Dog and Cat Bites: Rapid Evidence Review.

Animal bites are a significant burden to health care systems worldwide. In the United States, dog bites account for an average of 337,000 emergency visits and generate medical costs of up to $2 billion per year. Most animal bites in adults and children are from a dog, and most bite patients are children who have been bitten by animals known to them. Dog bites may cause crush and soft-tissue avulsion, whereas cat bites usually cause deeper puncture-type wounds. Children most often present with dog bites on the head and neck, and adolescents and adults usually present with dog bites on the extremities and hands. Bite wounds should be examined, cleaned, and irrigated with warm water or normal saline solution, and any foreign bodies and devitalized tissue should be removed. Neurovascular function (e.g., pulses, sensation) and range and movement of adjacent joints should be examined and documented. Antibiotic prophylaxis, with amoxicillin/clavulanate as the first-line choice, should be considered for all bites, particularly for those at increased risk of infection. Imaging and laboratory studies are usually not required unless there is suspicion of a retained foreign body, damage to underlying structures, infection, or extensive injury. Primary closure of bite wounds may be performed if there is low risk of infection. The need for tetanus vaccination and rabies postexposure prophylaxis should be evaluated for each patient; bites that do not break the skin generally do not require rabies postexposure prophylaxis.

Severe case of rhabdomyolysis following jellyfish envenomation in the Mediterranean Sea.

Jellyfish envenomation is a common problem in coastal areas all over the world; usually symptoms are self-limited with no long-lasting complications. Despite that, some jellyfish species, mainly populating the Indian Ocean, are renown to be potentially lethal and in some cases may cause severe myopathy. We report the first case of rhabdomyolysis following a jellyfish sting in the Mediterranean Sea. A 17-year-old patient was admitted to the intensive care unit of our hospital in life-threatening conditions. He was dyspnoeic and dysphagic with pain and functional impairment of upper and lower limbs. The evidence of a red mark in his face and the clinical presentation, coupled with the diagnostic test performed, allowed the diagnosis of toxidrome from jellyfish venom. Treatment with hydration, ventilatory support and steroids led to a progressive improvement of patient conditions. Our case report stresses the importance of prompt identification and treatment of potential rhabdomyolysis determined by jellyfish and rises awareness on the presence of such venomous species in the Mediterranean Sea.

Use of clonidine in the treatment of Irukandji syndrome: A 4-year retrospective cohort study on safety, efficacy and clinical utility.

OBJECTIVE: Irukandji syndrome (IS) is an extremely painful condition that causes a significant catecholamine surge and sympathetic autonomic response related to the envenomation from certain types of jellyfish. Current management involves intravenous fluids, magnesium sulphate and large doses of opioids for symptom control. Clonidine, a centrally acting alpha-2 agonist, is often used as an analgesic adjunct to reduce opioid requirements in acute pain. The present study explores the safety and efficacy of clonidine in reducing opioid requirements in IS. METHODS: All patients diagnosed with IS at Cairns Hospital between 1 March 2016 and 30 April 2020, and participants from the Magnesium in Irukandji Study Trial, were included in this retrospective study (n = 114). Cases were separated into two groups depending on whether or not they received clonidine, and subsequently analysed according to pre- and post-intervention opioid requirements, clonidine dose administered and adverse effects. RESULTS: Notably, 39 patients with IS received ≥1 mcg/kg clonidine and the remaining 75 did not. There was no difference in oral morphine equivalent daily dose (oMEDD) between groups before clonidine administration; however, there was a significant reduction in oMEDD required after patients received clonidine (26.1 mg; 95% CI 4.6-47.7) compared with those who did not (66.6 mg; 95% CI 56.9-86.1) (F = 8.722, df = 1 × 224, P = 0.003). One episode of hypotension occurred following the intervention. CONCLUSION: Patients with IS who received clonidine required significantly lower opioid requirements than those who did not receive clonidine. Clonidine was safe to administer and should be considered early when treating IS. The optimal clonidine dose remains unclear and requires prospective studies to validate our findings.

Terrestrial envenomations in pediatric patients: identification and management in the emergency department.

The majority of bites and stings from terrestrial animals are not dangerous. However, due to their smaller size, children may be more susceptible to the effects of venom, and they may experience more-severe envenomation effects than adults. This issue reviews the basic epidemiology and underlying pathophysiology of the bites and stings of spiders, bees and wasps, fire ants, scorpions, snakes, and lizards. Clinical presentations are reviewed, and evidence-based recommendations are provided for management of the envenomated patient. While the pathophysiology and much of the presentation and treatment are similar for both children and adults, there can be subtle differences, which will be highlighted in this review.

First envenomation report of the Cnidarian Physalia physalis in Indonesia.

Despite the high number of victims every year, Physalia physalis's envenomations in Indonesia are scientifically unsounded. This annual event occurred mainly in Java's southern beaches and the Eastern Bali Islands, which are the most tourist destinations. The lack of scientific reports can lead to unaware and uneducated beachgoers resulting in a high number of victims, which in turn may ruin the economic sectors. Thus, this study aimed to report P. physalis's envenomation and its treatments in the southern beaches of the Special Region of Yogyakarta Province. It was based on the 15 beach lifeguards' and the primary health care units' reports in 2019-2020. The envenomation cases varied among beaches and years, whereas the highest number of cases were reported in the most popular beach (Parangtritis beach). The partial beach closing due to the pandemic COVID-19 caused the number of cases in 2020 was slightly lower than that in 2019. The envenomations' general symptoms were oedema and local pain that were treated with 5% food vinegar and hot water, if available. The severe cases (dyspnoea, nausea, vomiting, and cephalgia) were only reported twice in 2019. They were hospitalised in primary health care units; however, many people still practise the traditional non-scientific treatments, particularly in a chaotic situation.

Less-lethal law enforcement weapons: clinical management of associated injuries in the emergency department.

Less-lethal weapons and tactics are being increasingly used by law enforcement to minimize the reliance on more-lethal force. While these methods are designated as "less-lethal," they can cause morbidity and mortality when deployed. Knowledge of these weapons and tactics can help direct the workup and management of patients with injuries from these methods and can protect clinicians from secondary exposure and injuries. This issue reviews the most common less-lethal weapons and tactics used by law enforcement, describes their mechanism of action, and discusses associated common injury patterns. Recommendations are provided for the evaluation and management of these patients in the emergency department.

Diagnosis and Management of Cutaneous Lymphomas Including Cutaneous T-cell Lymphoma.

The cutaneous lymphomas are malignancies of T-cell and B-cell lymphocytes in which the skin is the primary organ of involvement. The cutaneous T-cell lymphomas include variants that can mimic the presentation of common skin diseases or arthropod bites. Mycosis fungoides, the most common cutaneous T-cell lymphoma, usually presents as fixed asymptomatic patches or plaques in sun-protected areas. The cutaneous B-cell lymphomas have fewer variants that often present as papules or nodules that can mimic nonmelanoma skin cancers. Some therapies for cutaneous lymphoma have unique side effects such as central hypothyroidism, hyperlipidemia, and peripheral neuropathy.

Mite bites, comet signs and possible mammary prosthesis rejection after returning to a vacation home: a diagnostic challenge.

Pyemotes ventricosus is a free-living mite feeding on larvae or nymphs of insects, including moths, beetles, wasps and bees, that are usually found in grain, straw and firewood. When present in great number or when its food is lacking, it could accidentally bite mammals, including humans, causing a highly pruritic self-limiting dermatitis, sometimes followed by a lymphangitis known as "comet sign".We present a singular case of mite lymphangitis that surrounds and delimitates breast prosthesis in a 30-year-old Caucasian woman. Other bite in the lower abdomen did not present comet sign. The patient got the infestation in her vacation home in the South of Italy, uninhabited for 10 months since COVID-19 confinement. We hypothesize that the previous surgery made the lymphatic vessels more prone to inflammation and we compare other insect bites that can occur vacationing in a long period uninhabited room.A delayed diagnosis of comet sign implies a retarded fumigation allowing new mite bites and, in this case, extends the patient's preoccupation about the prosthesis rejection.

Rat bite injuries in children: description of a novel classification.

PURPOSE: Rats are common intruders into human settlements. Apart from their role as disease vectors, they can also cause bite injuries. We describe the clinical course of a series of children with rat bites, and characterise the injures. METHODS: A retrospective review of hospital records of children admitted for rat bites in a large regional hospital was undertaken. The demographics, wound characteristics, treatment given and clinical outcome of the patients are described. RESULTS: Fifty-nine children, with a mean age of 3.7 years, were admitted for rat bites. Three distinct types of wounds were treated: superficial scratches (Type I), deeper bites often with infection and ulceration (Type II) and full-thickness with loss of skin or underlying soft tissues (Type III). Few wounds displayed signs of inflammation. Only some Type II injuries required urgent local surgery in the form of drainage and debridement. Type III wounds required a skin graft. All patients recovered. CONCLUSION: We suggest that treatment of rat bites should be based on the wound type. Most patients do not require hospital admission or antibiotic treatment. Treatment should be mostly conservative wound care management. Surgery is only indicated for drainage of pus, debridement, skin graft or rarely reconstruction.

How to identify and treat common bites and stings.

A thorough history and physical are key to proper diagnosis and treatment following a patient's encounter with an insect, arachnid, or other arthropod.

Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes.

Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.

An outbreak of acute hemorrhagic papules on the posterior neck in children during the COVID-19 pandemic.

Within a two-week timespan in April 2020, multiple children presented with hemorrhagic macules, papules, and erosions localized to the posterior neck and occipital scalp. All of these patients were children of health care workers, with at least one confirmed COVID-19 exposure. The unique lesional morphology and the timing of onset led to SARS-CoV-2 antibody testing for all and biopsy of one child. Biopsy ultimately confirmed these lesions were consistent with arthropod bites, which coincided with an unprecedented surge in local populations of Simulium tuberosum, a biting gnat.

Variable Mechanisms of Dog-Related Deaths.

As the literature has tended to focus on injuries and deaths due to active dog attacks, the following review was undertaken to examine the range of circumstances and mechanisms that may be associated with all types of fatal encounters with dogs. A search was undertaken of the literature and the Forensic Science SA, Australia, autopsy database for cases where deaths had been caused by dog-related activity. Only 2 cases were found in the autopsy database over a 15-year period from 2005 to 2019. The first was a 55-year-old man who bled to death from a large degloving dog bite to his forehead exacerbating underlying cardiovascular disease. The second was a 40-year-old previously splenectomized man who died of Capnocytophaga canimorsus sepsis shortly after being bitten by his dog. Dogs may be involved in vehicle crashes if drivers swerve to avoid them or if pedestrians attempt to rescue dogs that have strayed onto roads. In the literature, trauma has also occurred from "non-bite dog-related injuries" where individuals have been pulled over by, or tripped on, dogs. Dogs may also be responsible for specific types of infections such as echinococcosis and C. canimorsus, which may have potentially lethal consequences. Thus, the types of cases of injuries, illnesses, and deaths associated with dogs encountered by pathologists in a forensic context may be extremely diverse and not always straightforward.

Pediatric Hand Infections.

Infections are an important source of morbidity in pediatric hands that come from frequent exposure to mouths and other dangers while exploring the world. Although Staphylococcus aureus is still the most common organism in pediatric hand infections, it is less common than in adults because pediatric patients are more likely to develop mixed aerobic/anaerobic infections or group A Streptococcus pyogenes infection. Pediatric patients with open physes potentially may sustain Seymour fractures of the distal phalanges that may become infected and sources for osteomyelitis if not recognized early.

Avian mite bites acquired from pigeons: Report of three cases and review of the literature.

BACKGROUND: Skin lesions caused by avian mite bites are uncommon and often misdiagnosed. They are usually caused by bites from avian mites that have infested domestic poultry or birds nesting in or near human habitation. We report three cases of human skin lesions from avian mites infesting pigeons. OBSERVATIONS: Three persons working in the same place developed similar skin pruritic papules simultaneously. The diagnosis remained unknown until Dermanyssus gallinae (chicken mite) was found on the computer's table of the three individuals workplace, situated near a window where pigeons used to live. Antihistaminic treatment was carried out with a skin disinfestation. In two cases, symptoms resolved after one week of treatment. In the third case, corticosteroids were needed. CONCLUSIONS: Avian mite bites skin lesions can remain unrecognized or misdiagnosed. Inquiry about contact with pigeons or poultry may be helpful in patients with nonspecific skin lesions.

Algunos aspectos clínicos y epidemiológicos relacionados con mordeduras de perro en niños / Some clinical and epidemiological aspects related to dog bites in children

Introducción: Las mordeduras de perro afectan fundamentalmente a pacientes en la edad pediátrica, estas engendran peligros como secuelas estéticas y la posibilidad implícita de transmisibilidad del virus de la rabia a seres humanos. Objetivo: caracterizar el comportamiento clínico-epidemiológico de las mordeduras de perro en niños. Métodos: Se realizó un estudio observacional, longitudinal y prospectivo en pacientes con diagnóstico de mordedura de perro con necesidad de inmunización pasiva y activa, ingresados en el Servicio de Miscelánea del Hospital Infantil Sur Antonio María Béguez César de Santiago de Cuba, del 1ro de enero de 2017 al 31 de diciembre de 2018. Resultados: En los pacientes incluidos en el estudio predominaron los del sexo masculino (57,7 por ciento), los grupos de edades de 1 a 5 años 11 meses y 29 días, y de 6 a 10 años 11 meses y 29 días fueron los de mayor incidencia. Aunque no existió asociación estadística entre la localización anatómica de las lesiones y la edad, fueron las de miembros inferiores las más frecuentes en todas las edades con 63 pacientes (40,4 por ciento); destacándose como complicaciones la celulitis, las lesiones óseas y las secuelas estéticas; ningún niño presentó infección rábica. En el 50 por ciento de los casos la mordedura ocurrió en el horario nocturno y los perros de otro domicilio causaron la mayor parte de las agresiones. Conclusiones: El diagnóstico de mordeduras de perro se realizó con mayor frecuencia en niños del sexo masculino de uno y más años, en el horario nocturno y la principal complicación fue la celulitis(AU)

Introduction: Dog bites mainly affect patients in pediatric ages. They pose dangers such as esthetic sequels and the implicit possibility of transmission of the rabies virus to human beings. Objective: Characterize the clinical-epidemiological behavior of dog bites in children. Methods: An observational longitudinal prospective study was conducted of patients diagnosed with dog bite requiring passive and active immunization admitted to the Miscellany Service of Antonio María Béguez César South Children's Hospital in Santiago de Cuba from 1 January 2017 to 31 December 2018. Results: Among the patients included in the study there was a predominance of the male sex (57.7 percent). The age groups 1 to 5 years 11 months and 29 days and 6 to 10 years 11 months and 29 days showed the greatest incidence. Though no statistical association was found between anatomical location of the injuries and age, bites on the lower limbs were the most common at all ages with 63 patients (40.4 percent). Outstanding complications were cellulitis, bone lesions and esthetic sequels. No child had rabies infection. In 50 percent of the cases the bite occurred in the night hours. Most of the attacks were performed by dogs from other households. Conclusions: Dog bite diagnosis was more common among male children aged one year and over. Most bites occurred in the night hours. The main complication was cellulitis(AU)