Envenomations Caused by Animals: A Dermatologic Guide to Clinical Recognition and Treatment 3031350839, 9783031350832

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Envenomations Caused by Animals A Dermatologic Guide to Clinical Recognition and Treatment Vidal Haddad Jr.

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Envenomations Caused by Animals

Vidal Haddad Jr.

Envenomations Caused by Animals A Dermatologic Guide to Clinical Recognition and Treatment

Vidal Haddad Jr. Department of Infectology and Dermatology Botucatu Medical School, São Paulo State University Botucatu, São Paulo, Brazil

ISBN 978-3-031-35083-2    ISBN 978-3-031-35084-9 (eBook) https://doi.org/10.1007/978-3-031-35084-9 The translation was done with the help of artificial intelligence (machine translation by the service DeepL.com). A subsequent human revision was done primarily in terms of content. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Dedicated to Lorenzo and Ariadne gifts that the life has given me.

Preface

This book is the result of decades of studies and research, combining the knowledge of Dermatology with Zoology and with the specific study of venomous animals. The author has been interested in the subject for a long time, and he was encouraged by us in his childhood, which made him acquire the training of a biologist and physician, a fundamental condition for the realization of the work. From small insects to snakes, envenomations cause repercussions on human skin. Knowing the signs and symptoms of these is knowing how to identify and medicate these diseases. We hope that the book will be useful for dermatologists and for anyone interested in the subject, since the Man is increasingly approaching forests and aquatic environments, increasing the chance of interaction with these animals and accidents. We also hope that our effort has been worthwhile, originating a person with a dignified role in society and in the scientific environment. We regret not being around to see it more, but we are happy where we are now. São Paulo, Brazil Vidal Haddad Maria Stella Teixeira Haddad

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Acknowledgments

Dr. João Luiz Costa Cardoso To my brothers William and Cristiane, my brothers-in-law Margareth and Paulo Cezar, and to my nephews. To Adriana Mendes Dr. Neuza Lima Dillon, in memoriam, and colleagues of the Department of Dermatology, FMB-UNESP. Manoel Francisco de Campos Neto, MD

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Contents

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Introduction������������������������������������������������������������������������������������������������   1 1.1 Venomous and Poisonous Animals ����������������������������������������������������   2 References����������������������������������������������������������������������������������������������������   2

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Skin Lesions Caused by Contact with Poisons����������������������������������������   3 2.1 Coleoptera (Beetles)����������������������������������������������������������������������������   3 2.2 Millipedes��������������������������������������������������������������������������������������������   6 2.3 Stink Bugs ������������������������������������������������������������������������������������������   9 References����������������������������������������������������������������������������������������������������  10

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Skin Lesions Caused by Venom Inoculations������������������������������������������  13 3.1 Ants ����������������������������������������������������������������������������������������������������  13 3.2 Bees and Wasps ����������������������������������������������������������������������������������  18 3.3 Moths and Caterpillars������������������������������������������������������������������������  20 3.4 Centipedes (Chilopoda)����������������������������������������������������������������������  25 3.5 Spiders������������������������������������������������������������������������������������������������  26 3.6 Scorpions��������������������������������������������������������������������������������������������  33 3.7 Belastomatidae (Giant Water Bugs)����������������������������������������������������  35 3.8 Coleoptera (Beetles)����������������������������������������������������������������������������  36 3.9 Cnidarians (Jellyfish, Portuguese Man of’ War, Corals, Anemones)������������������������������������������������������������������������������������������  38 3.10 Echinoderms (Sea Urchins)����������������������������������������������������������������  44 3.11 Venomous Fish������������������������������������������������������������������������������������  47 3.12 Venomous Snakes��������������������������������������������������������������������������������  53 References����������������������������������������������������������������������������������������������������  59

Conclusions��������������������������������������������������������������������������������������������������������  63 References����������������������������������������������������������������������������������������������������  63 Index��������������������������������������������������������������������������������������������������������������������  71

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Chapter 1

Introduction

The toxicology studies the venoms overall, including inorganic substances, while the toxinology studies poisons and venoms of living beings. Poisons and venoms are different concepts: venomous animals do not have devices to inoculate toxins (tree frogs, pufferfish, some beetles) while venomous animals inoculate their toxins through stingers, fangs, and other structures (snakes, spiders). The venoms and poisons are most often mixtures composed of various toxins. An envenomation happens when venoms or poisons act on a victim’s organs and systems, causing damage to health. Dermatology is the medical specialty that studies the manifestations of diseases in the human skin. Among other conditions that cause dermatological diseases, injuries caused by venomous and poisonous animals are not uncommon in the daily work of the dermatologists. The causative organisms range from small arthropods that cause discrete manifestations on the skin to extensive skin necrosis caused by spiders, snakes, and some fish. In between these extremes, there are many clinical presentations that are always evaluated by dermatologists after the acute emergency phase. If the animal is not identified, the diagnosis becomes clinical, especially days after the envenomation and in injuries that occur in children. An immense variety of animals can cause envenomations, such as beetles, caterpillars, spiders, scorpions, jellyfish, Portuguese man-o’war, sea urchins, fish, snakes, and others. Most injuries have expressions on the human skin, with their own characteristics. The knowledge about these allows the diagnosis and treatment to be performed by dermatologists. This work reflects the author’s 30 years of experience on the theme, with extensive iconographic material and texts based on works already published in dermatological and Tropical Medicine Journals.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Haddad Jr., Envenomations Caused by Animals, https://doi.org/10.1007/978-3-031-35084-9_1

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1.1 Venomous and Poisonous Animals The lesions with dermatological expression caused by venomous and poisonous animals can be classified into two types: skin surface and by inoculation. Skin surface lesions result from superficial contact with irritating substances, with crushing or pressure on the so-called poisonous animals, while inoculation lesions arise when the venom is injected into the victim, which can cause cutaneous necrosis of varying degrees and involvement of several organs and systems. The second group causes the most serious envenomations, due to the characteristic of deep inoculation of the toxins. Venomous animals fall into the second group, presenting complex venom injection apparatus, as seen in arthropods and vertebrates such as reptiles and fish [1–5].

References 1. Ministério da Saúde. Manual de diagnóstico e tratamento de acidentes por animais peçonhentos (Guideline of diagnosis and treatment of envenomations caused by animals). BRASIL, Health Ministry. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 1997. Portuguese 2. Haddad V Jr, Cardoso JLC. Dermatoses provocadas por animais venenosos (dermatosis caused by venomous animals). An Bras Dermatol. 1999;74:441–7. 3. Haddad V Jr. Tropical dermatology: venomous arthropods and human skin part I. J Am Acad Dermatol. 2012;67:331.e1–331.e14. 4. Haddad V Jr, Cardoso JLC, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin part II. J Am Acad Dermatol. 2012;67:347.e1–9. 5. Haddad V Jr, Amorim PCH, Haddad WT Jr, Cardoso JLC. Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries. Rev Soc Bras Med Trop. 2015;48:650–7.

Chapter 2

Skin Lesions Caused by Contact with Poisons

2.1 Coleoptera (Beetles) Some beetle can produce vesicant substances that cause inflammatory reactions in human skin (Figs. 2.1 and 2.2). The vesicant and aphrodisiac properties of cantharidin have been known for a long time, extracted from the hemolymph of some beetles of the Lytta and Epicauta genera (Meloidae family) and used in Dermatology as rubefacients and in Veterinary Medicine as a stimulant for animal reproduction. The genus Lytta or “Spanish Fly” has a long history of human injuries and medical uses, mainly in Europe [1–8]. Pederin, obtained from beetles of the genus Paederus, has the same skin irritant properties as cantharidin, but causing greater skin inflammation than cantharidin. The pederin, among other toxins, is the most active component of the venom. It is a crystalline, caustic and vesicant amide capable of blocking mitosis by acting on cellular DNA [6–8]. The initial description of the envenomation by Paederus beetles was made by Pirajá da Silva in Bahia (Brazil) in 1912 [7]. We must keep in mind that injuries by vesicants beetles can happen in all tropical and subtropical regions of the planet. Fig. 2.1  Paederus sp., the “potó.” This genus is associated with injuries in humans around the world. Photo: Vidal Haddad Junior

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Haddad Jr., Envenomations Caused by Animals, https://doi.org/10.1007/978-3-031-35084-9_2

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Fig. 2.2  Beetles from the Meloidae family produce cantharidin, which was once a dermatological drug (in the image, the species Epicauta sp.). Photo: Vidal Haddad Junior

Fig. 2.3  An injury by Paederus sp. with the presence of vesicles and crusts. Photo: Vidal Haddad Junior

Cantharidin or pederin discharge occurs when the victim crushes or pressure the coleopteran against the skin, usually on the cervical region. However, any exposed area can be compromised [6–8]. After the contact of the arthropod’s hemolymph with the human skin, burning, erythema, and edema appear, which evolve to the formation of vesicles and sterile pustules, resulting from the neutrophil diapedesis to the site by the action of toxins. Subsequently, exulceration and crusts occur (Figs. 2.3 and 2.4). Secondary bacterial infections and eczema are very common, complicating the injury. Multiple contacts mostly happen in places with single light sources, such as tents and streetlamps in isolated spots. According to the extent of the condition and number of lesions, systemic phenomena such as nausea, vomiting, and fever may occur [7].

2.1 Coleoptera (Beetles)

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Fig. 2.4  The “kiss sign” occurs in the envenomations by vesicant beetles when one surface touches other in body folds. Photo: Vidal Haddad Junior

A typical coleopteran injury presents as an acute dermatitis consisting of initial edema, erythema, and burning, followed by vesicles, blisters, and pustules, with a bizarre and linear distribution of lesions, mostly located in exposed areas of the body. The differential diagnosis of lesions caused by beetles is made with phytophotomelanosis, which also presents vesicles, erythema, burning, and a bizarre distribution of lesions; with contact dermatitis by sensitization, especially in the cervical region (perfumes and other cosmetic substances), with pellagra, which can be manifested by cervical lesions with vesicles, blisters, and exulcerations, and with bullous autoimmune diseases [3, 5, 7]. Histopathological examinations of skin lesions caused by Paederus, Epicauta, or Lytta show the formation of blisters inside the epidermis permeated by necrosis. There may be acanthosis and even acantholysis, which can confuse the disease with autoimmune bullous diseases [7]. The treatment of an injury by vesicant beetle depends on when the lesions occurred. In the initial stages, it is possible that the rigorous asepsis of the place with water and soap removes the toxins. When inflammation appear, asepsis is still important, but the use of topical corticosteroids is recommended, with special attention to the development of secondary bacterial infections, when topical or systemic antibiotics are necessary [1–8].

Box 1 Patient living in a tropical area with the appearance of an erythematous plaque, vesicles, pustules, and crusts in the left cervical region approximately 48 h before the observation. He reported staying outdoors under an electric light pole and irritation after “slapping a insect.”

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Photo: Vidal Haddad Junior

2.2 Millipedes Millipedes are arthropods capable of ejecting irritants substances from a distance, although most species only release bodily toxins when crushed or heavily compressed. These arthropods have an elongated and segmented body, with two pairs of legs on each segment and curl up when disturbed (Fig. 2.5). When compressed, they can release quinones and other substances that cause significant inflammation in the human skin, with erythema, edema, and sometimes, skin vesiculation. After approximately 24 h, the pigmentation appears, giving rise to violet, brownish, or blackened hyperchromic macules at the point of contact, usually the feet and especially the toes (Figs. 2.6 and 2.7). This happens because these animals look for dark places to

2.2 Millipedes

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Fig. 2.5  A Millipede in locomotion position and in defensive position (curled up). Photo: Vidal Haddad Junior

Fig. 2.6 Brown pigmentation on the toes after an injury by Millipede. The foots are commonly affected, as the animal takes refuge in shoes. Photo: Vidal Haddad Junior

take refuge and with that they penetrate shoes, being crushed by the victim’s foot. In middle-aged and elderly individuals, pigmentation mimics arterial insufficiency and necrosis of the extremities, causing great concern in emergency centers. [1–5, 9–12] The histopathological examination is nonspecific, showing inflammatory cells early in the process and dark pigmentation in the chronic phases of envenomation. In the early stages, it is considered that the application of ether can dissolve toxins in contact with the skin. However, the injury is rarely noticed by the victim, who crushes small animals against the shoes and does not present significant symptoms after the initial contact. The envenomation is perceived by the inflammation and hyperchromic macules and after the inflammatory phase, which is rapid and can be controlled with topical corticosteroids, only the macules will remain (resulting from the infiltration and action of quinones in the skin), which will spontaneously disappear after a few weeks [9–12].

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Fig. 2.7  Typical lesions caused by Millipedes. Attention to the differential diagnosis with peripheral arterial obstruction and necrosis of the extremities (pulses are palpable, the temperature is normal and the blood flow is normal). Photo: Vidal Haddad Junior

Box 2 Typical case: A 23-year-old male patient presented with violet/blackened macules on his toes after finding a bug crushed in his boot in a hotel in a coastal town.

Photo: Vidal Haddad Junior

2.3 Stink Bugs

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2.3 Stink Bugs Hemipteran insects of the Pentatomidae family (stink bugs) produce irritating and unpleasant-smelling substances to protect themselves from predators. In contact with human skin, these toxins can cause manifestations similar to those observed in vesicants beetles envenomations [1–5, 10, 13]. These insects are common all over the planet, with the exception of the polar zones (Fig. 2.8), but only recently have they been described as poisonous animals capable of injuring the human skin. Most envenomations happen by crushing the animal against the victim’s body [13]. Little is known about the composition of this poison, but the dermatitis that originates from contact is quite similar to those caused by pederin and cantharidin (Fig. 2.9), including similarities in the histopathological examination. Treatment is also similar, using corticosteroid creams or ointments and, if necessary, topical antibiotics to control secondary bacterial infections.

Fig. 2.8  There are several species of stink bugs with many variations of colors and shapes. Photos: Vidal Haddad Junior

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Fig. 2.9 Pentatomidae poisonings occur in exposed areas, especially on the skin of the cervical region. Photos: Vidal Haddad Junior

Box 3 Typical case: Male patient, 42 years old, with the appearance of erythematous plaques and burning sensation in the cervical region the day before, which appeared after contact with an insect, which was brought by the victim to the consultation.

Photo: Vidal Haddad Junior

References 1. Ministério da Saúde. Manual de diagnóstico e tratamento de acidentes por animais peçonhentos (Guideline of diagnosis and treatment of envenomations caused by animals). BRASIL, Health Ministry. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 1997. Portuguese

References

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2. Haddad V Jr, JLC C. Dermatoses provocadas por animais venenosos (Dermatosis caused by venomous animals). An Bras Dermatol. 1999;74:441–7. 3. Haddad V Jr, JLC C, Lupi O, Tyring SK.  Tropical dermatology: venomous arthropods and human skin. J Am Acad Dermatol. 2012;67:331.e1–331.e14. 4. Haddad V Jr, JLC C, Lupi O, Tyring SK.  Tropical dermatology: venomous arthropods and human skin part II. J Am Acad Dermatol. 2012;67:347.e1–9. 5. Haddad V Jr, PCH A, Haddad WT Jr, JLC C. Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries. Rev Soc Bras Med Trop. 2015;48:650–7. 6. MJN D. Dermatite de contato pela pederina, estudo clínico e epidemiológico no Estado do Ceará, Brasil (Pederin contact dermatitis, clinical and epidemiological study in the State of Ceará, Brazil). Rev Inst Med Trop. 1994;36:59–65. 7. JLC C, Haddad V Jr. Acidentes por Coleópteros vesicantes e outros artrópodos (Injuries caused by vesicant coleoptera and other arthropoda). In: JLC C, FOS F, Wen FH, CMS M, Haddad Jr V, editors. Animais peçonhentos no Brasil: biologia, clínica e terapêutica dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). 2nd ed. São Paulo: Editora Sarvier; 2009. 8. Haddad V Jr. “Sign of the kiss” in dermatitis caused by vesicant beetles (“potós” or Paederus sp.). An Bras Dermatol. 2014;89(6):996–7. 9. Haddad V Jr, JLC C, Rotta O, Eterovic A. Acidentes provocados por Millipede com manifestações dermatológicas: relatos de dois casos. An Bras Dermatol. 2000;75:471–4. 10. JLC C, Haddad V Jr. Acidentes por Coleópteros vesicantes e outros artrópodos (Injuries caused by vesicant coleoptera and other arthropoda). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. 11. CAJ L, Talhari S, Haddad V Jr. Exogenous pigmentation in toes feigning ischemia of the extremities: a diagnostic challenge brought by arthropods of the Diplopoda class (“millipedes”). An Bras Dermatol. 2010;85:391–2. 12. Haddad V Jr, Manço DG. An unusual dark macular lesion in the plantar region of a child. Rev Soc Bras Med Trop. 2019;52:e20190011. 13. Haddad V Jr, Cardoso JL, Moraes RHP. Skin lesions caused by insects of the order Hemiptera (Pentatomidae): first report of accidents in humans. Wilderness Environ Med. 2002;13:48–50.

Chapter 3

Skin Lesions Caused by Venom Inoculations

3.1 Ants The human interest in the capacity of the ants to cause envenomations and allergy in humans is very old, due to the constant presence of these arthropods in domestic and rural environments. In 1917, Roquette Pinto studied in Brazil the true tocandiras or bullet ants, the Paraponera clavata. The abdominal stinger of these ants injects a potent venom, which causes intense pain, local erythema, and systemic symptoms such as fever, malaise, nausea, and vomiting (Fig. 3.1) [1, 2]. These ants are used in the adult rites of passage of the Sateré-Mawé Indians, in the Amazon, where young Indians have to put their hand in special gloves where dozens of ants are placed so that their resistance to pain can be seen [1]. Fig. 3.1 Tocandira (Paraponera clavata). The stings of these ants cause serious envenomations, due to the intense pain. Photo: Vidal Haddad Junior

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Haddad Jr., Envenomations Caused by Animals, https://doi.org/10.1007/978-3-031-35084-9_3

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Roquette Pinto’s original description said: “At the point of the bite, a whitish stain forms, shortly afterwards emaciated, painful to the extreme. The pain, deep, progressively invades the entire limb, about 12  h later, it reaches its maximum degree and remains so, colossal, for 24–48  h. Adenitis appears, the victim turns pale, the heart rate rises to 100 beats per min, the armpit temperature always rises to 37.5–38 °C. Chills and vomiting appear. The pain subsides within 24–48 h.” There are other ants that the sting causes violent pain and local inflammation similar to those caused by tocandiras, as the bull ants (Myrmecia spp.), found in Oceania [1]. The most important ants for dermatology, however, are the small red fire ants, belonging to the Solenopsis invicta species (Fig. 3.2) called red imported fire ants, these are originally from Brazil and are now found in several countries, becoming a pest in the USA when they are introduced in cargo from Brazil in sea and river ports [3–10]. The fire ant is aggressive and attacks in large numbers whoever approaches the anthill (Figs. 3.3 and 3.4). The sting occurs by means of an abdominal stinger, and the ant attaches itself with the jaws on the skin and rotates the body stinging, applying about 10 stings in a circle, if not removed [9]. The venom of this species is composed of alkaloids (originating from plant extracts), which is different from most other animal venoms, which are composed of protein material. Solenopsin A is the component of the venom that has a cytotoxic effect and causes mast cell degranulation. There are also non-toxic proteins that can trigger allergic reactions, including anaphylactic shock [10]. Initially, a wheal appears at the site (Fig. 3.5) and, approximately 24 h later, sterile pustules form, which soon give rise to exulcerations (Fig. 3.6). Therefore, urticarial papules or a sudden pustulosis appearance in children or alcoholic individuals who have been in open environments suggest the possibility of injuries by these ants. When the victims are adults, it is common for them to refer to the stings of the ants during the consultation [9]. Fig. 3.2  Fire ant anthill (Solenopsis invicta). Photo: Vidal Haddad Junior

3.1 Ants Fig. 3.3  Red imported fire ant stinging a victim. Photo: Vidal Haddad Junior

Fig. 3.4  Urticarial papules (wheals) at the sites of fire ant stings. Photo: Vidal Haddad Junior

Fig. 3.5  The same site as the Fig. 3.7 after 24 h, with sterile pustule formation. Photo: Vidal Haddad Junior

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Fig. 3.6  Typical injury by red imported fire ant, with edematous papules that appear immediately after the stings. Photo: Vidal Haddad Junior

The differential diagnosis includes subcorneal pustulosis, pustular psoriasis, and other acute pustulosis. The histopathological examination of a fire ant injury shows edema and inflow of polymorphonuclear cells in early stages, which are organized into a sterile pustule composed almost of neutrophils in a later stage, formed by neutrophil diapedesis due to venom toxins. The army ants are of the genus Eciton and move in the forests in large numbers, preying on living beings found on the way. The novice ant (Pseudomyrmex) has a very active venom and clusters inside hollow trees, biting people that damage its habitat (Fig. 3.7). Both have potent venoms, which cause intense pain at the sting site, but small inflammations [11].

3.1 Ants Fig. 3.7  Novice ant (Pseudomyrmex sp.) in a defensive position in their habitat in hollow branches of the novice tree. Photo: Vidal Haddad Junior

Box 3.1 Typical case: Patient presenting pustules and erythema after a scientific excursion and wearing high boots in an area of difficult access. He did feel the stings, but did not take out the boots and the pustules were noted at the next day.

Photo: Vidal Haddad Junior

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3.2 Bees and Wasps Bees (Apidae) and wasps (Vespidae) are venomous insects of social behavior, with division of functions in colonies (Figs. 3.8 and 3.9). The venom is composed of various toxins and can damage various organs when multiple stings occur. In bees, the most important toxins are melittin and apitoxin [3–7]. The hybridization of honeybees from Europe with African bees has generated Africanized bees, which are more aggressive than both the initial species. The fact happened after a colony of African bees escaped in Brazil, in the 1950s. Today, the generating species no longer exist, and Africanized bees have expanded throughout the Americas, often causing deaths and serious envenomations [3–7, 12–14]. Bee stings can cause several effects: one sting can cause papules and inflammatory plaques at the sting site with pain, swelling, and erythema (Fig. 3.10). More than 100 bites can lead to systemic envenomation, which can provoke renal and hepatic failure, shock, bleeding, heart failure, and death (Fig. 3.11) [13]. By other side, bees and wasps (as well as ants) have an enormous capacity to provoke allergic phenomena with just one sting, if the individual is sensitized. In

Fig. 3.8  Bees of the genus Apis grouped in a colony. Photo: Vidal Haddad Junior

Fig. 3.9 Wasps (Vespidae). These insects can also cause multiple stings, although less frequently than the bees. Photo: Vidal Haddad Junior

3.2 Bees and Wasps

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Fig. 3.10  Isolated bee sting, showing the intense edema and erythema caused by the venom in an area of ​​loose tissue. Photo: Vidal Haddad Junior

Fig. 3.11  Multiple attack by a swarm of Africanized bees on a farmer, who died from the envenomation. Note sticking stingers and bees still attached to the body on necroscopic examination. Photo: Vidal Haddad Junior

this case, an increased local reaction and/or systemic allergy, manifested by angioedema or anaphylactic shock, may occur. These last two conditions are serious and urgent, requiring immediate treatment in Emergency Centers [12]. Some stingers remain adhered to the skin and, if they remain there, the musculature present in them ends up injecting the contents of the gland, which also occurs if the venom gland is pressed. Thus, careful removal of the remaining stingers, without pressing the upper portion of the stinger attached to the skin, can change the prognosis of victims of multiple envenomations. Histopathological examination of bee stings is not specific. The edema is intense at the point of the bite and, as a result of the toxins, there is hemorrhage in the skin and other organs. There are inflammatory cells (mainly neutrophils and eosinophils). The hemorrhagic and myolytic effect of the venom can induce muscle necrosis and consequent renal failure [13]. Treatment of one or a few bee or wasp stings uses antihistamines and topical corticosteroids, but severe toxicity will require emergency treatment because there

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is no antivenom serum for bee or wasp stings. Adequate treatment of severe allergic conditions in Emergency Departments includes injectable corticosteroids, antihistamines, and epinephrine due to the high risk of death [3–7, 12–14]. Box 3.2 Typical case: A 12-year-old patient was attacked by a swarm of bees while hunting birds in a wooded area. He presented more than 300 stings and had fever and local intense pain. Systemic effects were noted, including myoglobinuria and and elevation of liver enzymes, but the boy fully recovered.

Photo: João Luiz Costa Cardoso

3.3 Moths and Caterpillars The order Lepidoptera comprises two suborders: Rhopalocera, which has adult specimens that fly during the day and are called butterflies, and Heterocera, which has nocturnal activity and whose specimens are called moths [3–7, 15–19]. The Lepidopterism occurs through body bristles of moths of the genus Hylesia (Saturniidae family), which in certain climatic conditions (hot and rainy months) have population explosions and cause epidemics of papular dermatitis in rural areas (Fig. 3.12). Similar episodes have been described in central Africa, caused by species of the genus Anaphase [17].

3.3 Moths and Caterpillars

21

Fig. 3.12  Hylesia moths (Saturniidae family) can have population explosions and cause epidemics of papular dermatitis. Photo: Roberto Moraes

Females in the breeding season are attracted to light sources and when they crash into the focus, they release “clouds” of abdominal bristles, causing an irritative dermatitis (without toxins) as they enter the skin. The irritation is intense, manifesting as extremely pruritic erythematous papules, edema, and erythema. The histopathological examination is compatible with a foreign body reaction, which may present with granulomas [15]. The manifestations caused by moth bristles may have an epidemic character, affecting populations living near forested areas. The erythematous papules caused by the penetration of barbed bristles (“flechettes”) are intensely itchy and can appear both in small groups (such as families on vacation in favorable environments) and in larger groups in stands. The treatment of these dermatitis uses antihistamines and topical corticosteroids, being necessary the use of topical or systemic antibiotics if there are secondary infections precipitated by the scratching. Erucism (erucae = larvae) is the injury caused by caterpillars of moths. The erucism is more serious and common than the lepidopterism and it is caused by injected toxins. Although there are a lot of families of moths in virtually in every country, two major zoological families are most associated with injuries in humans. The Megalopygidae family has a large number of venomous body bristles, which cover the entire body of the caterpillar (Fig. 3.13). The most important genera are Podalia and Megalopyge. Caterpillars of the Saturniidae family have bristles resembling small pine trees, also full of toxins (Fig. 3.14). The most important genera are Automeris, Dirphia, and Lonomia. The latter genus assumes special importance, as the species Lonomia causes a potentially fatal hemorrhagic syndrome, caused by contact with colonies of caterpillars that are located on tree trunks near to the ground [15, 16].

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Fig. 3.13  Moth larvae of the Megalopygidae family. Note the amount of body bristles capable of injecting venom. Photo: Vidal Haddad Junior

Fig. 3.14  Caterpillars of the Saturniidae family have bristles similar to small pine trees on the back and are commonly associated with lesions in humans. Photo: Vidal Haddad Junior

The stinging properties occur due to the presence of hollow bristles in which there are liquids secreted by cells located at the base of the same, called trichogen cells. When the bristle penetrates the skin and breaks, the liquid exerts its painful and irritating action. These venoms are mixtures of several toxins, composed of thermolabile proteins. Some species have proteolytic enzymes and histamine and others activate plasminogen. A contact with a moth larva is manifested by immediate and intense pain at the site, accompanied by moderate inflammation, but with relatively mild erythema and edema when compared to the intense symptomatology. In some cases, vesicles, blisters, and superficial skin necrosis can be observed (Fig. 3.15) [15–19]. As a rule, the pain is disproportionate to the erythema and edema seen at the points of the contact. The differential diagnosis is made with contact dermatitis caused by primary irritants and chemical and physical burns, but the sudden intense pain and the victim’s vision of the caterpillar help the health professional. Special

3.3 Moths and Caterpillars

23

Fig. 3.15  In some situations, caterpillar envenomation can cause vesicles, blisters, and superficial necrosis in victims. Photo: Vidal Haddad Junior

Fig. 3.16  The genus Lonomia is restricted to Central and South America.The caterpillars are gregarious and group together at the base of trees, causing skin injuries accompanied by a severe hemorrhagic syndrome. Note the ecchymosis on the patient. Photo: Vidal Haddad Junior

attention should be paid to cutaneous or systemic bleeding after contact with a caterpillar, as Lonomia envenomations can be fatal without the use of its own antivenom sérum (Fig. 3.16). The histopathological features of erucism consist of spongiosis, hydropic degeneration, upper dermis, edema, and lymphoplasmocytic infiltrate [15].

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3  Skin Lesions Caused by Venom Inoculations

The treatment of these envenomations uses cold water compresses and oral analgesics (dipyrone is the rule, but the use of more potent analgesics such as tramadol hydrochloride may be necessary). When analgesics do not control pain, local anesthetic nerve block can be used (2% lidocaine—4.0 mL for adults). We suggest the use of commercial topical anesthetics with 0.25% lidocaine and 0.25% prilocaine to greatly reduce or eliminate pain, as the application takes about half an hour to act and lasts for several hours. They are easy to use and are especially useful for children and patients whose lesion’s site does not allow for blockages.

Box 3.3 Typical case (Lepidopterism): Two children presented with acute cutaneous manifestations, with erythematous and intensely itchy papules about 24  h after staying at the family’s beach house, which had been empty for months.

Photos: João Luiz Costa Cardoso and Roberto Moraes

Box 3.4 Typical case (Erucism): A woman had sudden severe pain and mild erythema in the second finger. She was working in the garden of her house.

3.4 Centipedes (Chilopoda)

25

Photo: Vidal Haddad Junior

3.4 Centipedes (Chilopoda) Centipedes are myriapods of the Chilopoda class with the capacity of to cause envenomations in humans. These animals have an elongated body divided into several segments, with a pair of legs in each segment (Fig. 3.17). They are very effective predators, hunting mainly cockroaches and other invertebrates, which causes them to occasionally enter houses through the sewers [20]. They are agile, unlike millipedes (that are also myriapods, but are the Diplopoda class) with which they are confused. Their forcipules are adapted pairs of legs that

Fig. 3.17  Chilopoda of about 10 cm in diameter, with detail of the venom inoculation apparatus. Photography: Vidal Haddad Junior

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3  Skin Lesions Caused by Venom Inoculations

simulate fangs (Fig. 3.17) and inject venom, which causes intense pain, erythema and local swelling, and rarely, blisters and skin necrosis) [20]. In some cases, headaches, fever, malaise, anxiety, and dizziness have also been observed. The envenomations are not described as potentially fatal, even in children, but these animals can bite repeatedly, which adds to the pain.

Box 3.5 Typical case: A woman of 22 years old was bitten on the lip sleeping in her bed, while trying to remove the animal from her face. There was intense pain and swelling at the bite site.

Photo: Vidal Haddad Junior

3.5 Spiders Despite the large number of existing species and all spiders having venom, only a few genera cause envenomations, once that most the species have short chelicerae that cannot inject deeply the venom into the skin, which makes them harmless to humans [3–7, 21, 22]. The wandering or banana spiders (Phoneutria sp.—Fig. 3.18) are large, aggressive, and have a strong neurotoxic venom, rarely causing skin lesions at the point of venom inoculation. The same occurs with spiders of the genus Latrodectus, the black widows (Fig.  3.19). These two genera have few cutaneous manifestations, which are manifested by erythema and local edema, almost always mild. This group of neurotoxic venom spiders also includes the funnel-web spiders, which belong to the group of Mygalomorphae spiders. They are large, aggressive spiders found in

3.5 Spiders

27

Fig. 3.18  Phoneutria sp., the banana spider or wandering spider. This spider is one of the most dangerous in the world, along with the funnel-web spiders of Australia, causing severe and fatal envenomations in children and debilitated individuals. Despite the severity of the envenomation, the manifestations on the human skin are minimal, not collaborating with the diagnosis of the bites. Photo: Vidal Haddad Junior Fig. 3.19  The spiders of the genus Latrodectus are the black widow spiders. They present a neurotoxic venom that has an intense effect on the victim’s musculature, causing spasms and muscle stiffness and may rarely cause deaths. The wandering and funnel-­ webs spiders provoke discrete manifestations on human skin. Photo: Vidal Haddad Junior

Australia and belonging to the genera Atrax, Hadronyche, and Illawarra [3–7, 21, 22]. The Phoneutria venom blocks sodium channels, which results in the massive release of neurotransmitters. The envenomation can lead to arterial hypertension/ hypotension, pulmonary edema, intracranial hypertension, and death. The venom of the funnel-web spiders has similar effects. Envenomation can be treated with specific antiserum in both envenomations. Interestingly, the majority of the group of huge spiders (Mygalomorphae/tarantulas), which can be over 20 cm long, have a venom that acts little on mammals, almost all species being practically harmless (Fig. 3.20).

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Fig. 3.20  A typical Mygalomorphae spider. Note the large size and amount of body bristles. The bite of Mygalomorphae does not cause serious problems for humans, with the exception of the funnel-web spiders and the genus Trechona. Photo: Vidal Haddad Junior

Fig. 3.21 Irritant dermatitis (papuloerythematous) caused by the throwing of abdominal bristles by the paws of a Mygalomorphae spider that was kept as a pet by the victim. Photo: Vidal Haddad Junior

Mygalomorphae spiders have an interesting feature for the dermatologists: despite the reduced effect of the venom on humans, they are raised as pets by several people and not infrequently, they use another defense mechanism, which is to provoke a “cloud” of abdominal bristles thrown with their paws. These bristles can cause eyes and skin damage. On the skin, they give rise to a papular and pruritic dermatitis that can progress to granulomas (Fig. 3.21). Treatment is performed with corticosteroid and antihistamine creams, and the victim must refrain from direct contact with the animal [3–7, 21, 22]. The most important spiders for the dermatologists are the Loxosceles genus, the brown spiders. They are shy, non-aggressive spiders, present in subtropical and tropical areas, with a wide worldwide distribution (Fig. 3.22) [21, 22]. Their venom has an intense action on human skin, causing important necrosis and inflammation, and the envenomation can simulate several dermatological diseases in their phases of evolution. The main enzyme of the venom is

3.5 Spiders

29

Fig. 3.22  Loxosceles sp., the brown spider. This genus occurs in tropical and subtropical areas of the Earth. Photo: Vidal Haddad Junior

Fig. 3.23  Marble plaques interspersed with blue (cyanosis), pale (ischemia), and erythematous (inflammation) colors, being characteristic of the initial phase of loxoscelism envenomation and denoting the local ischemia. Photo: Vidal Haddad Junior

sphingomyelinase D, capable of injuring membranes of red blood cells and pericytes, which causes necrosis by ischemia and hemolysis. The brown spider is a spider originally from wild regions, but is currently found inside household environments (storage rooms, dusty areas in pantries and offices, and in garages). The bite occurs when the spider feels in danger, being the most common situation when the animal is pressed against the victim’s body when wearing clothes, for example. In an initial stage, lasting approximately 8 h, a hardened plaque is formed at the bite site, intermingled with erythema, pallor, and cyanosis, demonstrating the installed ischemia. The necrosis will establish itself over the area delimited by ischemia. This lesion is called marble plaque and is characteristic of brown spider bites (Figs. 3.23) [21, 22]. After days, the plaque darkens and an eschar forms at the point of the bite (Figs. 3.24 and 3.25). Finally, the eschar is eliminated (around 1 or 2 months after

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3  Skin Lesions Caused by Venom Inoculations

Fig. 3.24  The eschar resulting from marble plaque necrosis is part of the evolutionary process of the brown spider bite and shall be considered in conjunction with the previous presence of the marble plaque. Photo: Vidal Haddad Junior

Fig. 3.25  The eschar tends to be eliminated, although it is very adherent. When it detaches, it results in a deep ulcer very difficult to heal. Photo: Vidal Haddad Junior

the bite), exposing a deep ulcer, with raised edges, granular bottom and difficult to heal (Figs. 3.26, 3.27, 3.28, and 3.29). The differential diagnosis of loxoscelism is wide and can confuse the dermatologists in many situations: 1. Marble plaque and eschar: application of legal and illegal drugs, vascular necrosis, and necrotizing or non-necrotizing skin infections (erysipelas, especially on the face, gangrenous ecthyma, and necrotizing fasciitis). 2. Ulcers: chronic ulcers of infectious or tumoral origin, particularly leishmaniasis, sporotrichosis in the single ulcerated form, paracoccidioidomycosis, coccidioidomycosis, cutaneous tuberculosis, pyoderma gangrenosum, tropical ulcer, squamous cell carcinoma, and lymphomas. The histopathological examination of a brown spider bite shows the effects mainly of the toxin sphingomyelinase D, which attacks the membranes of pericytes

3.5 Spiders

31

Fig. 3.26  The ulcer with raised edges resulting of a brown spider bite can be confused with other skin necrosis and with granulomatous and neoplastic diseases. Photo: Vidal Haddad Junior

Fig. 3.27  The raised edges and granular bottom of the ulcers resulting of the brown spider bites can pose diagnostic difficulties, The envenomations should be considered as a differential diagnosis for chronic ulcers. Photo: Vidal Haddad Junior

and erythrocytes. There is degeneration of cutaneous vessels, edema, hemorrhage, thrombosis of vessels, and neutrophil diapedesis that will increase the obstruction of the vessels in the bite site. In the ulcer phase, there are fibrosis and neovascular formations, without granulomas or other specific findings [23, 24]. The treatment depends on the stage of envenomation, and there is no time scientifically established for the use of antiarachnidic serum. Moderate cases (systemic changes without hemolysis) may need five ampoules and cases (with hemolysis) may require up to ten ampoules. When there is skin necrosis without hemolysis, it is possible to use sulfone (100–300 mg/day orally), which acts by blocking the neutrophil diapedesis at the site and inhibiting the extension of the necrosis. The administration of oral corticosteroids is controversial, but indicated in some protocols. In later stages, chronic healing ulcers can be treated with skin grafts or excision of the compromised area [25].

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Fig. 3.28  Chronic ulcers without granulomatous components on histopathological examination may be indicative of Loxosceles injuries, which are not uncommon. Photo: Vidal Haddad Junior

Fig. 3.29  Typical ulcer of loxoscelism, resulting from the formation of the marble plate and the detachment of the eschar. Photo: João Luiz Costa Cardoso

Box 3.6 Typical case (Loxoscelism): Male patient, 46 years old, is a carpenter. He felt a slight pain in his thigh and noticed that there was a “insect” walking under his pants. The pain increased and in about 24 h a plaque was formed showing alternating colors on the surface and infiltrated base.

3.6 Scorpions

33

Photo: Vidal Haddad Junior

3.6 Scorpions Scorpions are arthropods arachnid that carry a sophisticated venom inoculation apparatus, with the toxins being injected by a stinger located in the telson, at the end of the tail, which remains elevated (Fig. 3.30). The envenomations can be serious and even fatal, especially in children and the elderly. There is dissociation of actions of the Autonomic Nervous System (ANS) and an extensive symptomatology with cardiac and pulmonary involvement, in addition to intense pain. Scorpions are common in domestic environments, where they hunt cockroaches and other invertebrates [3–7]. The scorpion sting, due to its predominantly neurotoxic effect, does not cause important manifestations on the skin, but there may be mild erythema and edema at the site and occasionally, the disturbance of the ANS can provoke horripilation around the inoculating perforation.

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Fig. 3.30  Yellow scorpion (Tityus serrulatus), a dangerous South American scorpion. Note the telson with the stinger at the end of the tail. Photo: Vidal Haddad Junior

In the scorpion stings, the slight local reaction is reflected in the histopathological examination, which shows mild edema and few inflammatory cells at the sting site. The treatment is done with anesthetic blockade of the bite (generally in the hands and feet) and in case of systemic manifestations, the application of antivenom serum is indicated [3–7].

Box 3.7 Typical case: A 42-year-old female patient was stung in her right hand while picking up an object from the home’s pantry. She felt intense pain and presented horripilation in the site of the sting, but had no systemic repercussions and was medicated with injectable anesthetics, with pain improvement.

The dermatological manifestations of scorpion stings are mild, but occasionally we can observe horripilation at the point of inoculation of the toxins. Photo: Vidal Haddad Junior

3.7 Belastomatidae (Giant Water Bugs)

35

3.7 Belastomatidae (Giant Water Bugs) The Belastomatidae family comprises aquatic hemiptera distributed worldwide in temperate and tropical areas. Giant water bugs are classified into two major genera (Lethocerus and Belostoma). These insects reach large sizes (up to 10 cm in diameter) and only exist in freshwater collections, especially in streams, where they voraciously hunt other insects and even vertebrates such as small fish, tadpoles, and adult amphibians [26]. Giant water bugs have a short, stout “beak” that they use to attack their prey and inject venom. This is composed of potent proteolytic enzymes that liquefy the victim’s tissues (Fig. 3.31). Some studies demonstrate the presence of lysophospholipids in the saliva of the species Belostoma anurum. These can cause paralysis in prey. The bites in humans are not common and produce, in addition to intense pain, mild inflammation at the initial moment. In later stages, small necrosis may occur, resulting from the enzymatic action of the venom. Another possibility is bacterial infections, and the hypothesis of transmission of Mycobacterium ulcerans (Buruli ulcer) is considered, due to the finding of this mycobacteria in the saliva of these insects [26]. Treatment for the bite is symptomatic, seeking to control pain and to treat the necrosis, ulcers, and complications caused by secondary infections.

Fig. 3.31  The Giant water bugs are large insects that can cause painful bites in humans. Note the venomous apparatus in the “beak” of the arthropod. Photo: Vidal Haddad Junior

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Box 3.8 Typical case: A male patient, 28 years old, biologist, suffered a bite and saw the animal while sampling small fish in a stream. He had violent pain, erythema, and swelling, but he did not develop necrosis or ulcers at the site. The lesion involuted in about 3 days.

Photo: Vidal Haddad Junior

3.8 Coleoptera (Beetles) Beetles, in addition to causing hemolymph injuries in humans (passives envenomations), can inoculate venom in a mechanism similar to that of scorpions, but using articulated antennae connected to venom glands. The species Onychocerus albitarsis (scorpion beetle) rarely causes envenomation (Fig. 3.32), but it can cause significant inflammation with edema and local erythema at the point of penetration of the antennae tips into the skin [27].

Box 3.9 Typical case: Biology student patient who, when handling a beetle for zoological collection, felt intense pain in his hand, which was inflamed for about 24 h.

3.8 Coleoptera (Beetles)

Photo: Antônio Sforcin Amaral

Fig. 3.32  Onychocerus albitarsis beetle. Note the long antennae capable of inoculating venom. Photo: Antônio Sforcin Amaral

37

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3.9 Cnidarians (Jellyfish, Portuguese Man of’ War, Corals, Anemones) Cnidarians are animals that mostly live in marine environments, having a body with a simple circular or tubular structure and several tentacles that originate in the body and serve for prey capture and self-defense. The tentacles can reach great lengths when in the water, like those of the Portuguese man of’ war, which can measure up to 30 m in length (98 ft) [3–5]. These animals, despite occupying early stages in the evolutionary scale, have a sophisticated venom apparatus, which consists of cells with stinging organelles (cnidocytes and nematocysts), with a venom composed of several toxins. Nematocysts are capable of shooting a thin tube filled with venom with neurotoxic and necrotizing effects. These actions serve primarily to capture prey (invertebrates and fish). Human envenomations happen by accidental contact with the animals and mainly in bathers. Cnidarians (jellyfish and Portuguese man of’ war) can cause injuries in sporadic contacts or during blooms, which is a term that expresses an overpopulation of jellyfish or Portuguese man of’ war on certain beaches. Blooms of cnidarians cause dozens and even hundreds of injuries in humans [3–7, 23, 24, 28–46]. Cnidarians are included in four zoological classes of interest to Human Medicine: Anthozoa (anemones and corals), Hydrozoa (Portuguese man of’ war and some small jellyfish), Scyphozoa (true jellyfish), and Cubozoa (jellyfish with a cuboid body and four tentacles). The Cubomedusae are implicated in serious envenomations in humans, especially the Cubozoa species Chironex fleckeri, associated with several fatal injuries in the Indo-Pacific region and considered the most lethal of the jellyfish. Cubozoa also includes the genera Chiropsalmus, Tamoya, Carybdea, Carukia, and others (Fig. 3.33). The Portuguese man of’ war also causes serious envenomations, although more rarely (Fig. 3.34). Most of this cnidarian envenomations are mild or moderate, with severe pain, linear skin marks, but no systemic symptoms. Photo: Alvaro Migotto, USP. The lesions caused by free cnidarians are characteristic: the tentacles (and occasionally the body) of the animal have their shape reproduced on the skin, presenting as a papular or plaque eruption, erythematous and with linear distribution with criss-cross marks, initially of urticarial appearance (Figs.  3.35 and 3.36). Linear edematous plaques occasionally have horripilation on their surface, from changes caused by toxins in the sympathetic nervous system. The pain is intense and immediate [23, 24, 28–46]. The appearance of vesicles, bullae, and superficial necrosis after hours is not uncommon (Figs. 3.37 and 3.38). When envenomation is caused by a jellyfish with little active venom, the pain subsides and disappears after a few hours, but the plaques can leave hyperchromic macules at the site that persist for weeks (Fig. 3.39). Injuries by potentially dangerous species, such as cubomedusas and Portuguese

3.9 Cnidarians (Jellyfish, Portuguese Man of’ War, Corals, Anemones) Fig. 3.33 The Cubomedusae have a cuboid body and four tentacles. These cnidarians can cause serious envenomations in humans. Photo: Álvaro Esteves Migotto

Fig. 3.34  Portuguese man o’ war are beautiful hydrozoans with the potential to cause blooms in certain regions. The envenomations can be serious. Photo: Rosângela M. P. Camargo

39

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Fig. 3.35  Injuries caused by cnidarians shortly after the contact cause a lot of pain and linear, urticarial-like erythematous plaques. Photo: Vidal Haddad Junior Fig. 3.36  The appearance similar to urticaria may resemble allergy in initial cases of cnidarian stings, but the intense pain clarifies the diagnosis. Photo: Vidal Haddad Junior

3.9 Cnidarians (Jellyfish, Portuguese Man of’ War, Corals, Anemones)

41

Fig. 3.37 Bullous-­ appearing envenomations can simulate phytophotomelanosis, but sudden onset accompanied by pain still in the water indicates contact with cnidarians. Photo: Vidal Haddad Junior

man of’ war, may be associated with systemic phenomena. The cause of the signs and symptoms is the general disorganization of nervous activity and heart failure. Cardiogenic shock, respiratory failure, hemolysis, and kidney abnormalities can occur. Cardiorespiratory impairment is responsible for deaths in severe cases [23, 24, 28–46]. Seabather’s eruption is an envenomation caused by larvae of cnidarians, especially the hydrozoa Linuche unguiculata. They cause a papular, erythematous and itchy rash, which occupies precisely the places covered by bathing suits. The typical location of the lesions lightens the diagnosis. The disease is common in tropical areas, mainly in the Caribbean, and can be treated with antihistamines and topical corticosteroids (Fig. 3.40) [38, 44]. The dermatologist must keep in mind that in addition to the toxic manifestations, the substances injected by the cnidarians can precipitate emergency allergic reactions, such as angioedema and anaphylactic shock, as well as persistent reactions and the appearance of new plaques.

42 Fig. 3.38 High inoculations of venom cause more intense necrotic phenomena in the skin, which can cause vesicles, blisters, skin necrosis, and even purpura. Photo: Vidal Haddad Junior

Fig. 3.39 Late complications of the envenomation by cnidarians occasionally occur. The most common are prolonged skin inflammatory reactions, scars, and hyperchromic macules. Photo: Vidal Haddad Junior

3  Skin Lesions Caused by Venom Inoculations

3.9 Cnidarians (Jellyfish, Portuguese Man of’ War, Corals, Anemones)

43

Fig. 3.40  The Seabather’s eruption is an eruption caused by cnidarian larvae with typical distribution under bathing suits. Photo: André Luiz Rossetto

The aspects of the histopathological exam of the envenomations show are d­ istinctive: it is possible to see nematocysts that extend to the dermis still attached to the skin, when we recent stings. The epidermis becomes edematous, separating its layers by the edema. The Malpighian stratum is thinned, with cell degeneration, which show pyknotic nuclei. The dermis has no changes [35–55]. The care of patients victimized by jellyfish and Portuguese man of’ war is usually done in emergency rooms, but late or allergic lesions are observed by the dermatologists. Shortly after the envenomation, compresses of ice-cold seawater improve the local pain. The use of freshwater should be avoided once it triggers skin-fixed nematocysts by osmosis. We think that the nociceptive activity of the venom is influenced by extreme temperatures, not exclusively by hot or cold water, as cold water also has a good analgesic effect. Acetic acid 5% (vinegar) inactivates still-intact nematocysts on the skin or in tentacles that have not been removed. Certain popular treatments such as alcohol, urine, antihistamines, or Coca-Cola® do not have effect. Some patients may experience potentially fatal systemic manifestations such as arterial hypotension/hypertension, direct cardiotoxicity with cardiac arrhythmias, and secondary pulmonary edema. A patient with these signs and symptoms should be urgently referred to a hospital. Persistent and severe pain after first aid should also be treated in a hospital (in these cases, an ampoule of intramuscular dipyrone seems to be able to control the pain, but but it is possible to have to use opiates). Cardiac arrhythmias should be treated with intravenous verapamil [45, 46]. Hyperchromias and possible scarring at the points of lesions are late complications that can be treated with skin bleaching agents and infiltration of corticosteroids into the scars.

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Box 3.10 Typical case: A 26-year-old male patient was surfing on a Brazilian beach and while bringing the board to the beach he felt a contact on the back and soon after an intense pain in the area. Supported by lifeguards when he arrived at the beach, he noticed long reddish lines on his thorax and arms, having shortness of breath and palpitations. Once in hospital, he was treated symptomatically and with cold seawater and vinegar, compresses, and analgesics, with gradual improvement and discharge in about 8 h.

3.10 Echinoderms (Sea Urchins) Sea urchins belong to the Phylum Echinodermata. They are rounded marine invertebrates, slow moving, with an external skeleton composed of calcium carbonate and with sharp projections (spicules), which serve for the animal’s defense. (Fig. 3.41) Sea urchins inhabit rocky walls and coral reef floors in tropical and subtropical areas. The spicules of some sea urchins may have toxins on the surface or inside the spines, and several pharmacologically active substances can be isolated from the body surface of sea urchins, such as steroids, histamine, bradykinin, and others. Most injuries are traumatic, and the penetration of the spines deep into the skin can cause problems for the immediate removal. In later stages, the spines the spikes embedded in the skin can precipitate foreign body granulomas, as so bacterial and fungal infections [46–49].

3.10 Echinoderms (Sea Urchins)

45

Fig. 3.41  Black sea urchin (Echinometra lucunter). Note the sharp body spicules. Photo: Vidal Haddad Junior

Fig. 3.42  Typical sea urchin injuries caused by a non-venomous black sea urchin. The pain only manifests itself when the victim stepped on the ground, showing the absence of toxins. Photo: Vidal Haddad Junior

The penetration of spicules leaves a pigmented spot at the entrance, which does not guide the size of the fragment in the skin (Figs. 3.42, 3.43, and 3.44). Depending on the size of the fragment, the removal is not difficult, but small fragments can be very difficult to extract. The most commonly affected areas are the feet and ankles of victims, but divers and sea urchin collectors for culinary purposes may have trauma and spicules on the hands and if joints are penetrated, synovitis may result [46–49]. The systemic symptoms occur when spicules of venomous species cause perforations (paraesthesia, radiating pain, hypotension, muscle weakness, dyspnea). Histopathological examinations of sea urchin trauma show the absence of inflammatory phenomena and the presence of spicules in the early stages. When there is

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3  Skin Lesions Caused by Venom Inoculations

Fig. 3.43  The spicules of sea urchins can be of various diameters, some being thick and capable of hindering ambulation. Photo: Vidal Haddad Junior

Fig. 3.44  Foreign body granulomas occur when spicules are not removed in the initial phase of the injury. The solution is surgical, with extraction of the nodules. Photo: André Luiz Rossetto

retention of spicules, in the late nodular phases, it is possible to see a granulomatous reaction, of the sarcoid type, with fragments of spicules in the center of the nodule [47, 48]. Treatment of venomous sea urchin recommends immersion of the affected site in hot water (43–46 °C); which inactivates toxins and eliminates pain. Most of injuries, however, are traumatic, and the spicules removal is necessary. The spicules break easily. They must be removed with two large-gauge needles, with one of them locking the spicule and the other pressing upwards. This works well for larger spikes, but some are very small and can be resolved by spontaneous elimination. Fine tweezers can also be used. Foreign body granulomas require surgery with excision of the nodules with the fragments inside [46–49].

3.11 Venomous Fish

47

Box 3.11 Typical case: Patient presents to the dermatologist with a history of stepping on a colony of sea urchins after walking in lagoons formed by rocks between two beaches. He removed part of the spicules in an emergency room, but many remained.

3.11 Venomous Fish There are several species of venomous and poisonous marine and freshwater fish. Catfish (Siluriformes) envenomations are the most common in both freshwater and marine environments, but also occur envenomations by stingrays (Batoidea), scorpionfish (Scorpaenidae), toadfish (Batrachoididae), moray eels (Muraenidae), and others [50–61]. There are no statistics on the number of the envenomations of this type in the world, but it is known that envenomations by venomous fish in Brazil correspond to 28.5% of the injuries caused by marine animals, which in turn are 1% of all emergencies that enter the coastal emergency rooms [1–5]. Catfish have 3 bony stingers on the pectorals and dorsal fins, covered by glands with toxins (Fig. 3.45). Marine and freshwater stingrays also have 1–4 serrated dentin stingers that are covered by a toxic mucus that is released when the stinger enters the skin (Fig. 3.46). The effects of toxins are local necrosis, neurotoxicity, and cardiotoxicity. The main signs and symptoms of envenomation by both these fish are intense: disabling pain, edema, erythema, and skin necrosis (Figs. 3.47, 3.48 and 3.49) [52–56].

48 Fig. 3.45  The catfish are the major cause of envenomations caused by fish in humans. The wounds are caused by stingers located in anterior position on the pectoral and dorsal fins. Photo: Vidal Haddad Junior

Fig. 3.46  Marine and freshwater stingrays have 1–4 serrated stingers covered with venomous epithelium and used as a defense mechanism. Photo: Vidal Haddad Junior

Fig. 3.47 Beachgoers walking on beaches often step on small catfish without economic value and thrown on the sand by fishermen. Photo: Vidal Haddad Junior

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3.11 Venomous Fish

49

Fig. 3.48 Envenomations caused by stingrays cause local traumas with copious bleeding and intense pain. Photo: Daniela Santos Medeiros da Silva

Envenomations by scorpionfish, lionfish (Scorpaenidae), and stonefish (Synanceiidae) are caused by the fins rays, which present channels with venomous glands (Figs. 3.50 and 3.51). Scorpionfish, lionfish, and stonefish cause excruciating pain, myotoxicity, neurotoxicity, and direct harmful effects on the myocardium. Scorpionfish are present in tropical and temperate waters around the world and stonefish and lionfish live in the Indo-Pacific region, although lionfish have recently become invasive on the east coast of the Atlantic Ocean, from the USA to Brazil [50]. These fish have venoms with systemic action, which can cause deaths, unlike catfish, stingrays and toadfish, fish that have venoms of local action (Figs. 3.52 and 3.53). Toadfish have glands attached to spicules and can inject the venom. Fish venoms are neurotoxic (severe pain, nerve block) and dermonecrotic, with varying effects on each type of fish [50]. Injuries caused by fish stingers, especially those caused by catfish and stingrays, can cause skin necrosis with intense local edema and erythema, manifested in histopathological examinations by aggression to vessels and polymorphonuclear infiltrate. When in the ulcer phase, only fibrosis and vascular neoformation are observed.

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Fig. 3.49  Stingray injuries are more serious than catfish envenomations, causing greater skin necrosis and pain. Photos: Vidal Haddad Junior

The venoms of all fish are thermolabile and intensely vasoconstrictor, which recommends immersion of the affected limb in hot water for 30–90 min to relieve the pain caused by ischemia. The wound should also be explored, with the removal of stinger fragments or the epithelium of the stingers or fins. Auxiliary measures such as radiological exploration of the wound for stinger fragments and tetanus vaccination are necessary [50–61]. If there is significant systemic involvement, which occurs due the venom and to late secondary infections, refer the patient urgently to a hospital care. Warm water is the only immediate effective measure for pain management in an initial envenomation by fish. The vasodilation relieves the ischemia process and greatly improves the pain, but it does not prevent the skin necrosis. Any other measure is useless, with the exception of the application of analgesics. Two possible complications are the breakage of stingers with retention of fragments in the wound and the secondary bacterial infections, which can be serious. The use of cephalosporin or amoxicillin with clavulanate is indicated in these situations.

3.11 Venomous Fish Fig. 3.50  Fragments of stingers of stingrays can be retained in the wound, requiring further surgery. Photo: Marco Antônio Pandini

Fig. 3.51  The scorpionfish are fish from tropical and temperate waters that have venom with systemic action, causing severe envenomations. Photo: Vidal Haddad Junior

51

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Fig. 3.52  Local mild edema and erythema are observed in envenomations caused by scorpionfish, in contrast with the severe systemic effects. Photo: Vidal Haddad Junior

Fig. 3.53  Left: stonefish and right: lionfish. The stonefish is the only fish that cause proven deaths from envenomations, but the injuries by lionfish also can be very severe. Photo: Vidal Haddad Junior

3.12 Venomous Snakes

53

Box 3.12 Typical case: A 24-year-old male patient was stung by a stingray while collecting the fish from a net on the bottom of his boat. He had excruciating pain at the point of the sting and intense inflammation after a few hours. He had improvement in pain after immersion of the left foot in hot water, but the wound became infected after 1 day and it had to be treated with antibiotics. An ulcer developed at the site and after about 1 month it had healed.

3.12 Venomous Snakes The envenomations caused by venomous snakes are a public health problem, especially in poor countries, and are currently classified by the WHO (World Health Organization) as one of the neglected diseases worldwide [62–64]. The bites can be extremely serious, due to the large amount of toxins present in the venoms and the various organs and systems compromised in the victims. There are two zoological families that are the main causes of envenomation: the Viperidae family comprises most of the New World species (cottonmouth, moccasins, rattlesnakes (Fig. 3.54), bushmaster (Fig. 3.55), and pit vipers) (Fig. 3.56), being also present in Africa and Asia. The snakes of the Elapidae family are presented in Oceania (taipans, brown snakes and others), but they are also found in the Americas, being the American coral snakes (Fig. 3.57), in the Africa (cobras and black and green mambas) and in Asia (cobras, king snakes, and others).

54

Fig. 3.54  The rattlesnakes (Crotalus sp.) are Viperidae present throughout the New World. They are capable of seriously envenom human beings, due to the neurotoxic and myolytic venom effects. Photo: Vidal Haddad Junior

Fig. 3.55 The Lachesis sp. (bushmasters) are the largest venomous snakes in the Americas, but the effects of envenomation are poorly known, as the snakes live in dense forest environments, with little human interference. Photo: Marco Antônio de Freitas

Fig. 3.56 The Bothrops genus (jararacas or pit vipers) have several species in Central and South America. The Viperidae family have a venom with high tissue destruction power at the bite site. Photo: Vidal Haddad Junior

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3.12 Venomous Snakes

55

Fig. 3.57  Coral snakes of the Americas are highly venomous snakes, with a similar venom action to other Elapidae inhabitants of Africa, Asia, and Oceania. Photo: Vidal Haddad Junior

Fig. 3.58  The muscle damage caused by Elapidae bites can cause death, but the local manifestations are discrete. Photo: Vidal Haddad Junior

Elapid envenomation is characterized by muscle blockages by the action of various toxins. We must pay attention to signs such as the “drunk face,” eyelid ptosis and progressive respiratory difficulty, which can quickly progress to apnea and death (Fig. 3.58). The bites of some Elapidae species can cause repercussions on the skin (necrosis and inflammation), but these are not usually important as in the Viperidae bites. Snakes of the Viperidae family are of most interest to dermatologists. Due to the fact that the venom contains necrotic toxins (with the primary function of digesting victims’ tissues) the envenomation can express itself in a catastrophic way on the human skin. There are vipers on every continent, with the exception of the Oceania. Among these, some are well-known snakes such as the European vipers (Vipera sp.) and the Bothrops sp. (jararacussu pit vipers), Lachesis sp. (bushmasters), and Crotalus sp. (rattlesnakes) in the New World. In Africa, severe envenomations are caused by the Gabon viper (Bitis gabonica) and the saw-scaled viper (Echis carinatus).

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The venom of the Viperidae contains toxins that promote severe deleterious effects on the human body, such as marked inflammation at the bite site, manifested by intense edema and erythema and tissue necrosis. Rattlesnakes may also have a neurotoxic factor that causes muscle weakness and eyelid ptosis in victims [62–64]. The early presence of erythema, edema, and subsequent formation of blisters with hemorrhagic content and skin necrosis are indicators of the Viperidae’s bites, especially when the manifestations are located in a lower and unilateral limb (Figs. 3.59, 3.60, and 3.61). The pain is determined by the edema at the site of the bite. The differential diagnosis is basically that of bullous erysipelas when the blisters do not usually have hemorrhagic content and the fever will be higher due to the bacterial action. The histopathological findings in a Viperidae bite show intense aggression to the skin, especially in vessels, where fibrinoid necrosis of the walls can be seen and, as consequence, necrosis and thrombosis in the vessel lumen and hemorrhages. These effects are responsible for the extensive local necrosis observed in these envenomations. We must keep in mind that the marks of the fangs are not always visible and that the dermatological examination can be fundamental for the identification of the bite, especially in the initial stages of envenomation.

Fig. 3.59 The Bothrops (Viperidae) envenomation shows pronounced edema and blisters of hemorrhagic content, simulating erysipelas. Photo: Vidal Haddad Junior

3.12 Venomous Snakes

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Fig. 3.60  Some necrosis after the Viperidae bites can have catastrophic consequences, with limb amputations. Photo: Vidal Haddad Junior

Fig. 3.61  The bites of venomous snakes with necrotic toxins in the extremities are a risk factor, due to the presence of terminal circulation. Fingers are particularly sensitive to this problem. Photo: Vidal Haddad Junior

In later stages, there may be the action of other toxins with myolytic, hemolytic, coagulant, or hemorrhagic effects, which can lead to death due to intracranial bleeding and renal failure. In these phases, the clotting time must be performed, as it is a simple test and interferes with the staging of the severity and the treatment of the bite.

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A very common complication in venomous snake bites is secondary bacterial infection, which we must be constantly aware of. This is most often caused by Gram negative and anaerobic bacteria and is precipitated by the large areas of necrosis that occur in some bites, which can lead to abscesses. Differential diagnosis: in the initial phase, the manifestations are similar to erysipelas and cellulitis. Ecchymosis and hemorrhagic suffusions must be distinguished from other clotting disorders. Acute necrotic areas can be confused with those caused by anticoagulants, by the microangiopathic obstructions of diabetes or of large arterial vessels, by atherosclerosis. In later stages, rule out sickle cell ulcer and stasis ulcer. In some situations, the intense edema at the bite site can cause compression of important structures such as muscles, vessels, and nerves, which can lead to ischemia and deep necrosis. This complication is called compartment syndrome and is a very severe condition, requiring urgent surgical intervention to decompress the structures (fasciotomy). Snake envenomations have only one specific treatment: the application of antivenom serum, although this treatment is lacking in poor countries. The antivenom neutralizes the toxins that cause the fatal effects systemically. However, the serums do not act fully for local manifestations and measures to control residual ulcers and other local complications must be carried out by the dermatologist for some time [62–64]. Box 3.13 Typical case: A farmer, 40 years old, 2 days before the appointment, felt a “sting” in his ankle when he was walking at night on the bank of a river, but he did not see the cause. The site became painful and ecchymoses with blisters of hemorrhagic content and bleeding gums appeared. Treated with antivenom, he had problems with the local necrosis, but recovered with scars at the point of the bite.

References

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References 1. Haddad V Jr, Cardoso JL, França FOS, et  al. Acidentes por formigas: Um problema dermatológico (Injuries caused by ants: a dermatological problem). An Bras Dermatol. 1996;71(6):527–30. 2. Haddad V Jr, Cardoso JLC, RHP M. Description of an injury in a human caused by a false tocandira (Dinoponera gigantea, PERTY, 1883) with a revision on folkloric, pharmacological and clinical aspects of the giant ants of the genera Paraponera e Dinoponera (sub-family Ponerinae). Rev Inst Med Trop. 2005;47:235–8. 3. Ministério da Saúde. Manual de diagnóstico e tratamento de acidentes por animais peçonhentos (Guideline of diagnosis and treatment of envenomations caused by animals). BRASIL, Health Ministry. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 1997. Portuguese 4. Haddad V Jr, Cardoso JLC.  Dermatoses provocadas por animais venenosos (Dermatosis caused by venomous animals). An Bras Dermatol. 1999;74:441–7. 5. Haddad V Jr, Cardoso JLC, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin. J Am Acad Dermatol. 2012;67:331.e1–331.e14. 6. Haddad V Jr, Cardoso JLC, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin part II. J Am Acad Dermatol. 2012;67:347.e1–9. 7. Haddad V Jr, Amorim PCH, Haddad WT Jr, Cardoso JLC. Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries. Rev Soc Bras Med Trop. 2015;48:650–7. 8. Conceição LG, Haddad V Jr, Loures FH. Pustular dermatosis caused by fire ant (Solenopsis invicta) stings in a dog. Vet Dermatol. 2006;17:453–5. 9. Haddad V Jr, Cardoso JLC.  Insetos (Insecta). Ants. In: Cardoso JL, França FOS, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 10. Haddad V Jr, Larsson CE. Anaphylaxis caused by stings from the Solenopsis invicta, lava-pés ant or red imported fire ant. An Bras Dermatol. 2015;90:22–5. 11. Haddad V Jr, Bicudo LRH, Fransozo A. The Triplaria tree (Triplaris spp.) and Pseudomyrmex ants: a symbiotic relationship with risks of attacks for humans. Rev Soc Bras Med Trop. 2009;42:727–9. 12. Cardoso JLC, Haddad V Jr. Insetos (Insecta). Bees and wasps. In: Cardoso JL, França FOS, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 13. Campos Neto M, Haddad V Jr, Levi LMP, Magalhães CA. Massive attack of Africanized bees leading to death: case report–Cáceres-MT-Brazil. Int J Legal Med. 2012;126:248. 14. Machado M, Sousa DER, Landi MFA, et al. Reação tóxica sistêmica causada por picadas de abelhas em cães. Acta Sci Vet. 2018;46(Suppl 1):271. 15. Cardoso AEC, Haddad V Jr. Accidents by Lepidoptera (larvae and adults of moths): study of epidemiological, clinical and therapeutic aspects (Portuguese). An Bras Dermatol. 2005;80:571–8. 16. Cardoso JLC, Haddad V Jr. Insetos (Insecta). Moths and caterpillars. In: Cardoso JL, França FOS, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 17. Moreira SC, Lima JC, Silva L, Haddad V Jr. Description of an outbreak of lepidopterism (dermatitis associated with contact with moths among sailors in Salvador, Bahia state). Rev Soc Bras Med Trop. 2007;40:591–2. 18. Haddad V Jr, Lastória JC. Envenomation by caterpillars (erucism): proposal for simple pain relief treatment. J Venom Anim Toxins Incl Tropical Dis. 2014;20:21.

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19. Criado PR, Haddad V Jr. The train tracks sign is a valuable skin marker of envenomations caused by caterpillars. Rev Soc Bras Med Trop. 2018;51:565. 20. Haddad V Jr, Amorim PCH, da Cruz CR, Amaral ALS. Centipede envenomation (Chilopoda): case report. Rev Soc Bras Med Trop. 2021;55:e0601–2022. 21. Lucas MS. Spiders in Brazil. Toxicon. 1988;26:759–72. 22. Cardoso JLC, Haddad V Jr. Araneísmo (Arachnidism). In: Cardoso JL, França FOS, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 23. Haddad V Jr. Atlas of dangerous aquatic animals in Brazil: medical guide to identification and treatment (Portuguese). São Paulo: Roca; 2000. p. 145. 24. Haddad V Jr, Cardoso JLC, Silveira FL. Seabather’s eruption: report of five cases in southeast region of Brazil. Rev Inst Med Trop São Paulo. 2001;43(3):171–2. 25. Haddad V Jr, Cardoso JLC, Stolf HO.  Tratamento cirúrgico da úlcera loxoscélica; solução prática para um problema de difícil resolução (Surgical treatment of loxoscelic ulcer; practical solution to a difficult problem). Diagnóstico Tratamento. 2012;17:56–8. 26. Haddad V Jr, Schwartz EM, Schwartz CA, Carvalho LN.  Report of seven human envenomations caused by giant water bugs of Belostomatidae family (Hemiptera, Heteroptera). Wilderness Environ Med. 2010;21:130–3. 27. Amaral ALS, Castilho AL, Borges AL, Haddad V Jr. Envenomations in humans caused by the venomous beetle Onychocerus albitarsis: observation of two cases in São Paulo state. Brazil J Clin Toxicol. 2018;8:1–2. 28. Kingston W, Souhcott RV. Skin histopathology in fatal jellyfish stinging. Trans R Soc Trop. 1960;54:373–6. 29. Haddad V Jr, Cardoso JLC, França FOS.  Acidentes provocados por celenterados: aspectos clínicos e terapêuticos (Envenomations caused by coelenterates: clinical and therapeutic aspects). An Bras Dermatol. 1997;72:206–10. 30. Haddad V Jr. Epidemiological, clinical and therapeutic evaluation of accidents caused by venomous marine animals in the southeast region of Brazil. Thesis (PhD)–Escola Paulista de Medicina. São Paulo: Universidade federal de São Paulo; 1999. p. 109. 31. Haddad V Jr, Silveira FL, Cardoso JLC, Morandini AC.  A report of 49 cases of cnidarian envenoming from southeastern Brazilian coastal waters. Toxicon. 2002;40:1445–50. 32. Haddad V Jr, Lupi O, Lonza JP, Tyring SK. Tropical dermatology: marine and aquatic dermatology. J Am Acad Dermatol. 2009;61:733–50. 33. Cardoso JLC, Haddad V Jr. Animais Aquáticos (Aquatic animals). In: Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 34. Haddad V Jr, Migotto AE, Silveira FL. Skin lesions in envenoming by cnidarians (Portuguese man-of-war and jellyfish): etiology and severity of the accidents on the Brazilian coast. Rev Inst Med Trop São Paulo. 2010;52:43–6. 35. Risk JY, Haddad V Jr, Cardoso JLC. Envenoming caused by Portuguese man-o’-war (Physalia physalis) manifesting as purpuric papules. An Bras Dermatol. 2012;87:644–5. 36. Haddad V Jr. Environmental dermatology: skin manifestations of injuries caused by invertebrate aquatic animals. An Bras Dermatol. 2013;88:496–506. 37. Haddad V Jr, Virga R, Bechara A, Silveira FL.  An outbreak of Portuguese man-of-war (Physalia physalis–Linnaeus, 1758) envenoming in southeastern Brazil. Rev Soc Bras Med Trop. 2013;46:641–4. 38. Rosetto A, Silveira FL, Morandini AC, Haddad V Jr. Seabather’s eruption: report of fourteen cases. An Acad Bras Ciênc. 2015;34:34. 39. Haddad V Jr. Medical emergencies caused by aquatic animals: a zoological and clinical guide. Cham: Springer; 2016.

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40. Guevara BEK, Dayrit JF, Haddad V Jr. Delayed allergic dermatitis presenting as a keloid-­ like reaction caused by sting from an indo-Pacific Portuguese man-o’war. Clin Exp Dermatol. 2017;42(2):182–4. 41. Bastos DMRF, Haddad V Jr, Nunes JLS. Human envenomations caused by Portuguese man-­ of-­war (Physalia physalis) in urban beaches of São Luis City, Maranhão state, northeast coast of Brazil. Rev Soc Bras Med Trop. 2017;50:130–4. 42. Pereira JCC, Spilzman D, Haddad V Jr. Anaphylactic reaction/angioedema associated with jellyfish sting. Rev Soc Bras Med Trop. 2018;51:115–7. 43. Haddad V Jr, Morandini AC, Rodrigues LE.  Jellyfish blooms causing mass envenomations in aquatic Marathonists: report of cases in S and SE Brazil (SW Atlantic Ocean). Wilderness Environ Med. 2018;29:142–5. 44. Rossetto AL, Venzon SL, Cruz CCB, Dimatos OC, Rossetto AL, Morandini AC, Haddad V Jr. Seabathers eruption: description of a new clinical manifestation. J Eur Acad Dermatol Venereol. 2020;34(11):e714–6. 45. Haddad V Jr. Medical emergencies caused by aquatic animals: a biological and clinical guide to trauma and envenomation. Cham: Springer; 2021. 46. Cardoso JLC, Haddad V Jr. Animais Aquáticos (Aquatic animals). In: Cardoso JLC, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 47. Rossetto AL, Mora JM, Haddad V Jr. Sea urchin granuloma. Rev Inst Med Trop. 2006;48:303–6. 48. Haddad V Jr. Observation of initial clinical manifestations and repercussions from the treatment of 314 human injuries caused by black sea urchins (Echinometra lucunter) on the southeastern Brazilian coast. Rev Soc Bras Med Trop. 2012;45:390–2. 49. Haddad V Jr. Aquatic animals of medical importance. Rev Soc Bras Med Trop. 2003;36:591–7. 50. Haddad V Jr, Martins IA, Makyama HM.  Injuries caused by scorpionfishes (Scorpaena plumieri Bloch, 1789 and Scorpaena brasiliensis Cuvier, 1829) in the southwestern Atlantic Ocean (Brazilian coast): epidemiologic, clinic and therapeutic aspects of 23 stings in humans. Toxicon. 2003;42:79–83. 51. Haddad V Jr, Pardal PPO, Cardoso JLC, Martins IA. The venomous toadfish Thalassophryne nattereri (niquim or miquim): report of 43 injuries provoked in fishermen of Salinópolis (Pará state) and Aracaju (Sergipe state). Rev Inst Med Trop São Paulo. 2003;45:221–3. 52. Haddad V Jr, Garrone Neto D, Paula Neto JB, Marques FPL, et al. Freshwater stingrays: study of epidemiologic, clinic and therapeutic aspects based in enzimatic activities of the venom. Toxicon. 2004;43:287–94. 53. Haddad V Jr, Martins IA. Frequency and gravity of human envenomations caused by marine catfish (suborder Siluroidei): a clinical and epidemiological study. Toxicon. 2006;47:838–43. 54. Haddad V Jr, Souza RA, Auerbach P. Marine catfish sting causing fatal heart perforation in a fisherman. Wilderness Environ Med. 2008;19:114–8. 55. Haddad V Jr. Brazil’s potentially dangerous aquatic animals: a medical and biological guide. São Paulo: Editora Roca; 2008. 56. Leme FCO, Negreiros MMB, Koga FA, Bosco SMG, Bagagli E, Haddad V Jr. Evaluation of pathogenic fungi ocurrence in traumatogenic structures of freshwater fish. Rev Soc Bras Med Trop. 2011;44:182–5. 57. Haddad V Jr, Cardoso JLC, Garrone Neto D. Injuries by marine and freshwater stingrays: history, clinical aspects of the envenomations and current status of a neglected problem in Brazil. J Venom Anim Toxins Incl Trop Dis. 2013;19:16. 58. Haddad V Jr, et al. Report of 15 injuries caused by lionfish (Pterois volitans) in aquarists in Brazil: a critical assessment of the severity of envenomations. J Venom Anim Toxins Incl Trop Dis. 2015;21:8.

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59. Aquino GNR, Souza CC, Haddad V Jr, Sabino J.  Injuries caused by the venomous catfish pintado and cachara (Pseudoplatystoma genus) in fishermen of the Pantanal region in Brazil. An Acad Bras Ciênc. 2016;88:1–7. 60. Carvalho IEM, Silva GVF, Haddad V Jr, Wosnick N, Nunes JLS. Lesão com infecção secundária e sequelas graves causadas por um peixe-robalo (Centropomus spp.) em um ­pescador (Lesion with secondary infection and serious sequelae caused by a bass fish (Centropomus spp.) in a fishermen). Rev Bras Saude Ocup. 2021;46:1–6. 61. Haddad V Jr, Giarizzo T, Soares MO.  Lionfish envenomation on the Brazilian coast: first report. Rev Soc Bras Med Trop. 2022;55:e0241. 62. Paula Neto JB, Ribeiro RSP, Luz JA, Galvão M, Carvalho SMD, Haddad V Jr. Clinical and epidemiological characteristics of injuries caused by venomous snakes observed at the Hospital for tropical diseases of Araguaína, Tocantins State, Brazil, from 1995 to 2000. J Venom Anim Toxins Trop Dis. 2005;11:422–32. 63. Cardoso JLC, et  al. Ofidismo (Ophidism). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. 64. Lima PHS, Haddad V Jr. A snakebite caused by a bushmaster (Lachesis muta): report of a confirmed case in state of Pernambuco, Brazil. Rev Soc Bras Med Trop. 2015;48:636–7.

Conclusions

Several lesions caused by venomous animals occur by the action of toxins on and within the skin, causing manifestations that can be confused with other skin diseases. The knowledge about these envenomations and their differential diagnoses is important for dermatologists and clinicians, allowing diseases to be diagnosed and treated at early stages, which almost always interfere with the prognosis of the injury.

References 1. Ministério da Saúde. Manual de diagnóstico e tratamento de acidentes por animais peçonhentos (Guideline of diagnosis and treatment of envenomations caused by animals). BRASIL, Health Ministry. Brasília: Ministério da Saúde, Fundação Nacional de Saúde; 1997. Portuguese. 2. Haddad V Jr, Cardoso JLC. Dermatoses provocadas por animais venenosos (dermatosis caused by venomous animals). An Bras Dermatol. 1999;74:441–7. 3. Haddad V Jr. Tropical dermatology: venomous arthropods and human skin part I. J Am Acad Dermatol. 2012;67(331):e1–331.e14. 4. Haddad V Jr, Cardoso JLC, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin part II. J Am Acad Dermatol. 2012;67(347):e1–347.e9. 5. Haddad V Jr, Amorim PCH, Haddad WT Jr, Cardoso JLC. Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries. Rev Soc Bras Med Trop. 2015;48:650–7.

Poisonous Beetles 6. Diógenes MJN. Dermatite de contato pela pederina, estudo clínico e epidemiológico no Estado do Ceará, Brasil (Pederin contact dermatitis, clinical and epidemiological study in the State of Ceará, Brazil). Rev Inst Med Trop. 1994;36:59–65. Portuguese.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Haddad Jr., Envenomations Caused by Animals, https://doi.org/10.1007/978-3-031-35084-9

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Millipede 9. Haddad V Jr, Cardoso JLC, Rotta O, Eterovic A. Acidentes provocados por Millipede com manifestações dermatológicas: relatos de dois casos. An Bras Dermatol. 2000;75:471–4. Portuguese. 10. Cardoso JLC, Haddad V Jr. Acidentes por Coleópteros vesicantes e outros artrópodos. (Injuries caused by vesicant coleoptera and other arthropoda). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. Portuguese. 11. Lima CAJ, Talhari S, Haddad V Jr. Exogenous pigmentation in toes feigning ischemia of the extremities: a diagnostic challenge brought by arthropods of the Diplopoda class ("millipedes"). An Bras Dermatol. 2010;85:391–2. 12. Haddad V Jr, Manço DG. An unusual dark macular lesion in the plantar region of a child. Rev Soc Bras Med Trop. 2019;52:e20190011.

Pentatomidae: Stink Bugs 13. Haddad V Jr, Cardoso JL, Moraes RHP. Skin lesions caused by insects of the order Hemiptera (Pentatomidae): first report of accidents in humans. Wilderness Environ Med. 2002;13:48–50. 14. Cardoso JLC, Haddad V Jr. Acidentes por Coleópteros vesicantes e outros artrópodos. (Injuries caused by vesicant coleoptera and other arthropoda). In: Cardoso JL, Fos F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. Portuguese.

Ants 15. Haddad V Jr, Cardoso JLC. Insetos (Insecta). Ants. In: Cardoso JL, FOS F, FH W, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). Editora Sarvier: São Paulo; 2009. Portuguese. 16. Haddad V Jr, Cardoso JLC, Morais RHP. Description of an injury in a human caused by a false tocandira (Dinoponera gigantea, PERTY, 1883) with a revision on folkloric, pharmacological and clinical aspects of the giant ants of the genera Paraponera e Dinoponera (sub-family Ponerinae). Rev Inst Med Trop. 2005;47:235–8.

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17. Conceição LG, Haddad V Jr, Loures FH. Pustular dermatosis caused by fire ant (Solenopsis invicta) stings in a dog. Vet Dermatol. 2006;17:453–5. 18. Cardoso JL, França FOS, Wen FH, Malaque MS, Haddad V Jr. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous Animals in Brazil: Biology, Clinic and Therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. 19. Haddad V Jr, Larsson CE. Anaphylaxis caused by stings from the Solenopsis invicta, lava-pés ant or red imported fire ant. An Bras Dermatol. 2015;90:22–5. 20. Haddad V Jr, Bicudo LRH, Fransozo A. The Triplaria tree (Triplaris spp.) and Pseudomyrmex ants: a symbiotic relationship with risks of attacks for humans. Rev Soc Bras Med Trop. 2009;42:727–9.

Bees and Wasps 21. Cardoso JLC, Haddad V Jr. Insetos (Insecta). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. 22. Campos Neto M, Haddad V Jr, Levi LMP, Magalhães CA. Massive attack of Africanized bees leading to death: case report-Cáceres-MT-Brazil. Int J Legal Med. 2012;126:248. 23. Machado M, Sousa DER, Landi MFA, et al. Reação tóxica sistêmica causada por picadas de abelhas em cães. Acta Sci Vet. 2018;46(Suppl 1):271.

Moths and Caterpillars 24. Cardoso AEC, Haddad V Jr. Accidents by Lepidoptera (larvae and adults of moths): study of epidemiological, clinical and therapeutic aspects (Portuguese). An Bras Dermatol. 2005;80:571–8. 25. JLC C, Haddad V Jr. Insetos (Insecta). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. 26. Moreira SC, Lima JC, Silva L, Haddad V Jr. Description of an outbreak of lepidopterism dermatitis associated with contact with moths among sailors in Salvador, Bahia state. Rev Soc Bras Med Trop. 2007;40:591–2. 27. Haddad V Jr, Lastória JC. Envenomation by caterpillars (erucism): proposal for simple pain relief treatment. J Venom Anim Toxins Incl Tropical Dis. 2014;20:21. 28. Criado PR, Haddad V Jr. The train tracks sign is a valuable skin marker of envenomations caused by caterpillars. Rev Soc Bras Med Trop. 2018;51:565.

Centipedes: Chilopoda 29. Haddad V Jr, Amorim PCH, da Cruz CR, Amaral ALS. Centipede envenomation (Chilopoda): case report. Rev Soc Bras Med Trop. 2021;55:e0601–2022.

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Spiders 30. Lucas MS. Spiders in Brazil. Toxicon. 1988;26:759–72. 31. Cardoso JLC, Haddad V Jr. Araneísmo (Arachnidism). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). Editora Sarvier: São Paulo; 2009. 32. Haddad V Jr, Cardoso JLC, Stolf HO.  Tratamento cirúrgico da úlcera loxoscélica; solução prática para um problema de difícil resolução (Surgical treatment of loxoscelic ulcer; practical solution to a difficult problem). Diagnóstico Tratamento. 2012;17:56–8.

Scorpions 33. Cardoso JLC, Haddad V Jr. Araneísmo (Arachnidism). In: Cardoso JL, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamentos dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). São Paulo: Editora Sarvier; 2009. p. 488. 34. Haddad V Jr, Cardoso JLC, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin part II. J Am Acad Dermatol. 2012;67:347.e1–9. 35. Haddad V Jr, PCH A, Haddad WT Jr, JLC C. Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries. Rev Soc Bras Med Trop. 2015;48:650–7.

Belastomatidae: Giant Water Bugs 36. Haddad V Jr, Schwartz EM, Schwartz CA, Carvalho LN.  Report of seven human envenomations caused by giant water bugs of Belostomatidae family (Hemiptera, Heteroptera). Wilderness Environ Med. 2010;21:130–3.

Venomous Beetles 37. Amaral ALS, Castilho AL, Borges AL, Haddad V Jr. Envenomations in humans caused by the venomous beetle Onychocerus albitarsis: observation of two cases in São Paulo state. Brazil J Clin Toxicol. 2018;8:1–2.

Cnidarians 38. Kingston W, Souhcott RV. Skin histopathology in fatal jellyfish stinging. Trans R Soc Trop. 1960;54:373–6. 39. Haddad V Jr, Cardoso JLC, França FOS.  Acidentes provocados por celenterados: aspectos clínicos e terapêuticos (Envenomations caused by coelenterates: clinical and therapeutic aspects). An Bras Dermatol. 1997;72:206–10.

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Sea Urchins 58. Cardoso JLC, Haddad V Jr. Animais Aquáticos (Aquatic animals). In: JLC C, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). Editora Sarvier: São Paulo; 2009. Portuguese.

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Venomous Fish 63. Haddad V Jr. Aquatic animals of medical importance. Rev Soc Bras Med Trop. 2003;36:591–7. 64. Haddad V Jr, Martins IA, Makyama HM.  Injuries caused by scorpionfishes (Scorpaena plumieri Bloch, 1789 and Scorpaena brasiliensis Cuvier, 1829) in the southwestern Atlantic Ocean (Brazilian coast): epidemiologic, clinic and therapeutic aspects of 23 stings in humans. Toxicon. 2003;42:79–83. 65. Haddad V Jr, PPO P, JLC C, Martins IA. The venomous toadfish Thalassophryne nattereri (niquim or miquim): report of 43 injuries provoked in fishermen of Salinópolis (Pará state) and Aracaju (Sergipe state). Rev Inst Med Trop São Paulo. 2003;45:221–3. 66. Haddad V Jr, Garrone Neto D, Paula Neto JB, Marques FPL, et al. Freshwater stingrays: study of epidemiologic, clinic and therapeutic aspects based in enzimatic activities of the venom. Toxicon. 2004;43:287–94. 67. Haddad V Jr, Martins IA. Frequency and gravity of human envenomations caused by marine catfish (suborder Siluroidei): a clinical and epidemiological study. Toxicon. 2006;47:838–43. 68. Haddad V Jr, Souza RA, Auerbach P. Marine catfish sting causing fatal heart perforation in a fisherman. Wilderness Environ Med. 2008;19:114–8. 69. Haddad V Jr. Brazil’s potentially dangerous aquatic animals: a medical and biological guide. São Paulo: Editora Roca; 2008. Portuguese. 70. Cardoso JLC, Haddad V Jr. Animais Aquáticos (Aquatic animals). In: JLC C, FOS F, Wen FH, Malaque MS, Haddad Jr V, editors. Animais Peçonhentos no Brasil: biologia, clínica e tratamento dos acidentes (Venomous animals in Brazil: biology, clinic and therapeutics). Editora Sarvier: São Paulo; 2009. Portuguese. 71. Leme FCO, Negreiros MMB, Koga FA, Bosco SMG, Bagagli E, Haddad V Jr. Evaluation of pathogenic fungi ocurrence in traumatogenic structures of freshwater fish. Rev Soc Bras Med Trop. 2011;44:182–5. 72. Haddad V Jr, Cardoso JLC, Garrone ND. Injuries by marine and freshwater stingrays: history, clinical aspects of the envenomations and current status of a neglected problem in Brazil. J Venom Anim Toxins Incl Trop Dis. 2013;19:16. 73. Haddad V, Stolf HO, Risk JY, França FO, Cardoso JL. Report of 15 injuries caused by lionfish (Pterois volitans) in aquarists in Brazil: a critical assessment of the severity of envenomations. J Venom Anim Toxins Incl Trop Dis. 2015;21:8. 74. Aquino GNR, Souza CC, Haddad V Jr, Sabino J.  Injuries caused by the venomous catfish pintado and cachara (Pseudoplatystoma genus) in fishermen of the Pantanal region in Brazil. An Acad Bras Ciênc. 2016;88:1–7. 75. Haddad V Jr. Medical emergencies caused by aquatic animals: a zoological and clinical guide. Cham: Springer; 2016. 76. Carvalho IEM, Silva GVF, Haddad V Jr, Wosnick N, Nunes JLS.  Lesão com infecção secundária e sequelas graves causadas por um peixe-robalo (Centropomus spp.) em um pescador (Lesion with secondary infection and serious sequelae caused by a bass fish (Centropomus spp.) in a fishermen). Rev Bras Saude Ocup. 2021;46:1–6.

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Index

A Acute pustulosis, 16 Africanized bees, 19 Ants, 13–18 Autonomic nervous system (ANS), 33

E Eczema, 4 Elapidae bites, 55 Erucism, 21 Eschar, 30

B Bacterial infections, 4 Banana spider, 27 Bees, 18–20 Beetles, 1, 36 Belastomatidae, 35 Black sea urchin, 45 Bothrops (Viperidae), 54, 56 Brown spider, 29

F Fire ant anthill, 14 Foreign body granulomas, 46

C Cantharidin/pederin discharge, 4 Caterpillars, 1, 20–25 Catfish, 47, 48 Centipedes, 25, 26 Chronic ulcers, 32 Cnidarians, 38, 40–43 Coleoptera (beetles), 3–6, 36–38 Coral snakes, 55 Cubomedusae, 39 D Dermatological diseases, 1

G Giant water bugs, 35 H Hylesia moths, 21 Hyperchromias, 43 I Irritant dermatitis, 28 Isolated bee sting, 19 J Jellyfish, 1 L Lachesis sp., 54 Lepidopterism, 20

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 V. Haddad Jr., Envenomations Caused by Animals, https://doi.org/10.1007/978-3-031-35084-9

71

72 Lionfish, 52 Local mild edema, 52 Loxosceles sp., 29 M Marble plaques, 29, 30 Marine and freshwater stingrays, 48 Millipedes, 6, 7 Moth larvae, 22 Moths, 20–25 Mygalomorphae spiders, 28 Myrmecia spp., 14 N Nematocysts, 38 Novice ant, 17 O Onychocerus albitarsis beetle, 37 P Paederus sp., 3, 4 Paraponera clavata, 13 Phoneutria sp., 27 Phylum echinodermata, 44 Poisonous animals millipedes, 6, 7 stink bugs, 9 Portuguese man-o´war, 39 Pustular psoriasis, 16 R Rattlesnakes, 54 S Scorpionfish, 51 Scorpions, 1, 33 Seabather´s eruption, 41 Sea urchins, 44–46 Skin surface lesions, 2 Snake envenomations, 58

Index Solenopsin A, 14 Solenopsis invicta, 14 Spiders, 1, 26–33 Stingray injuries, 50 Stink bugs, 9 Subcorneal pustulosis, 16 T Tocandira, 13 Typical coleopteran injury, 5 Typical ulcer, 32 U Ulcers, 30 Urticariform papules, 15 V Venom inoculations ants, 13–18 bees and wasps, 18–20 belastomatidae, 35 centipedes, 25, 26 cnidarians, 38, 41, 43 coleoptera, 36–38 moths and caterpillars, 20–25 scorpions, 33 sea urchins, 44–46 spiders, 26–33 venomous fish, 47–53 venomous snakes, 53, 55–58 Venomous and poisonous animals, 2 Venomous fish, 47–53 Venomous snakes, 53, 55–58 Veterinary medicine, 3 Viperidae´s bites, 56, 57 W Wandering/banana spiders, 26, 27 Wasps (Vespidae), 18–20 Y Yellow scorpion, 34