Beruflich Dokumente
Kultur Dokumente
Title
Cellulitis From Insect Bites: A Case Series
Permalink
https://escholarship.org/uc/item/45k424gt
Journal
Western Journal of Emergency Medicine: Integrating Emergency Care with Population
Health, 4(2)
ISSN
1936-9018
Authors
Derlet, Robert W
Richards, John R
Publication Date
2003-01-01
Peer reviewed
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h orb3~x-n~ Hn addition, okigoiag infection (he Baterai aspect of the lefi lower leg just below the
horn abscesseb, ulce~s,and folliculitis may ~p!!ead The patien: $el: a sharp sting and had been
be3ond a self-ii~mitedcapsule to s.x?,-oucd-ngsk.1n a,n~~eno~a";ed by the ~ i m ehe bmshed *taway Be
2c~uteelya~tdrapidly. In some cases, no insxle to the c,eas;ed h e wsw~dwith soap and water 1hediate1y
skin or ~ I S S U Gca.3 be idenkified and gie has been hy- x7e1;he sing.The initial erythema and pain at the
r,--Lhesized that 53~0s"-borne b a ~ t e ~2i-a1 2 sree
~ g {$solvedcompletelyw l i h 1% hours. Foil-
sub- s ~ k site
c~~hneous tissue resu1tPag incell~ihks.~ eigkt holm a f t e ~the sting he developed pain and
e;-s,'C~ema~tthe sitee.The patlent presented for evalaa-
$,el%n14tis, as a result of an insect bite, hzs been de- atmn faux days zfier Lhe sting. The patient9sv?a1 signs
sc~ibedand may initially be c o ~ h s e \with d an early 3% presentaZaon to the ED were as follows: blood
allergic reaction to the insect sfing or The f01- :%zessmeof 173196m m Bg, pulse 79 beats per
lowing swen cases were treated by the authors dm- Tespiratoqrate B 6 breaths per minute, and tempera-
k g the summer of 200%.They axe presented to illvs- mre %'@~ On examination, he had an area of
hate the associatisir.;between insect bites and eelluli- a-ythema9edemz, and tenderness approximately 5
tis and to a k d providers lo the possibility of mist&- by 5 crn around the bite snte. Re "sad full range of
ing a2 acute localized allergic reac~ionwithce1Iulitis ~ao'sionaf his knee and no inguinal nodes. Be was
treated wth one gram s f cefazolin hkavenously and
GASES <ischargedhome with a prescip~onfix cefalexh 500
P7iae cases described below are slmmarized in 'ifable mg by mouth QID for one week. Complete resolu-
#I. tion occw~edat day seven.
Case +i3A A52 yea-old male was stung by a bee on Case #3: A 20 year-old male was stung by a bee on
the le!? anterior f l g h while riding a road bike. The the lateral aspect offhe right Bower leg. Be devel-
bee sting was witnessed and occurred through oped erythema and pain ediately around the sting
&h,eightly-firdng bike shork. The patient was unable site, which then resolved. TwenQ-fow hours later he
to bmsh offthe bee for fear of losing conk01 of his bi- developed new ewhema mdpain, and on day thee
-- - . -- -
presented to the ED for evaluation. His vital signs $When he was called back for re-examination ~t day
were as follows: blood pressure 124156 Hg, five, there was coraplete resoi~tionof symptornsS
pulse 93 beats per te, resphatov rate 14breaths
per minute, md temperame 36.go@. At that time he Case #6:A 47year-old male was $&en on the light
was found to have a 4 by 5 cm red area ofcellulitis hand by a spider vvhile w m h g outdoors. Be devel-
that was tender to palpation. There was no inmhal ~ p e initial
d pain and erythema wkeh he stated nearly
lymphadenopathy~He was given a loading dose of completely resolved. However, 24 hours after his
cefaaolin, one gram intravenousl6gr,then prescribed sting, he noted pain inthe !v~nd.f i e pain progressed,
cephalexh 500 mg orally QIID. He vvas called thee and the erythema invoking the entire dorsW GFEQ~
days later and stated he had 90% resolution of s i p s hand. We presented to a physic~anand was started
and symptoms. He was lost to follow-up thereafter. on amoxici18in-cla\rfiIanate 500 mg by mouth TID.
Despite this reghen, the erythema, edema, and pain
Case #4: A 52 year-old male was stung by a bee on of his hand increased, and he developed a 2 crn di-
h e right ankle while doing g m d e h g work. &&ou@ ameter abscess. He presented to the ED six days
the patient could not precisely recall times, the initial after his sting. The patient's vital signs on presenta-
pain and erythema resolved. The next day he had tion to the ED were as follows: blood pressure H 241
increased edema and eqthema, w~hichprogressed Hg, pulse 102 beats per minute, respiratory
proximally &-omthe ankle to the lower leg. FVhen he rate 14 breaths pef minute, and temperabuse 38°C.
presented to the ED his blood pressure was B22/8 1 A hand sewice consultation was oStained, and the
rnm Mg,pulse was 88 beats per minute, and tern- patie~~t was started on cefaolin inkavenously. Tne
perahre was 38°C. Be had an ecchyr~oticarea 3 abscess was incised a d &med s3-1the operating :ooixaa.
crn indiameter x o w d the site, with edema e k e n h g The wound culture showed no growth. He was ad-
to the lateral d d e . Erythema extended 20 cm proxi- m9tted to the haaid s e ~ ~ ifor
c ehvo days and treated
mal to a level just below the h e e . Because the hos- with i$tiravenauseefazolin and discharged on oral
pital was filled and no beds were available, he was cephalexin. Fis symptoms resolved ten days after
obsewed in the ED for 118 hours which time he ED presentation $16 days after bite)
received three doses of hedenom cefmhn one p m
each. He improved over this time period and was Case #7:A 37 year-old male was gardening at dusk
discbarged on clindamycin 600 mg BID orally and and bitten by a ~ o s c p i t oon the Lateral asp~ctsf the
had complete resolution of his s y ~ p t o ~ m bys day upper right arm. There was immediate edema and
seven. erfiqem, folHovredby intensepmitis a.t the sateaThese
symptoms subsided later that evening, but returned
Case #5: A 39 year-old wale was bitten by a spider the following day. The patient denied cleaning the
vvPi%eeating. He felt a s h p sting mdemea& the table wound or applying topical antibacterial or steroid
and pulled back to find a spider scampei-angoff his creams after the bite. At day thee he developed an
leg. He develop& initial locd e m e ~ nxa ~ d v?hich
p ~ ulceration at the bite site with ircreased pain, edexz,
he said resolved by the next m o ~ gTho 0 days afier eq$herna and he presented to the ED- His v;(raH
being bitten, he developed increased pxh and edema signs were as fo~hws:ternp5raku-e37. &"C, p ~ i s 64
e
which persisted. On day t h e e he presented to the beats per minute, respiratory rats 12 breaths per
ED. His vital signs were as follows: blood pressure ninute, and blood pressme 12467rnx Eg.Exami-
Hg, pulse 83 beats per minute, respira- nation of the worn$ revealed a 2 by 2 cm ulceration
tions 16 breaths per minute, m d temperame 36.5"C. wlth S-moundingerythema, and an obvious "honey
On physical exmination he had a 6 by 18cm area sf crust9' a&here~tfilma The w o ~ a was d clear sed vdifl-~
eryfllerna on his left upper thgh. He had left ing~inai Betadine a d peroxide so;ntions, then aggessavely
Ipphadenopafiy but good m g e ofmotion of his hip deb~dedwit91 a 80-blade scalpel. Bacikacin oktrflea-it
joint He was given a prescription for cephalexin 500 was applied with a large occlusive &+essing.The pa-
rng by mouth QIiD for seven days and discharged. tient w* started on cephde~&500mg by r n ~ ~QD ~th
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for seven days for treatment of presumptive grarn- The microorgmisms responsible for cee%lulitis in our
positive ceilulitis with secondary impetigo. On foi- seven cases were not identified. Fasl.bLhemore,and
lo~w-up the pat;ent reported the v~oundhealed slowly, most hpomt8gi, it 1s
i~ritllcomplete ~sesoieataor~ after ten days. developed as a result of inoculation of preexisting
bacteria on the s h n info the wound or as a result of
DISCUSSION exogenous bacteria inoculated into the wound from
Stings m.d erdenomatim by insects commordy result an insect that sewed either as a reservoir or vector
in a localized a%lergicreaction cl~aacierizedby pa&? for ppathogenic bacteria. In oae published case a pa-
rqdhema, pwitis and, insome eases, ecchj~mosisa ~ d tient developed ATocardia bmsl'kiensdsas a result of
eden-a."ien these patients present acutely fo injection of the bacteria by the insect &sk5 Other
- ~
the ED, e diagnosis of awte allergic reaction mgy be stud~essuggest that pafhoge~icbacteria may be h a -
nade and patients afe comimonly treated with a ~ d - bored Sj7 insects. Insects have been described as
b j ~ t a ~ b n eisn. severe czses, pale::ts v d h systawic c a ~ ~ - - ai nn~~rnber
g of bacteria including Salmone%la,
.~ ~