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Nonvenomous Insect
Bites

Stanley Varghese, PA-S Yangjun Lu, MD-S

Hofstra University AUC School of Medicine

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Lyme Disease
Most common tickborne disease in the US

▪ Spirochetal infection caused by Borrelia burgdorferi

▪ MC vector being the Ixodes scapularis tick

▪ Native to the Northeast and parts of the upper Midwest
▪ Ixodes pacificus another vector, native to West Coast states

▪ Hosts include white-tailed deer, small mammals such as foxes,

mice, and even birds

▪ Endemic areas include Connecticut, Delaware, Maryland,

Massachusetts, Minnesota, New Jersey, New York,
Pennsylvania, Rhode Island, and Wisconsin (as of 2019).
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Courtesy of the CDC

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1.
DDX: Tinea corporis, nummular eczema,
cellulitis, erythema multiforme,
another insect bite!
2.
Of course, take a
thorough history!
3.
3 Stages of Illness
Early, localized (1-2 weeks after bite)
▪ Erythema migrans, single lesion, at least 5 cm w/ a median of 15 cm. There is the
classic notion of a “bulls-eye” target lesion, however lesions that are uniformly
erythematous have been reported.
▪ Nonspecific symptoms at presentation: fever, fatigue, myalgia, malaise, lethargy,
headache, arthralgia, regional LAD
Early, disseminated (weeks to months)
▪ Multiple erythema migrans lesions (MC), cranial nerve (facial) palsy, meningitis,
carditis (manifests as complete/partial heart block)
▪ ^Presence of multiple lesions permit clinical diagnosis w/out need for labs in the
US.
▪ B/L facial nerve palsy virtually pathognomonic for Lyme disease (peripheral
neuropathy vs irritation from basilar meningitis)
▪ Lyme meningitis presents similarly to enteroviral meningitis. Distinguishing factors:
age (10.5 vs. 5.5 y/o), duration of symptoms (12 vs. 7 days), ass. symptoms of CN
palsy, EM, papilledema (lean towards Lyme)
Late disease (months to years)- Mono-/Oligo-articular arthritis is MC (knee 90%)
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Note that serological testing in a patient presenting

w/ signs of early localized infection (EM) will
more often than not be negative. Thus, EM >5 cm
is sufficient for diagnosis according to the CDC.
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Causes can be neurologic, infectious

(Lyme), inflammatory
(neurosarcoidosis), traumatic (basilar
skull fracture), neoplastic, or
metabolic.
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Diagnosis & Treatment

1. Traditional two-tier method

▪ Start with ELISA antibody test. If negative, stop here. Rx-
▪ If ELISA is positive or equivocal, perform Western Blot. -PPX: 1 dose of
▪ Doxycycline 4.4 mg/kg
*IgG rises in 1-4 weeks and peaks at 6-8 weeks before receding
PO (max: 200 mg)
at 6 months. IgM rises within 2-8 weeks and often never returns -EL: Doxy 2 mg/kg/dose
to negative levels. PO BID x10 days
2. Modified two-tier method
▪ Both the initial and subsequent confirmatory test are enzyme
immunoassays (EIAs)

The traditional method has more widespread availability however the

modified method has shown to be of some benefit in patients presenting
with early disseminated infection (high sensitivity and specificity)
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Alternative Treatments

▪ Doxycycline is the preferred treatment for both early localized and

early disseminated manifestations of Lyme disease even in children
<8 y/o if treated for less than 21 days (AAP recommendation)
EXCEPT
▪ Lyme arthritis necessitates treatment for 28 days, ruling out the use
of doxycycline in this age group. An acceptable alternative is
Amoxicillin 50 mg/kg/day PO divided 3 times daily (Max: 500
mg/dose) x28 days.
▪ For severe cardiac or neurological manifestations: Ceftriaxone 50-
75 mg/kg IV q daily (max: 2 g) for 14-21 days and 14-28 days,
respectively.
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Rocky Mountain Spotted Fever

▪ Caused by Rickettsia Rickettsii, a gram negative obligate

intracellular bacterium
▪ MC vector is the dog tick, dermacentor variabilis (South-Central
US)
▪ Rocky Mountain dog tick, dermacentor andersoni (Western US)
▪ Incubates for 2-14 days (5-7 MC)
▪ As w/ Lyme Disease, many patients don’t realize they’ve been
bitten.
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Symptoms

▪ Classic presenting symptoms of fever, malaise, myalgia, headaches,

N/V and arthralgias. Can evolve into cough, abdominal pain, edema,
seizures, and conjunctivitis (which can lead to confused diagnosis)
▪ Rash appears most commonly between the 3rd and 5th days of illness,
with a centripetal distribution spreading inwards. The rash is initially
macular with lesions 1-4 mm in diameter that blanch before turning
petechial in nature. The rash can also present on the palms and soles of
the feet if the illness is allowed to progress. The rash doesn’t have to
present in this order.
▪ Major complications include skin necrosis (digits, ears), encephalitis,
cardiac arrhythmias, myocarditis, noncardiogenic pulmonary edema,
ARDS, GI bleeds, and DIC (secondary to consumption of clotting
factors)
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Rumpel-Leede Phenomenon
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Diagnosis & Treatment
▪ Thrombocytopenia
▪ Hyponatremia, azotemia
▪ Elevated LFTs, indirect bilirubin, prolonged PT/PTT
▪ CSF: elevated protein and WBCs <100 cells/microL (primarily
monocytes)
▪ Dx: IgG indirect immunofluorescence antibody (IFA) assay (just like in
Lyme dz, labs are usually negative in the first week). PCR is not as helpful
(low sensitivity) because R. rickettsii does not usually build significant
numbers in the blood before the severe manifestations of the dz develop.
▪ Children <45 kg: Doxycycline 2.2 mg/kg/dose PO divided 2x/daily (max:
200 mg/day) until 3 days after fever resolution.
▪ Children >45 kg: Doxycycline 100 mg PO BID
▪ Alt.: Chloramphenicol 50 mg/kg PO divided 4x/daily
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Ehrlichiosis

▪ E. chaffeensis, obligate intracellular bacteria that grows within

membrane-bound vacuoles in human and animal leukocytes
▪ southeastern, south-central, and mid-Atlantic regions of the US
▪ Spring and Summer
▪ Lone Star tick vector and White tail deer reservoir
▪ fever , headache, myalgia, rash, NV, AMS, lymphadenopathy
▪ Leukopenia and/or Thrombocytopenia
▪ IFA for diagnosis
▪ Doxycycline or Rifampin
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Chagas
Kissing Bug

▪ Trypanosoma cruzi, protozoan parasite

▪ Humans becomes infected when triatomine vector defecates into
wounds
▪ Vectors found in continental Americas
▪ Congenitally from mom to infant, transfusion of blood
components, organ transplants, consumption of contaminated
food/drink
▪ Prevalent in Bolivia, Argentina, Paraguay, El Salvador, and
Guatemala. US is mostly found from immigrants from El Salvador
and Mexico
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▪ Incubation of one to two weeks

▪ Acute phase - 8-12 weeks
▪ Circulating trypomastigotes
▪ Asymptomatic or nonspecific (malaise, fever, anorexia)
▪ Chagoma, Romaña’s Sign
▪ Acute myocarditis, pericardial effusion, and/or
meningoencephalitis (1%)
▪ Dx: suspected in individuals who lived or spent time in Latin America.
Lived in houses with adobe walls and/or thatched roofs
▪ Usually not detected in the acute period, PCR
▪ DDx: Preseptal cellulitis, Infectious Mononucleosis, HIV
▪ lifetime risk of cardiac or gastrointestinal disease(20 to 30 percent)
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Congenital Chagas

▪ 1-10% of infants from infected mothers

▪ Transmission rate- 4.7%
▪ Asymptomatic or non-specific, have to do laboratory screening
▪ Low birth weight (<2500g), hepatosplenomegaly,
meningoencephalitis, respiratory insufficiency
▪ Same risk for Cardiac and GI disease
▪ Benznidazole and nifurtimox, 90% parasitological cure if within
first year of life
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References

▪ Maeda K, Markowitz N, Hawley RC, et al. Human infection with Ehrlichia cani
s, a leukocytic rickettsia. N Engl J Med 1987; 316:853.
▪ Messenger LA, Gilman RH, Verastegui M, et al. Toward Improving Early Diag
nosis of Congenital Chagas Disease in an Endemic Setting. Clin Infect Dis 20
17; 65:268.