Jabberwocky The jaws that bite The claws that catch

1. JabberwockyThe jaws that biteThe claws that catch Bites And the great outdoors Jim Giesen, M.D.

2. JabberwockyLewis Carroll‘Twas brillig, and the slithey tovesDid gyre and gimble in the wabe:All mimsy were the borogoves, And the mome raths outgrabe.Beware the Jabberwock, my son!The jaws that bite, the claws that catch!Beware the Jubjub bird, and shun the frumious Bandersnatch!

3. Blood Sucking Arthropodsand the Joy They Bring Us

4. Mosquitoes • Vector to more disease in humans than any other blood feeding arthropod • Worldwide greater than 3 million deaths per year from malaria alone • Mosquito transmitted disease will be responsible for the death of one out of seventeen people currently alive

5. Mosquito Borne Diseases • Eastern and Western equine encephalitis • St.Louis and La Crosse encephalitis • West Nile Virus • Malaria • Dengue • Bancroftian filariasis • Epidemic polyarthritis • Chikungunya fever • Rift Valley fever

6. Mosquito Facts • Only females suck blood(true Amazons)while wimpy males sip on nectar and plant juices • Consume up to their own weight in blood every 3-4 days • Some species are zoophilic some anthropophilic and some switch hosts seasonally providing a means for transmitting disease from animals to humans

7. Mosquito Attractants • Visual,thermal, and olfactory stimuli attract them • Visual stimuli important for in flight orientation. Thermal and olfactory more important as the mosquito closes in • Carbon dioxide and lactic acid are two well studied attractants • Carbon dioxide can draw mosquitoes from as far away as 100 feet • Volatile compounds, sweat, and fragrances from lotions, soaps, perfumes may be attractants • Men preferred over women, adults over children, my wife over me

8. Blackflies • Late Spring Early Summer scourge of the northwoods • Mouthparts tear the skin surface and produce a pool of blood from which the fly feeds • Rare systemic reactions-fever, urticaria, and rarely anaphylaxis • Intensely pruritic, painful,and slow to heal • Tropical species transmit Onchocerca volvulus-the parsitic cause of river blindness

9. Other Flies and Bugs • Tabanids- horseflies, deerflies have been shown capable of transmittting tularemia • Sandflies- Tiny flies associated with leishmaniasis • Tsetse flies- African trypanosomiasis(sleeping sickness) • Kissing bugs(Assassin bugs)- Vector for Trypanosoma cruzi the causative agent of Chagas disease • Fleas- Plague and murine typhus • Chigger mites-Pierce the skin with mouthparts and secrete a proteolytic saliva that dissolves host tissue creating a porridge which is then lapped up. Transmit scrub typhus

10. General Treatment of Insect Bites • Oral antihistamines • Ammonium solution 3.6% (After Bite) relieves Type1 hypersensitivity symptoms dramatically • Watch for secondary infection

11. Ticks • Most noted for high nuisance potential • Efficient vectors for a large number of zoonoses • In the US ticks outrank mosquitoes as vectors and tick-borne illnesses constitute an important infectious disease problem

12. Tick envenomation • Ticks cause disease by either transmitting microorganisms or by secreting toxins or venoms • Some trigger potent immune responses others have direct tissue toxicity • Clinical effects range from localized reactions to anaphylaxis, paralysis, and death

13. Pajaroello Tick Bites • Desert southwest,California, and Mexico • Thought to be locally necrotizing toxin resulting in a 2-3 cm • Local erythema, pain, and edema followed by tissue necrosis and ulceration • Rare severe allergic reactions

14. Tick Paralysis • First reported by Todd in 1912 • Acute ascending motor paralysis appearing similar to Guillan Barre, botulism,or myesthenia gravis • 43 different species of tick have been implicated in the US and Australia • Neurotoxic venom secreted from the tick salivary gland causes the paralysis

15. Clinical Features • Paralysis develops 5-6 days after a female tick attaches, usually to the head or neck • Restlessness, irritability, and paresthesias followed by ascending, symmetric flaccid paralysis • Cerebellar dysfunction may occur with incoordination and ataxia • Resolution of paralysis with tick removal establishes the diagnosis

16. Ticks as Vectors • Lyme Disease • Rocky Mountain Spotted Fever • Relapsing Fever • Colorado Tick Fever • Ehrlichiosis • Babesiosis • Tularemia

17. Ehrlichiosis • Two forms in humans:Human monocytic ehrlichiosis(HME) and human granulocytic ehrlichiosis(HGE) • HME is transmitted by the Lone Star Tick and is found in the south and east • HGE is found in the upper Midwest and Northeast. Range tends to overlap areas where Lyme disease is endemic • 70% occur in May-July • Broad clinical spectrum of disease from mild viral-like illness to life threatening neurological complications

18. Ehrlichiosis • HGE only develops rash 10% of the time • Caused by Ehrlichia equi like organism with reservoir hosts including sheep, deer, and rodents • Confirm with serologic testing after initiating empiric therapy with doxycycline 100 mg BID for a minimum of 7-10 days

19. Prevention and Prophylaxis Prophylaxis not usually recommended. Even if tick is infected the risk of transmission is low if the tick is found and removed promptly Proper tick removal technique is imperative Proper clothing can help DEET containing sprays and lotions repel ticks. Use formulas containing less than 10% DEET for children Permanone is a tick repellant for use on clothing and its active ingredient permethrin kills ticks on contact. Field tests have shown permethrin to be 90% effective in preventing tick bites

20. Tick Pix

21. Case Report • 20 year old intoxicated college student presented to Tucson’s El Dorado Hospital ER with severe cramping back and leg pain. He had stumbled home and plopped himself naked into the bath tub. He woke up sometime later crying out with pain. His friend brought the patient and a flattened black spider to the ER

22. The Suspect

23. Widow Spiders • Shiny black spider with characteristic red hourglass on the abdomen • Latrodectus spiders are worldwide in their distribution and in the US occur in every state except Alaska • Tend to bite defensively when accidentally crushed

24. Widow Spider Venom • Potent mammalian neurotoxin which causes massive neurotransmitter release from presynaptic endings • Latrodectism, the syndrome resulting from envenomation, is characterized by widespread sustained muscle contraction rather than for local tissue injury

25. Clinical Presentation • Involuntary spasm of large muscle groups of abdomen, limbs, and lower back can appear within 30-60 minutes of the envenomation • Abdominal symptoms can mimic acute abdomen • Associated signs may include fasciculations, weakness, ptosis, priapism, fever, salivation, diaphoresis, and bronchorrhea • Symptoms may remain severe for several days. Care is largely supportive though an antivenin is available for life threatening cases • Special care must be taken in pregnancy(premature labor) in severe hypertension and in children

26. Recluse Spiders

27. Recluse Envenomation • Complex venom with at least 8 or 9 major protein bands • Components are both dermonecrotic and directly hemolytic • Clinical spectrum ranges from mild and transient skin irritation to severe local necrosis and dramatic hematologic and renal injury

28. Recluse Bites

29. Another Recluse Bite

30. Tarantula

31. Urticating Hairs • Abdominal hairs which are barbed and may contain an irritant venom • Type 1,2,3,and4 hairs cause varying degrees of inflammation • Urticating hairs of Tarantulas can be transmitted hand to eye and are the cause of potentially severe ophthalmic injury

32. Wisconsin Venomous Reptile Bites • A middle aged fly fisherman was working the banks of Black Earth Creek a couple of years ago. He felt a sharp pain in his lower leg. Over a period of several hours the pain intensified and the leg became red and swollen. A middle aged plastic surgeon with whom I shared a beer or two in medical school astutely noted the paired puncture wounds on the leg, measured the distance between the two punctures and arrived at the correct diagnosis.

33. Massasauga

34. Timber Rattlesnake

35. Field Treatment of Pit Viper Bites • Little science and lots of anecdotal recommendations • Weigh benefit against risk of treatment • Severe envenomations require antivenom and all due haste should be made to get the victim to a site for definitive care • Avoid mechanical suction devices • Avoid tourniquets even simple veno occlusive band as they may make local tissue necrosis worse • Recognize that defensive bites may be “dry” with little or no delivery of venom

36. Antivenom • Antivenin(Crotalidae)Polyvalent is derived from horse serum • Derived from horses immunized against two North American and one South American viper • Can be used for treatment of bites by any North American pit viper • Risk of acute reaction to antivenom itself. Should not be used in the field unless full resuscitative support is available • Newer sheep derived and purified antivenom, CroFab has been approved by the FDA for mild to moderate envenomations

37. Other Bites and Issues • Other envenomations and stings • Mammalian Bites: Local wound issues, microbiology of wound infections, tetanus and rabies prophylaxis • Large animal attacks: Bear, mountain lion, muskie • Homo horribilus- drunk on a Saturday night

38. ‘Twas brillig and the slithey tovesDid gyre and gimble in the wabe:All mimsy were the borogoves,And the mome raths outgrabe.The End ‘