jabberwocky the jaws that bite the claws that catch jabberwocky the jaws that bite the claws that...
TRANSCRIPT
JabberwockyJabberwockyThe jaws that biteThe jaws that bite
The claws that catchThe claws that catch
BitesBites
And the great outdoorsAnd the great outdoors
Jim Giesen, M.D.Jim Giesen, M.D.
JabberwockyJabberwockyLewis CarrollLewis Carroll
‘Twas brillig, and the slithey toves‘Twas brillig, and the slithey tovesDid gyre and gimble in the wabe:Did gyre and gimble in the wabe:
All mimsy were the borogoves, All mimsy were the borogoves, And the mome raths outgrabe.And the mome raths outgrabe.
Beware the Jabberwock, my son!Beware the Jabberwock, my son!The jaws that bite, the claws that catch!The jaws that bite, the claws that catch!
Beware the Jubjub bird, Beware the Jubjub bird, and shun the frumious Bandersnatch!and shun the frumious Bandersnatch!
MosquitoesMosquitoes
Vector to more disease in humans Vector to more disease in humans than any other blood feeding than any other blood feeding arthropodarthropod
Worldwide greater than 3 million Worldwide greater than 3 million deaths per year from malaria alonedeaths per year from malaria alone
Mosquito transmitted disease will be Mosquito transmitted disease will be responsible for the death of one out responsible for the death of one out of seventeen people currently aliveof seventeen people currently alive
Mosquito Borne DiseasesMosquito Borne Diseases Eastern and Western equine encephalitisEastern and Western equine encephalitis St.Louis and La Crosse encephalitisSt.Louis and La Crosse encephalitis West Nile VirusWest Nile Virus MalariaMalaria DengueDengue Bancroftian filariasisBancroftian filariasis Epidemic polyarthritisEpidemic polyarthritis Chikungunya feverChikungunya fever Rift Valley feverRift Valley fever
Mosquito FactsMosquito Facts
Only females suck blood(true Amazons)while Only females suck blood(true Amazons)while wimpy males sip on nectar and plant juices wimpy males sip on nectar and plant juices
Consume up to their own weight in blood every 3-Consume up to their own weight in blood every 3-4 days4 days
Some species are zoophilic some anthropophilicSome species are zoophilic some anthropophilic
and some switch hosts seasonally providing a and some switch hosts seasonally providing a means for transmitting disease from animals to means for transmitting disease from animals to humanshumans
Mosquito AttractantsMosquito Attractants Visual,thermal, and olfactory stimuli attract themVisual,thermal, and olfactory stimuli attract them Visual stimuli important for in flight orientation. Thermal Visual stimuli important for in flight orientation. Thermal
and olfactory more important as the mosquito closes in and olfactory more important as the mosquito closes in Carbon dioxide and lactic acid are two well studied Carbon dioxide and lactic acid are two well studied
attractantsattractants Carbon dioxide can draw mosquitoes from as far away as Carbon dioxide can draw mosquitoes from as far away as
100 feet100 feet Volatile compounds, sweat, and fragrances from lotions, Volatile compounds, sweat, and fragrances from lotions,
soaps, perfumes may be attractantssoaps, perfumes may be attractants Men preferred over women, adults over children, my wife Men preferred over women, adults over children, my wife
over meover me
BlackfliesBlackflies Late Spring Early Summer scourge of the Late Spring Early Summer scourge of the
northwoodsnorthwoods Mouthparts tear the skin surface and Mouthparts tear the skin surface and
produce a pool of blood from which the fly produce a pool of blood from which the fly feedsfeeds
Rare systemic reactions-fever, urticaria, Rare systemic reactions-fever, urticaria, and rarely anaphylaxisand rarely anaphylaxis
Intensely pruritic, painful,and slow to healIntensely pruritic, painful,and slow to heal Tropical species transmit Onchocerca Tropical species transmit Onchocerca
volvulus-the parsitic cause of river volvulus-the parsitic cause of river blindnessblindness
Other Flies and BugsOther Flies and Bugs Tabanids- horseflies, deerflies have been shown capable of Tabanids- horseflies, deerflies have been shown capable of
transmittting tularemiatransmittting tularemia
Sandflies- Tiny flies associated with leishmaniasisSandflies- Tiny flies associated with leishmaniasis Tsetse flies- African trypanosomiasis(sleeping sickness)Tsetse flies- African trypanosomiasis(sleeping sickness) Kissing bugs(Assassin bugs)- Vector for Trypanosoma cruzi Kissing bugs(Assassin bugs)- Vector for Trypanosoma cruzi
the causative agent of Chagas diseasethe causative agent of Chagas disease Fleas- Plague and murine typhusFleas- Plague and murine typhus Chigger mites-Pierce the skin with mouthparts and secrete Chigger mites-Pierce the skin with mouthparts and secrete
a proteolytic saliva that dissolves host tissue creating a a proteolytic saliva that dissolves host tissue creating a porridge which is then lapped up. Transmit scrub typhusporridge which is then lapped up. Transmit scrub typhus
General Treatment of Insect BitesGeneral Treatment of Insect Bites
Oral antihistaminesOral antihistamines Ammonium solution 3.6% (After Bite) Ammonium solution 3.6% (After Bite)
relieves Type1 hypersensitivity relieves Type1 hypersensitivity symptoms dramaticallysymptoms dramatically
Watch for secondary infectionWatch for secondary infection
TicksTicks
Most noted for high nuisance Most noted for high nuisance potentialpotential
Efficient vectors for a large number Efficient vectors for a large number of zoonosesof zoonoses
In the US ticks outrank mosquitoes In the US ticks outrank mosquitoes as vectors and tick-borne illnesses as vectors and tick-borne illnesses constitute an important infectious constitute an important infectious disease problemdisease problem
Tick envenomationTick envenomation
Ticks cause disease by either Ticks cause disease by either transmitting microorganisms or by transmitting microorganisms or by secreting toxins or venomssecreting toxins or venoms
Some trigger potent immune Some trigger potent immune responses others have direct tissue responses others have direct tissue toxicitytoxicity
Clinical effects range from localized Clinical effects range from localized reactions to anaphylaxis, paralysis, reactions to anaphylaxis, paralysis, and deathand death
Pajaroello Tick BitesPajaroello Tick Bites
Desert southwest,California, and Desert southwest,California, and MexicoMexico
Thought to be locally necrotizing Thought to be locally necrotizing toxin resulting in a 2-3 cm toxin resulting in a 2-3 cm
Local erythema, pain, and edema Local erythema, pain, and edema followed by tissue necrosis and followed by tissue necrosis and ulcerationulceration
Rare severe allergic reactionsRare severe allergic reactions
Tick ParalysisTick Paralysis
First reported by Todd in 1912First reported by Todd in 1912 Acute ascending motor paralysis Acute ascending motor paralysis
appearing similar to Guillan Barre, appearing similar to Guillan Barre, botulism,or myesthenia gravisbotulism,or myesthenia gravis
43 different species of tick have been 43 different species of tick have been implicated in the US and Australiaimplicated in the US and Australia
Neurotoxic venom secreted from the Neurotoxic venom secreted from the tick salivary gland causes the tick salivary gland causes the paralysisparalysis
Clinical FeaturesClinical Features
Paralysis develops 5-6 days after a female Paralysis develops 5-6 days after a female tick attaches, usually to the head or necktick attaches, usually to the head or neck
Restlessness, irritability, and paresthesias Restlessness, irritability, and paresthesias followed by ascending, symmetric flaccid followed by ascending, symmetric flaccid paralysisparalysis
Cerebellar dysfunction may occur with Cerebellar dysfunction may occur with incoordination and ataxiaincoordination and ataxia
Resolution of paralysis with tick removal Resolution of paralysis with tick removal establishes the diagnosisestablishes the diagnosis
Ticks as VectorsTicks as Vectors
Lyme DiseaseLyme Disease Rocky Mountain Spotted FeverRocky Mountain Spotted Fever Relapsing FeverRelapsing Fever Colorado Tick FeverColorado Tick Fever EhrlichiosisEhrlichiosis BabesiosisBabesiosis TularemiaTularemia
EhrlichiosisEhrlichiosis Two forms in humans:Human monocytic Two forms in humans:Human monocytic
ehrlichiosis(HME) and human granulocytic ehrlichiosis(HME) and human granulocytic ehrlichiosis(HGE)ehrlichiosis(HGE)
HME is transmitted by the Lone Star Tick HME is transmitted by the Lone Star Tick and is found in the south and eastand is found in the south and east
HGE is found in the upper Midwest and HGE is found in the upper Midwest and Northeast. Range tends to overlap areas Northeast. Range tends to overlap areas where Lyme disease is endemicwhere Lyme disease is endemic
70% occur in May-July70% occur in May-July Broad clinical spectrum of disease from Broad clinical spectrum of disease from
mild viral-like illness to life threatening mild viral-like illness to life threatening neurological complicationsneurological complications
EhrlichiosisEhrlichiosis
HGE only develops rash 10% of the HGE only develops rash 10% of the timetime
Caused by Ehrlichia equi like Caused by Ehrlichia equi like organism with reservoir hosts organism with reservoir hosts including sheep, deer, and rodentsincluding sheep, deer, and rodents
Confirm with serologic testing after Confirm with serologic testing after initiating empiric therapy with initiating empiric therapy with doxycycline 100 mg BID for a doxycycline 100 mg BID for a minimum of 7-10 daysminimum of 7-10 days
Prevention and ProphylaxisPrevention and Prophylaxis Prophylaxis not usually recommended. Even if Prophylaxis not usually recommended. Even if
tick is infected the risk of transmission is low if tick is infected the risk of transmission is low if the tick is found and removed promptlythe tick is found and removed promptly
Proper tick removal technique is imperativeProper tick removal technique is imperative Proper clothing can helpProper clothing can help DEET containing sprays and lotions repel ticks. DEET containing sprays and lotions repel ticks.
Use formulas containing less than 10% DEET for Use formulas containing less than 10% DEET for childrenchildren
Permanone is a tick repellant for use on clothing Permanone is a tick repellant for use on clothing and its active ingredient permethrin kills ticks on and its active ingredient permethrin kills ticks on contact. Field tests have shown permethrin to be contact. Field tests have shown permethrin to be 90% effective in preventing tick bites90% effective in preventing tick bites
Case ReportCase Report
20 year old intoxicated college 20 year old intoxicated college student presented to Tucson’s El student presented to Tucson’s El Dorado Hospital ER with severe Dorado Hospital ER with severe cramping back and leg pain. He had cramping back and leg pain. He had stumbled home and plopped himself stumbled home and plopped himself naked into the bath tub. He woke up naked into the bath tub. He woke up sometime later crying out with pain. sometime later crying out with pain. His friend brought the patient and a His friend brought the patient and a flattened black spider to the ERflattened black spider to the ER
Widow SpidersWidow Spiders
Shiny black spider with characteristic Shiny black spider with characteristic red hourglass on the abdomenred hourglass on the abdomen
Latrodectus spiders are worldwide in Latrodectus spiders are worldwide in their distribution and in the US occur their distribution and in the US occur in every state except Alaskain every state except Alaska
Tend to bite defensively when Tend to bite defensively when accidentally crushedaccidentally crushed
Widow Spider VenomWidow Spider Venom
Potent mammalian neurotoxin which Potent mammalian neurotoxin which causes massive neurotransmitter causes massive neurotransmitter release from presynaptic endingsrelease from presynaptic endings
Latrodectism, the syndrome resulting Latrodectism, the syndrome resulting from envenomation, is characterized from envenomation, is characterized by widespread sustained muscle by widespread sustained muscle contraction rather than for local contraction rather than for local tissue injurytissue injury
Clinical PresentationClinical Presentation Involuntary spasm of large muscle groups of Involuntary spasm of large muscle groups of
abdomen, limbs, and lower back can appear abdomen, limbs, and lower back can appear within 30-60 minutes of the envenomationwithin 30-60 minutes of the envenomation
Abdominal symptoms can mimic acute abdomenAbdominal symptoms can mimic acute abdomen Associated signs may include fasciculations, Associated signs may include fasciculations,
weakness, ptosis, priapism, fever, salivation, weakness, ptosis, priapism, fever, salivation, diaphoresis, and bronchorrheadiaphoresis, and bronchorrhea
Symptoms may remain severe for several days. Symptoms may remain severe for several days. Care is largely supportive though an antivenin is Care is largely supportive though an antivenin is available for life threatening casesavailable for life threatening cases
Special care must be taken in Special care must be taken in pregnancy(premature labor) in severe pregnancy(premature labor) in severe hypertension and in childrenhypertension and in children
Recluse EnvenomationRecluse Envenomation
Complex venom with at least 8 or 9 Complex venom with at least 8 or 9 major protein bandsmajor protein bands
Components are both dermonecrotic Components are both dermonecrotic and directly hemolyticand directly hemolytic
Clinical spectrum ranges from mild Clinical spectrum ranges from mild and transient skin irritation to severe and transient skin irritation to severe local necrosis and dramatic local necrosis and dramatic hematologic and renal injuryhematologic and renal injury
Urticating HairsUrticating Hairs
Abdominal hairs which are barbed Abdominal hairs which are barbed and may contain an irritant venomand may contain an irritant venom
Type 1,2,3,and4 hairs cause varying Type 1,2,3,and4 hairs cause varying degrees of inflammationdegrees of inflammation
Urticating hairs of Tarantulas can be Urticating hairs of Tarantulas can be transmitted hand to eye and are the transmitted hand to eye and are the cause of potentially severe cause of potentially severe ophthalmic injuryophthalmic injury
Wisconsin Venomous Reptile BitesWisconsin Venomous Reptile Bites
A middle aged fly fisherman was working A middle aged fly fisherman was working the banks of Black Earth Creek a couple of the banks of Black Earth Creek a couple of years ago. He felt a sharp pain in his lower years ago. He felt a sharp pain in his lower leg. Over a period of several hours the leg. Over a period of several hours the pain intensified and the leg became red pain intensified and the leg became red and swollen. A middle aged plastic and swollen. A middle aged plastic surgeon with whom I shared a beer or two surgeon with whom I shared a beer or two in medical school astutely noted the in medical school astutely noted the paired puncture wounds on the leg, paired puncture wounds on the leg, measured the distance between the two measured the distance between the two punctures and arrived at the correct punctures and arrived at the correct diagnosis.diagnosis.
Field Treatment of Pit Viper BitesField Treatment of Pit Viper Bites
Little science and lots of anecdotal Little science and lots of anecdotal recommendationsrecommendations
Weigh benefit against risk of treatmentWeigh benefit against risk of treatment Severe envenomations require antivenom and all Severe envenomations require antivenom and all
due haste should be made to get the victim to a due haste should be made to get the victim to a site for definitive caresite for definitive care
Avoid mechanical suction devicesAvoid mechanical suction devices Avoid tourniquets even simple veno occlusive Avoid tourniquets even simple veno occlusive
band as they may make local tissue necrosis band as they may make local tissue necrosis worseworse
Recognize that defensive bites may be “dry” with Recognize that defensive bites may be “dry” with little or no delivery of venomlittle or no delivery of venom
AntivenomAntivenom Antivenin(Crotalidae)Polyvalent is derived from Antivenin(Crotalidae)Polyvalent is derived from
horse serumhorse serum Derived from horses immunized against two Derived from horses immunized against two
North American and one South American viperNorth American and one South American viper Can be used for treatment of bites by any North Can be used for treatment of bites by any North
American pit viperAmerican pit viper Risk of acute reaction to antivenom itself. Should Risk of acute reaction to antivenom itself. Should
not be used in the field unless full resuscitative not be used in the field unless full resuscitative support is availablesupport is available
Newer sheep derived and purified antivenom, Newer sheep derived and purified antivenom, CroFab has been approved by the FDA for mild to CroFab has been approved by the FDA for mild to moderate envenomationsmoderate envenomations
Other Bites and IssuesOther Bites and Issues
Other envenomations and stingsOther envenomations and stings Mammalian Bites: Local wound Mammalian Bites: Local wound
issues, microbiology of wound issues, microbiology of wound infections, tetanus and rabies infections, tetanus and rabies prophylaxisprophylaxis
Large animal attacks: Bear, mountain Large animal attacks: Bear, mountain lion, muskielion, muskie
Homo horribilus- drunk on a Saturday Homo horribilus- drunk on a Saturday nightnight