UC Irvine

Western Journal of Emergency Medicine: Integrating Emergency

Care with Population Health

Title
Cellulitis From Insect Bites: A Case Series

Permalink
https://escholarship.org/uc/item/45k424gt

Journal
Western Journal of Emergency Medicine: Integrating Emergency Care with Population
Health, 4(2)

ISSN
1936-9018

Authors
Derlet, Robert W
Richards, John R

Publication Date
2003-01-01

Peer reviewed

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University of California

Cellulitis From Insect Bites:
A Case Series
Robert W. Derlet, IMD and John R.Riclmards, PdD
Di17ision of Emergency ii&e&che
University sf California, Davis School of Medicine
Sac~amem,California
EITKRODU L i XphbN
--Tp
Ce13~Iitisis arc acute mfechon ofthe skin that is corn--
manly seen ira emergency dcpafiments (EDs) T h e
~nfeckonresdsfiom ~ ~ O C U~Foacteia J ~ O I ~through
one sfmany mems inc1uhg a breaicdown i~b5e skin
Smier 60rn En abrasion, lace-mtioa,pm~ctuu-ev ~ o u ~ d , ,me #2.8.16B year-old male was stung by a bee on
cycle at high speed. Pain, erythema, and wamth
developed within a few minutes of the sting. He
cleaned the womd with Betadine solutionwithin 30
minutes. There was complete resolution of all s p p -
t o m w i h eight hours. Twenty-four hours later new
erythema was noted which spread rapidly Forty-
eight hours aAer the st.kng4a B O cm diameter area of
tender?slightly raised plaqce of e w e m a developed.
The patient was subsequentjy evaluated by one ofthe
xothors, 3%-epatient's vital s i p s were asfollows: blood
pesswe 130/80~ rHg, n pulse 100beats per minxte,
temperahe 37.5"6, and respiratory rate 1G breaths
per minute. Ee was prescribed c e h o ~ axetil e one
gym by ~noufi QHD for the fkst day followed by 580
mg by mouth QhD for an additional six days. The
infection stopped spreadasg within six hours of the
%st dose of antibisti~s.Xesslution sf the cellulitis
occas~edafter five days,
fl

c ~ s kjwj?
h orb3~x-n~ Hn addition, okigoiag infection (he Baterai aspect of the lefi lower leg just below the
horn abscesseb, ulce~s,and folliculitis may ~p!!ead The patien: $el: a sharp sting and had been
be3ond a self-ii~mitedcapsule to s.x?,-oucd-ngsk.1n a,n~~eno~a";ed by the ~ i m ehe bmshed *taway Be
2c~uteelya~tdrapidly. In some cases, no insxle to the c,eas;ed h e wsw~dwith soap and water 1hediate1y
skin or ~ I S S U Gca.3 be idenkified and gie has been hy- x7e1;he sing.The initial erythema and pain at the
r,--Lhesized that 53~0s"-borne b a ~ t e ~2i-a1 2 sree
~ g {$solvedcompletelyw l i h 1% hours. Foil-
sub- s ~ k site
c~~hneous tissue resu1tPag incell~ihks.~ eigkt holm a f t e ~the sting he developed pain and
e;-s,'C~ema~tthe sitee.The patlent presented for evalaa-
$,el%n14tis, as a result of an insect bite, hzs been de- atmn faux days zfier Lhe sting. The patient9sv?a1 signs
sc~ibedand may initially be c o ~ h s e \with d an early 3% presentaZaon to the ED were as follows: blood
allergic reaction to the insect sfing or The f01- :%zessmeof 173196m m Bg, pulse 79 beats per
lowing swen cases were treated by the authors dm- Tespiratoqrate B 6 breaths per minute, and tempera-
k g the summer of 200%.They axe presented to illvs- mre %'@~ On examination, he had an area of
hate the associatisir.;between insect bites and eelluli- a-ythema9edemz, and tenderness approximately 5
tis and to a k d providers lo the possibility of mist&- by 5 crn around the bite snte. Re "sad full range of
ing a2 acute localized allergic reac~ionwithce1Iulitis ~ao'sionaf his knee and no inguinal nodes. Be was
treated wth one gram s f cefazolin hkavenously and
GASES <ischargedhome with a prescip~onfix cefalexh 500
P7iae cases described below are slmmarized in 'ifable mg by mouth QID for one week. Complete resolu-
#I. tion occw~edat day seven.

Case +i3A A52 yea-old male was stung by a bee on
the le!? anterior f l g h while riding a road bike. The
bee sting was witnessed and occurred through
&h,eightly-firdng bike shork. The patient was unable
to bmsh offthe bee for fear of losing conk01 of his bi-
Case #3: A 20 year-old male was stung by a bee on
the lateral aspect offhe right Bower leg. Be devel-
oped erythema and pain ediately around the sting
site, which then resolved. TwenQ-fow hours later he
developed new ewhema mdpain, and on day thee
 -- - . -- -
presented to the ED for evaluation. His vital signs $When he was called back for re-examination ~t day
were as follows: blood pressure 124156 Hg, five, there was coraplete resoi~tionof symptornsS
pulse 93 beats per te, resphatov rate 14breaths
per minute, md temperame 36.go@. At that time he Case #6:A 47year-old male was $&en on the light
was found to have a 4 by 5 cm red area ofcellulitis hand by a spider vvhile w m h g outdoors. Be devel-
that was tender to palpation. There was no inmhal ~ p e initial
d pain and erythema wkeh he stated nearly
lymphadenopathy~He was given a loading dose of completely resolved. However, 24 hours after his
cefaaolin, one gram intravenousl6gr,then prescribed sting, he noted pain inthe !v~nd.f i e pain progressed,
cephalexh 500 mg orally QIID. He vvas called thee and the erythema invoking the entire dorsW GFEQ~
days later and stated he had 90% resolution of s i p s hand. We presented to a physic~anand was started
and symptoms. He was lost to follow-up thereafter. on amoxici18in-cla\rfiIanate 500 mg by mouth TID.
Despite this reghen, the erythema, edema, and pain
Case #4: A 52 year-old male was stung by a bee on of his hand increased, and he developed a 2 crn di-
h e right ankle while doing g m d e h g work. &&ou@ ameter abscess. He presented to the ED six days
the patient could not precisely recall times, the initial after his sting. The patient's vital signs on presenta-
pain and erythema resolved. The next day he had tion to the ED were as follows: blood pressure H 241
increased edema and eqthema, w~hichprogressed Hg, pulse 102 beats per minute, respiratory
proximally &-omthe ankle to the lower leg. FVhen he rate 14 breaths pef minute, and temperabuse 38°C.
presented to the ED his blood pressure was B22/8 1 A hand sewice consultation was oStained, and the
rnm Mg,pulse was 88 beats per minute, and tern- patie~~t was started on cefaolin inkavenously. Tne
perahre was 38°C. Be had an ecchyr~oticarea 3 abscess was incised a d &med s3-1the operating :ooixaa.
crn indiameter x o w d the site, with edema e k e n h g The wound culture showed no growth. He was ad-
to the lateral d d e . Erythema extended 20 cm proxi- m9tted to the haaid s e ~ ~ ifor
c ehvo days and treated
mal to a level just below the h e e . Because the hos- with i$tiravenauseefazolin and discharged on oral
pital was filled and no beds were available, he was cephalexin. Fis symptoms resolved ten days after
obsewed in the ED for 118 hours which time he ED presentation $16 days after bite)
received three doses of hedenom cefmhn one p m
each. He improved over this time period and was Case #7:A 37 year-old male was gardening at dusk
discbarged on clindamycin 600 mg BID orally and and bitten by a ~ o s c p i t oon the Lateral asp~ctsf the
had complete resolution of his s y ~ p t o ~ m bys day upper right arm. There was immediate edema and
seven. erfiqem, folHovredby intensepmitis a.t the sateaThese
symptoms subsided later that evening, but returned
Case #5: A 39 year-old wale was bitten by a spider the following day. The patient denied cleaning the
vvPi%eeating. He felt a s h p sting mdemea& the table wound or applying topical antibacterial or steroid
and pulled back to find a spider scampei-angoff his creams after the bite. At day thee he developed an
leg. He develop& initial locd e m e ~ nxa ~ d v?hich
p ~ ulceration at the bite site with ircreased pain, edexz,
he said resolved by the next m o ~ gTho 0 days afier eq$herna and he presented to the ED- His v;(raH
being bitten, he developed increased pxh and edema signs were as fo~hws:ternp5raku-e37. &"C, p ~ i s 64
e
which persisted. On day t h e e he presented to the beats per minute, respiratory rats 12 breaths per
ED. His vital signs were as follows: blood pressure ninute, and blood pressme 12467rnx Eg.Exami-
Hg, pulse 83 beats per minute, respira- nation of the worn$ revealed a 2 by 2 cm ulceration
tions 16 breaths per minute, m d temperame 36.5"C. wlth S-moundingerythema, and an obvious "honey
On physical exmination he had a 6 by 18cm area sf crust9' a&here~tfilma The w o ~ a was d clear sed vdifl-~
eryfllerna on his left upper thgh. He had left ing~inai Betadine a d peroxide so;ntions, then aggessavely
Ipphadenopafiy but good m g e ofmotion of his hip deb~dedwit91 a 80-blade scalpel. Bacikacin oktrflea-it
joint He was given a prescription for cephalexin 500 was applied with a large occlusive &+essing.The pa-
rng by mouth QIiD for seven days and discharged. tient w* started on cephde~&500mg by r n ~ ~QD ~th
 - - Page 29
for seven days for treatment of presumptive grarn- The microorgmisms responsible for cee%lulitis in our
positive ceilulitis with secondary impetigo. On foi- seven cases were not identified. Fasl.bLhemore,and
lo~w-up the pat;ent reported the v~oundhealed slowly, most hpomt8gi, it 1s
i~ritllcomplete ~sesoieataor~ after ten days. developed as a result of inoculation of preexisting
bacteria on the s h n info the wound or as a result of
DISCUSSION exogenous bacteria inoculated into the wound from
Stings m.d erdenomatim by insects commordy result an insect that sewed either as a reservoir or vector
in a localized a%lergicreaction cl~aacierizedby pa&? for ppathogenic bacteria. In oae published case a pa-
rqdhema, pwitis and, insome eases, ecchj~mosisa ~ d tient developed ATocardia bmsl'kiensdsas a result of
eden-a."ien these patients present acutely fo injection of the bacteria by the insect &sk5 Other
- ~

the ED, e diagnosis of awte allergic reaction mgy be stud~essuggest that pafhoge~icbacteria may be h a -
nade and patients afe comimonly treated with a ~ d - bored Sj7 insects. Insects have been described as
b j ~ t a ~ b n eisn. severe czses, pale::ts v d h systawic c a ~ ~ - - ai nn~~rnber
g of bacteria including Salmone%la,
.~ ~

& q $ c rezc$iox?&may also receive sieroids, &DC EI bfe Shigebja,a d E ~ - ~ o k iE-coli

. ~ J has i nfact been rarely
flrlreatakg sj.pdz~aa reported to cause cell~lids.~ Evans eta%report a case
of coimpwLmentsyndrome as a complic8tion of cellu-
Lq 290se p&ier;ts who susta;n irfiei;"bikes, by,a.t PTSS& Bitis due to sn insect bite."
to the ED ~ q e n q - f~~O~L~ ~r S ,t9i& bhe the &if&;'-
~ *
el~tia!diagi'3s;s sii.,iydMdzeexna~.&d~
Z- These g&ents M ~ s cellulitls
e seep hthe ED is attributed to an i~fec-
~, --
:coubz be , ~ ~ g cs.~q ~ ejc&&ed,
~ e n ~%.~cd,li~ed
~ ~ allzgic
a

rlon from Streptococcal group A or Staphylococctls

reac;aon
),
31cs& be dex~&nifig 2~-1 kLfa_&or1see~nd- species, althou&.ofner bactena kcl~dmgPafarella,
alqj the stingibi"? or both. "When p a t 8 . n ~are ~ &- V?brio A~pzciesy Eikenella csrrodens are known to
v,,cp~ng ee88.~litj.s
--p,i ~ as a result of a bite, ";hey maji mis- cause celia_~l~tis.','~-'~Six of the seven patients we re-
,-
,xJcedy be &iagnosedoldy as havkg XPLsllergrc reac- or^ h e x responded well t s inhaB treatment with a
~

tion and therefore risk progressio~.ofinfecki~nto a rsecond-generation cephalasporin, All cases

first- o
more szj5o.;:s lel~e!. h this case sefics, the patients all except one case liere managed as ou$atients. The
had con~pletceor nex-complete resolction of"ke3.r al- one patient who faded outpatient treatment had re-
lergic sy3"ipeamsprior "iddevelopiag sigis symp- celve6 amoicillh-~IavuBanatefor thee days. From
.
-t o n s of cell?;.$".,is.Tae asso@i~.fion
A- of insect an$ a t empi;ic microbiologsc standpoint,this was an ac-
celly.i;~shas beep previously descrjbed. Lq ace reeo-
7 .

aq"&b!e regifi~en,and ~tis unclear why outpatient

spective case series, 5% ofp%tientsdiagnosed with bxtment faded. M ~ o u &multiple agents can be used
celh~,Iitishad axassociated z"mopod bite.?However, to &at cellulitis hcludng flomoq~o1ones, macrobdes
the exact type of insectwas not described. md clhdarnycin9the majority of patients who receive
ED treatment generally receive a first-generation

9YSEtrn c~wick& bQ=xomz O W C O m @ o s t ED visiq

Bee E thigh 10 cm diameter C e h o x i n ~ aetil
e PO Resolution in 5 days
Bee L lower leg 5 cn-Idiameter Cefzolin (in ED)Cephaiexin PO Resolution 7 days
3ee R lower leg 4-5 x 4 cm Cefazolin IV (in ED)Cephalexin 90% resolution 3 days
Bee R an!&;: to R kqee Cefaolk Hsb (in ED)Clia&mycin PO Resolution 4-7 days
Spndey ,:"iighb:: 30cm Cephadexin PO Resolution 5 days
iT nalld \%iristjsinr Alnoxiciilin-cPavi~1anatePO(failed
Spplder
(

Abscess fonned day 3;

nitiaE outpatient k)Cefazolin IV I&D/admit, Resolved day 16
(admitted)CephaIexin PO (Discharge)
R a~-a%z
2cm ulcrer Cephaiexin PO Bacitracin topical Resoiution day 10
cephalo~porin.~.'~,'~ T h s was true in our case series.
Has the authors' expefience, some ~crobiologistsand
infectious disease experts argue that o q a ~ e therapy
~d
with oral cefalexin is a poor choice because of tl-ne
low absoytion rate horn the gas&ohtestirPaBtract and
higher minimum id~ibitoayconcentrations (MIC)
needed to k19 or &bit bacterial gomh compared to
other antibiotics, However, in the authors9experi-
ence and per discussions with nmerous emergency
physicians nationally, cephalexia-ahas been success-
fully used in the primary &eah~e% most co
kdec~om~
CONCLUSION
sumnaa%.,we have presented seven cases of celu-
litis associated with ~nssectbites. Emergency physi-
cians xust be careful to differentiate behieen a con-
h ~ locaked
g allergic reaction and the developn~ent
of infectionby a bacterial agent*INe could not deter-
mine ifthe insects sewed as vectors ofthe pathogenic
bacterial agent or whether the agent was present on
the s k n tissue prior to the bite.
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