Transcript Hazardous Marine Life of the Gulf of Maine

Wilderness Bites,
Stings, Rashes and
Allergic Reactions
A 45 year old male presents
with lip swelling after drinking
out of a soda can with a bee
crawling on it
What type of
hypersensitivity
reaction is this?
How should this be
treated?
Immunology: Type I Reaction
Hymenoptera
 Multiple Antigens
 40-50 Deaths/yr US
 Rare deaths from stings alone (> 50 stings)
 Africanized Bees
Types of hypersensitivity reactions
 Type I : IGE mediated/ anaphylactic
..immediate …allergic rhinitis
Anaphylaxis
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IGE mediated
90 % urticaria or angioedema
The more rapid the reaction the more severe
May be delayed ( up to 48 hours)
More severe reactions in older individuals
Look for:
– Dizziness
– Wheezing
– Vomiting
Treatment
 Prevent further stings
 Calm the patient and friends
 Rest
 Elevation
 Ice
Vive la Difference
 Bees sting once but have a muscular
stinging sac
 Wasps can sting multiple times
Treatment
 Antihistamine
– Benadryl: po v. IM
• 50 mg or 1 mg/kg
– H2 Blocker if severe
• Cimetidine
– 300 mg po or IM
 Epinephrine
– Epi –pen (jr)
• 0.3mg adult…0.15 mg child
• $65
Treatment
 Prednisone
– Reduces late phase reaction
– 1-2 mg/kg
 Glucagon
– Refractory symptoms on a B-blocker
– 1-5 mg IM
 Albuterol inhaler for wheezing
 Fluids/ pressor support
What would make you
want to evacuate the
patient?
WHEN TO EVACUATE:
Systemic symptoms
Diffuse Urticaria
History of severe reactions
On B-Blocker
Refractory to Benadryl
How long should you monitor the
patient?
 ~ 6 hours
 50 % severe in 10 minutes
 Most deaths < 1 hour
 Rare worsening after 5 hours
How long to treat?
 3-4 days with anti-histamines and steroids
How likely is the
patient to have the
same reaction if stung
again?
Good Question!
 In adults:
– Variable studies: ~ 10 to 60 % who had
Anaphylaxis may have no or mild reaction to
subsequent sting: 10- 20 % worse reaction
 In Children:
– Rare severe reaction < 10 y.o.
– ~ 10-20 % with severe reaction will have
similar subsequent reaction.
What should the patient
carry with him in case
this happens again?
What to Carry?
 Benadryl capsules
 Epi-pen
What would make the patient consider
immunotherapy in the future?
 Occupation
 Desire for wilderness experience
 Severity of Reaction
 95 % effective
 3- 5 years of therapy
 Hornets, honeybees, fire ants
2 weeks later the patient returns
to the ED with
Malaise, Joint pain, occasional
itching.
Type III: Immune Complex
Formation
 Serum Sickness
– 7-14 days
– Malaise, arthralgias, proteinuria
 Arthus Reaction:
– Site of the sting
– 8-12 hours
– Blister formation
 Resolve in 7-14 days
– Antihistamines, Steroids if severe
A 26 year old gardener was cleaning brush near
her cottage. She presents with a pruritic rash on
her neck. What is your diagnosis?
Cutaneous Lepidopterism
 Caused by the larvae of the Brown-tailed
moth
 Treatment
– Tape removal of setae
– Topical steroids,
– Benadryl
– Systemic steroids
 May induce asthma
Lyme Disease Clinical Pearls
 The erythema chronicum migrans (ECM) rash appears in
2-12 days after the bite…i.e engorgement.
– It is caused by the spread of Borellia
– A rash that occurs within the first day of a tick bite is
not ECM.
– ~ 70 % of infected patients will get ECM
– ECM may mimic cellulitis.
– Multiple ECM sites : immunocompromised or
systemic disease.
Lyme Disease Prophylaxis
 Doxycycline 200 mg po once
– Decr. Infection rate from 3.5 % to 0.4%
 Indications:
– >=12 years old ( doxy ok >=8y)
– Engorged deer tick ( if flat no doxy)
– Can’t talk the patient* out of it.
• (* mother, grandmother…etc)
 <8 yo…????
Lyme Disease Treatment
 ECM, Bell’s, 1st degree block:
– Doxycycline 100 mg b.i.d. : 14-21 days
– Amoxicillin 15 mg/kg t.i.d.: 14-21 days
 Serious Cardiac or Neuro
– Ceftriaxone 75 mg/kg daily: 14-21 days
 Arthritis:
– As per ECM but for 28 days
Lyme Disease Cousins
 Anaplasmosis:
– Causes low platelets and leukopenia
 Babesiosis:
– Causes anemia and hemolysis
A 40 year old man presents with an erythematous
macular papular rash on his bilateral lower
extremities. He was swimming today in Little
Sebago Lake and became very itchy within an
hour of getting out of the water.
Escagot’s Revenge or
Swimmers Itch
 Cercarial Dermatitis
 May be caused by the parasite
Trichobilharzia regenti
 Complicated life cycle involving both a
bird and a mollusc
 When exposed to humans, borrows into
skin and causes irritation
 Most cases do not require medical attention
A 22 year old “sternman” presents with a painful,
swollen left hand. He states he has “redfish poisoning”.
It is wicked bad this time. What is his medical
diagnosis?
Erysipeloid
 Well circumscribed erythema
 Fishing, shellfish, poultry industry
 Not systemically ill
 Sensitive to penicillins, cephalosporins,
fluoroquinolones
 Resistant to vancomycin
 Erysipelothrix rhusiopathiae
– Gram positive rod
A 5 year old is exploring a tide pool and has
sudden pain in his right foot. Mom sees a dark
dot on the sole of the foot. The dot is the spine
of the Green Sea Urchin (Strongylocentrotus
droebachiensis)
What should be the treatment?
Wounds in a Marine
Environment
 Local wound care …removal foreign
bodies
– Vinegar soaks or hot (105F) water for urchin
spines
 Immunocompetent: no prophylaxis for
minor wounds
 Immunocompromised, Liver disease, :
Cipro …2nd line: Bactrim
A 28 year old paddle boarder wearing a thin
wetsuit went swimming earlier today in the river.
He presents to the ED tonight with a painful itchy
rash. What is his diagnosis?
Sea Bather’s Eruption
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Larva of Jelly fish or anemone
Urticaria or papular within an hour of exposure
Under swim suit or nape of neck
Wash with salt water…scrape off cysts
Antipruritic treatment
Sun screen may be preventative
It is early september and a 65 yo man with no
psych history presents with agitation and
confusion for the past 2 days. He has a low
grade temp and complains of nausea and a
headache. What is your differential?
CSF:
20 WBC, 90 % lymphs
Glucose: 70 mg%
Protein: 60 mg%
Gram stain: negative
West Nile Virus:
 Flavivirus
– Japanese Encephalitis
 80 % asymptomatic
 19 % febrile illness
 1 % neuroinvasive
 Intermediary hosts: Crows/robins
Eastern Equine Encephalitis
 1 human case in Maine
Prevention
 Barrier
– Head nets
– Light colored clothing
– Socks over pant legs
 Behavior
– No scents
– no baths
– Avoid vigorous activity
– Avoid dusk and dawn
Insect Repellents
 The Pretenders
– Thiamine
– Skin So Soft, bug guard
– Citronella
– Oil of Eucalyptus
– Soy Bean oil ( “Blocker”)
Insect Repellents
 DEET is the word
– Safe even for kids
– Long lasting ( Ultrathon )
– Effective against a variety of insects
– 30% enough
• Dissolves plastics
• Seizures
Insecticides
 Permethrin
– Very effective combined with DEET
 Allethrin
– Thermacell
Attractants
 The mosquito magnet
– “converts propane into carbon dioxide
(propane tank not included), heat, and
moisture to simulate human breath”