihistamines are considered second
line to epinephrine and should not be
administered in lieu of epinephrine in the
treatment of anaphylaxis.”
http://goo.gl/oDh4CD
22. Public Domain: Mosquito, James Gathany, 2005 (CDC)
http://goo.gl/tXXSiO
• Exposure: Bites
• Type of Reaction: Allergic (delayed or immediate)
• Symptoms:
• Local allergic reaction
• Large local reaction (Skeeter Sydrome)
• Rarely, hives, anaphylaxis, or other immune reaction
• Treatment: Symptomatic
http://goo.gl/SanNFh
UpToDate: Author F Estelle R Simons, MD, FRCPC
Large local reactions to mosquito bites (Skeeter syndrome)
23. • Black Flies, Horse Flies
• Exposure: Bites
• Type of Reaction
• Allergic (delayed or immediate)
• Symptoms:
• Local allergic reaction
• Anaphylaxis
• Black Flies: Late systemic syndrome characterized by fever,
leukocytosis, lymphadenitis, and papular lesions.
• Treatment: Symptomatic
http://goo.gl/wWieEi
UpToDate: Insect bites Author Mariana C Castells, MD, PhD
http://goo.gl/QE3GDW
24. • larvae of the Trombiculidae family, a type of mite
• Exposure: Bites
• Type of Reaction: Allergic (delayed, possibly immediate)
• Symptoms:
• Local allergic reaction
• Rarely, hives, blistering or other rash
• Treatment: Symptomatic
By: CDC/ Dr. Cornelius B. Philip, Nat. Inst. of Allergy and Infectious Diseases (NIAID),
Rocky Mountain Laboratories (RML), Courtesy: Public Health Image Library
http://goo.gl/m0cEjp
http://goo.gl/fBWgp8
UpToDate: Chigger bites
Authors:Helge Riemann, MD
Whitney A High, MD
http://goo.gl/vBTHsr
25. • Exposure: Bites and Burrows
• Type of Reaction: Allergic (delayed-type)
• Symptoms:
• Local allergic reaction
• Diffuse itching, worse at night
• Treatment:
• Symptomatic
• Eradication with medication (oral ivermectin, topical permethrin)
http://goo.gl/BlCJ23
UpToDate: Scabies
Authors: Beth G Goldstein, MD, Adam O Goldstein, MD, MPH
http://goo.gl/s2daHI
26. • Exposure: Bites
• Type of Reaction: Allergic (delayed)
• Symptoms:
• Local allergic reaction
• Treatment:
• Symptomatic
• Eradication
By: CDC/ Harvard University, Dr. Gary Alpert; Dr. Harold Harlan; Richard Pollack, Courtesy:
Public Health Image Library http://goo.gl/z0XZps
27. • Exposure: Bites
• Type of Reaction: Allergic (delayed)
• Symptoms:
• Local Allergic Reaction
• Treatment: Symptomatic
UpToDate: Insect bites Author Mariana C Castells, MD, PhD
http://goo.gl/QE3GDW
http://goo.gl/IwwKUZ
28. • Exposure: Bites
• Type of Reaction: Irritation, Allergic (delayed or
immediate)
• Symptoms:
• Rarely, anaphylaxis
• Development of a meat allergy related to sensitization to a
carbohydrate in the tick’s saliva
• Treatment: Symptomatic
http://goo.gl/7MITvkUpToDate: Insect bites Author Mariana C Castells, MD, PhD
http://goo.gl/QE3GDW
29. • Exposure: Bites
• Type of Reaction: Allergic (delayed or immediate)
• Symptoms:
• Local allergic reaction
• Rarely, respiratory symptoms, especially if
cat allergic
• Treatment:
• Symptomatic
• Eradication
By: CDC/ Janice Haney Carr, Courtesy: Public Health Image Library
http://goo.gl/N7xiLC
UpToDate: Insect bites Author Mariana C Castells, MD, PhD
http://goo.gl/QE3GDW
30. • Exposure: Contact, Bites, Inhalation
• Type of Reaction: Allergic (immediate)
• Symptoms:
• Eye and Nose Symptoms
• Chronic cough
• Asthma
• Hives / Swelling
• Treatment:
• Symptomatic
• Eradication
http://goo.gl/EfR91b
Nakazawa T1, Satinover SM, Naccara L, Goddard L, Dragulev BP, Peters E, Platts-Mills TA.
Asian ladybugs (Harmonia axyridis): a new seasonal indoor allergen.
J Allergy Clin Immunol. 2007 Feb;119(2):421-7.
31. • A scale insect that lives on cacti in Central and South America
• Used to make Red Dye for food coloring, cosmetics
• Cochineal, or Carmine
• Exposure: Contact, Inhalation, Ingestion
• Type of Reaction: Allergic (delayed or immediate)
• Symptoms:
• Asthma
• Hives
• Anaphylaxis
• Contact Dermatitis
• Treatment:
• Symptomatic
• Avoidance
http://goo.gl/oI6SF9
http://goo.gl/Guwo7j
32. • Exposure: Inhalation, Contact, Ingestion (chocolate, peanut
butter, macaroni, fruit, cheese, popcorn and wheat)
• Type of Reaction: Allergic (immediate)
• Symptoms:
• Eye and Nose Symptoms
• Asthma
• Treatment:
• Symptomatic
• Eradication
• Allergy Immunotherapy
http://goo.gl/RNBRb3
By: CDC, Courtesy: Public Health Image Library
Per ABC news: Average chocolate bar
has 8 insect parts http://goo.gl/q8B1W
33. • 0.3 mm long
• 8 legs
• Sightless
• Live on skin scales
• Entirely dependent on
ambient humidity for their
moisture
• Optimum growth at 65-
80oF
• Mite fecal pellet
• Source of allergens
• 10-35 μm
• Dermatophygoides
farinae
• D. pteronyssinus
• D. microceras
• Blomia tropicalis
• Florida in the US
34. • Exposure: Inhalation, Contact
• Type of Reaction: Allergic (immediate)
• Symptoms:
• Eye and Nose Symptoms
• Asthma
• Treatment:
• Symptomatic
• Avoidance – Environmental Modifications
• Allergy Immunotherapy
http://goo.gl/kMl3Yg
35. • 2010 Cochrane Review, assessed as up to date end of
2009.1
• 9 trials (501 participants satisfied criteria)
• Mite-impermeable bedding covers (2 studies were
good quality)
• Acaricides (2 studies)
• HEPA filters (2 studies)
• Acaricides +/- covers (1 study)
1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:
House dust mite avoidance measures for perennial allergic rhinitis
Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
36. • Conclusions:
• Trials to date … small and of poor methodological quality…difficult
to offer any definitive recommendations on the role … of house
dust mite avoidance measures in the management of house dust
mite sensitive perennial allergic rhinitis.
• Use of acaricides and extensive bedroom-based environmental
control programmes may be of some benefit in reducing rhinitis
symptoms and, if considered appropriate, these should be the
interventions of choice.
• Isolated use of house dust mite impermeable bedding is unlikely to
prove effective.
1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:
House dust mite avoidance measures for perennial allergic rhinitis
Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009
42. • An estimated 0.4-0.8% of children, and 3% of adults,
have potentially life-threatening reactions to stings.
• Honey Bee
• Yellow Jacket
• Yellow-Faced Hornet
• White-Faced Hornet
• Paper Wasp
• Fire Ant
http://goo.gl/wi7PFc
43. • Stinging insects such as bees, wasps, hornets
and yellow jackets, are most active during late-
summer and early-autumn
• Fire ants are prevalent year round in the South
http://goo.gl/povKLP
http://goo.gl/YXhxoP
44. • Analysis of the National Mortality Database
• 2458 fatal anaphylaxis cases in the U.S. of all causes
• 0.69 persons per million
Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.
J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]
45. • Rate
• Differed by race
• 0.14 per million in white subjects
• 0.05 per million in African American subjects
• 0.03 per million in Hispanic subjects
• Increased with age
• 0.01 per million if ≤ 19 years
• 0.20 per million if age 60 to 79 years
Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.
J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]
46. • Rate
• Differed by gender
• 0.18 per million for male subjects
• 0.04 per million for female subjects
• no significant increase over time
Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.
J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]
47. • Children <16 years of age
• Family History: No evaluation needed
• Never had a reaction: No evaluation needed
• Local reaction only: No evaluation needed
• Skin reaction only: No evaluation needed
Epinephrine auto-injector not needed
• Anaphylaxis: Evaluation needed
Epinephrine auto-injector needed
Golden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D,
Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE,
Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI);
American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol.
Stinging insect hypersensitivity: a practice parameter update 2011.
2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.
48. • Adults and Children ≥16 years of age
• Local reaction only: No evaluation needed
• Skin reaction (hives and swelling): Increased risk of anaphylaxis
Evaluation needed
Epinephrine auto-injector
needed
• Anaphylaxis: Evaluation needed
Epinephrine auto-injector
neededGolden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D,
Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE,
Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI);
American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol.
Stinging insect hypersensitivity: a practice parameter update 2011.
2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.
49. • Venom allergy immunotherapy
• Decreases risk of anaphylaxis from 30-60% to
<5%
• Venom Allergy Anaphylaxis Action Plan
• Have injectible epinephrine on hand (2 doses)
• Medical Alert Bracelet
• Behavior modifications to reduce risk of
exposure
Golden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D,
Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE,
Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI);
American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol.
Stinging insect hypersensitivity: a practice parameter update 2011.
2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.
50. • Insects have 3 body segments, 6 legs and 2
antennae
• Arachnids have 2 body segments, 8 legs, and no
antennae
• An Allergic reaction is an immune reaction to a
trigger
• Allergic reactions to arachnids can occur through
contact, bites, inhalation, ingestion, and injection.
51. • Allergic reactions to arachnids can range from
mild and local, to severe, life-threatening and
systemic
• Venom allergy immunotherapy can greatly
reduce the future risk of anaphylaxis
• Epinephrine is the treatment of choice for
anaphylaxis