Hoed Jojo

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INSECTS AND ALLERGIC REACTIONS

Hoedojo

*)Department of Parasitology Faculty of Medicine, Trisakti University

Abstrak

Serangga jika mengigit atau menyengat, memasukkan secret air liur atau racun sengat

yang dapat menimbulkan reaksi alergis. Jenis reaksi yang ditimbulkan akibat gigitan atau

sangatan serangga bagi penderita tertentu sangat bergantung kepada spesies serangga dan

macam alergan. Tanda-tanda dan gejala klinis reaksi alergis akibat gigitan atau sengatan

serangan dapat berupa gatal-gatal, pembengkakan, bintik-bintik merah, gantal-gantal dan

bintik-bintik merah, urtikaria, pembentukan macula, papula, bula vesikula, muntah-muntah,diare dan syok anafilaktik. Makalah ini mengulas peran nyamuk, tuma, pinjal, kutu busuk dan

lebah dalam pengembangan reaksi alergis akibat gigitan atau sengatannya. Selain itu morfologi

dan perilaku serangga yang terlibat, gejala klinis akibat gigitan atau sengatannya dan

diagnosis serta pengobatan penyakit yang terkait, juga disajikan secara singkat dalam makalah

ini. (J edokter Trisakti !"""#$% (!&')-*$&.

Kata kunci : alergi, gantalgatal, serangan, syok

Introduction

+nsects constitute the largest class in numbers of species in the phylum rthropoda. There

are some $,)"",""" species of insects belonging to the +nsect orders of major medical

importance (iptera, Siphonaptera, ymenoptera, /oleoptera& and the +nsect orders of minor

medical importance (noplura, emiptera, ictyoptera, 0epidoptera&. They share the

follo1ing arthropod characteristics segmented body 1ith paired, segmented appendages,

bilateral symmetry, chitinous e2oskeleton and have the body divided into three distinct parts,

the head, the thora2 and the abdomen. The thora2 bears three pairs of segmented legs and in

addition usually t1o

pairs of 1ings. ($&

/ontact 1ith insects through their bites or stings can result in adverse reactions in humans that

range from mild annoyance to anaphylactic shock and death. Mos3uitoes, lice, fleas and

bedbugs inject salivar y secretions and venoms through speciall y

adapted mouth parts for piercing and sucking blood, 1hereas bees and ants inject venoms

through speciali4ed structure, the stinger.

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Salivary secretions and venoms are capable of producing allergic reactions. +nitially, there

is no discernible response # this is follo1ed by the appearance of only a delayed reaction.

5oth immediate and delayed reactions usually occur 1ith further e2posure. evelopment of

an insect allergy is dependent not only on the species of insect and the si4e of

infestations, but also on the type of allergens as 1ell as the duration of e2posure. Signs and

symptoms of allergic reaction include pain, s1elling of the throat, redness or discoloration at

the site of bite6sting, itching, hives, decreased consciousness and difficult or nois y

breathing including shock.(!&

This paper is aimed to revie1 certain species of insects that give rise to allergic reactions,

1ith special discussions on the morphology and habits, clinical picture, diagnosis and

treatment.

Mosquito Bites

Morphoo!" and habits

Mos3uitoes belong to the order iptera. They are slender and relatively small

insects, usually measuring about 7-8 mm in insects, though some species, ho1ever, can be as

small as !-9 mm 1hile others may be as long as $" mm or more. This creature possesses

conspicuous for1ard projecting proboscis as the piercing sucking mouth part. female

mos3uito must bite a host6man and take a blood meal to obtain the necessary nutrients for

the development of the eggs in the ovaries. +n the process of biting mos3uito injects saliva

that contains coagulants and6or haemagglutinins into the dermis, and this acts as a sensiti4er.

:rominent immediate and delayed reactions occur commonly in the sites of mos3uito bites,

particularly in children. More severe local and6or systemic reactions occur much less

commonly.

Cinica #icture

5ites from mos3uito usually cause itching, red bumps, itchiness and a central raised dot in

the s1elling. +n addition, mos3uito bite is also characteri4ed morphologically by the formation

of erythermatous papule, often urticarial in nature. vesicle at the site, or even generali4ed

urticaria may recult, but more commonly a pruritic papule forms at the inoculation site. +nsevere infestations, vesicular papules, vesicles or bullae may accur. This allergic reaction

might sometimes last for several 1eeks and leaves hyper pigmentation.(9-)&

;2aggerated hypersensitivity responses to mos3uito bites have been reported in patients

suffering from chronic lymphatic leukemia.(8&

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Dia!nosis

The diagnosis of mos3uito bites is based on the history of an disorder, the

presence of purities, and the morphology of the lesions. +n the differential diagnosis, vasculitis

and irritant contact dermatitis should be considered. The diagnosis of mos3uito bites is also

made by funding the mos3utoes that inhabit d1ellings and their surroundings.

Treat$ent

Treatment of the patient due to mos3uito bites is by means of tropical

application of medication that kill the mos3uito such as the use of calamine

lotion 1ith or 1ithout menthol and phenol. 0ocali4ed application of patient1ith severe itching, 1ill often markedly reduce the pruritus and

inflammation.

Lice In%estation edicuosis'

:ediculosis is also referred to as lousiness. There distinct varieties of lice

involved, are recogni4ed as obligate parasites for humans. They are

:ediculus humanus capitis (head louse&, :ediculus humanus corporis (body

louse& and :hthirus pubis (pubic or crab louse&. They are members of the

order noplura. ;ach variety of louse has a predilection for certain parts of

the body, attaches itself to the skin and lives upon the blood that it sucks. +n

piercing the skin, louse e2udates an antigenic salivary secretion producing

an allergenic reaction. The mechanical puncture through the skin and

secondary onfection due to scraching.

#edicuosis Capitis


The causative agent of pediculosis capitis is :ediculus humanus capitis. This louse is grey-

1hite in colour, an active insect, 9-7 mm long, and the female being a little larget than the

male. 5oth se2es are e3uipped 1ith mouth parts adapted to sucking blood and legs

adapted to grasping hairs. dults feed voraciously on both the scalp and adjacent areas on

the face and

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neck. :ediculosis capitis is encountered principally in children, but occurs in adults too. Shared

beds and interaction 1ith playmates at school are the chief epidemiologic factors.

Cinica picture

The chief complaint in pediculosis capitis is usually itching on the scalp, neck and ears. +t

is also associated 1ith rash and may be follo1ed by irritability and depression. +tching is due to

an allergic reaction to the bites. 5ecause of the itching, secondary complications 1ith impetigo

and furunculosis are common. ood?s light, the

nits fluoresce a pale blue, 1hich facilitates harvest for e2amination.()&

Treat$ent

ttention ahould be paid very carefull y to treat head louse infestation. :atient 1ith

secondary infection due to pediculosis capitis should be first treated by the use of

antibiotics to prevent into2ication of pediculicide that has been used. ;ffective drugs for the

destruction of the lice and the ova are'

0indane (gamma ben4ene he2achloride& shampoo ($@& may be thoroughly massaged into the

scalp for 7-) minutes, 1ell rinsed out and the hair dried# remaining nits may be removed 1ith

a fine-tooh comb

cetylcholinesterase inhibiting insecticides malathion and carbaryl has replaced gamma

ben4ene he2achlorine follo1ing evidence of the development of resistance to organochlorine.

Malathion and carbaryl preparations should remain on the scalp for

$! hours before being 1ashed off.

Treatment should be repeatd after $" days.

(,*&

:ayrethrins from the e2tract of /hrysanthemums and the synthetic pyrethroid permethrin

have been e2tensively evaluated in the treatment of pediculosis capitis. They are applied to the

scalp for $" minutes and 1ashed out. Aetreatment in a 1eek is recommended. (8&

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Topical crotamiton ($"@& lotion has also

been used and should ramin for !7 hours application.

#edicuosis corporis


:ediculosis corporis is also kno1 as pediculosis vestimenti or vagabond?s disease.(7&

:ediculus humans corporis is the cause of pediculosis corporis. This louse tends to

aggregate in clothing most fre3uently touching the skin. Bor e2ample you might find

body lice on under1ear, areas around the armpits, the 1aist-line, and

neck. 5ody lice fre3uently remain on clothing but may be also found on the skin since

there insects are highly dependent on the presence of their host. To live, adult lice as in the

head lice, need to feed on blood as their nourishment.

Cinica picture

+n most infested persons itching is the principal complaint, and the signs usually being

confined to linear e2coriations on the trunk and neck. :ruritus is the result of sensiti4ation to

salivary antigens. /lose inspection may reveal hemorrhagic punctae or 1heals from fresh

bites. +n those 1ho have harbored body lice for long periods of time, as being continuously

e2posed, the skim is often hyper pigmented (so-called&

vagabond?s disease or morbus errorum&, and this is probably a postinflammatory phenomenon.

Dia!nosis

The diagnosis, as a rule, is readily established by the generali4ed itching, by parallel

scratching marks, by hyperpigmentation, and by erythematous macules. :ruritus and urticaria

may cause some confusion. The diagnosis is positivel y established by finding the lice or nits in

the seams of clothing or in bedding sloth. +n heavy infestation, lice and nits are easily found

on scalp hairs.

Treat$ent

s in pediculosis capitis, treatment is 1ith $@ lindane shampoo. ll parts of the head and

body should be lathered thoroughly for four minutes, and then rinsed free and to1el dried.

+nfested clothing and bed linen should be heat 1ashed or dry cleaned.(),&

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/lothing could also be treated 1ith gamma

ben4ene he2achloride, permethrin and malathion dusting po1der.(8&

#edicuosis #ubis


This disease 1hich is also referred as CphthiriaisD or Cpediculosis ciliaris6palpebrarumD, is

contacted chiefl y by the adults as the result of se2ual intercourse, and not infre3uently from

bedding. The cause of pediculosis pubis is :hthirus pubis (the body 6 crab louse&. /rab louse is

a rounded stubby louse, !-9 mm long, and possesses the second and the third legs that

terminate in to sturdy crab-like cla1s ideally suited in si4e and mechanical design to the task

of grasping and holding on tightly to pubic and other body hair. The louse 1ill coloni4e on

the scalp hair, a2illary hair, eyebro1s, eyelashes, beard and hair on the trunk and limbs, in

addition to pubic hair. This louse belongs to a vessel feeder (solenophages&, introducing its

mouth parts directly into a blood vessel to 1ithdra1 blood. (8,&

Cinica picture

The principal symptoms due to phthiriasis are itching, mainly in the evening and at night.

+tching in the adults occurs mainly in the pubic area but also in the a2illae. 5luegray macules

(maculae caeruleae& are occasionally seen on the skin as the result of continuous feeding thatdo not itch. These macules about ".) cm in diameter, are located chiefly on the sides of the

trunk and on the inner aspects of the

thighs.(&

5ullous lesions attributed to crab

lice infestation also have been reported. +n children e2posed to heavy infestation in parents

occasionally develop a troublesome infestation of the eyelashes kno1 as pediculosis

ciliaris6palpebrarum.(8&

The patients complain of itching burning,

and irritation of the eyes, and continually rub at them. The rising bleepharitis is

usually bilateral, and there are reddish crusting and matting of the eyelashes. oedojo in $%7reported a patient suffered from general urticaria for more than ten years due to infestation

of public lice as the disease 1as misdiagnosed and treated for other skin disease.(*&

Dia!nosis

:ediculosis pubis fre3uentlyco e2ists 1ith other se2ually transmitted diseases such as

gonorrhea, syphilis, trichomoniasis and candidiasis, the diagnosis of pediculosis pubis,

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therefore, should be intiated by a search for the above mentioned se2uall y transmitted

diseases.

Treat$ent

pplication of lindane lotion or cream to infested areas should be made and 1ashed off

eight hours later. >hereas lindane shampoo is applied for four minutes and 1ashed off

follo1ing attention that it should not be used in pregnant 1omen or nursing mother.(&

:ermethrin $@ /ream Ainse is kno1 to be

safe and at least as effective as gamme2ane and application could be made for ten

minutes and 1ashed off. second application is made in ten days. Therapy for mild eyelash

infestation could be made b y mechanical removal of lice and nits 1ith fine forceps, after

eight days (t1ice daily& of application of ordinary petrolatum. Bluorescein drops

(concentrations of $"- !"@& are also said to be effective.

(&

ll members of the familyand se2ual contacts 1ho are infested should be treated at the same time. /lothing should

be laundered and ironed. +n the treatment of pediculosis capitis, corporis as 1el as pediculosis

pubis, shaving the infested 1ay to delouse lice infestations.

(ea bites


Bleas belong to the order Siphonaptera. These insects are small ($-*mm long&, 1ingless,

laterally compressed creatures 1hose adults are blood-sucking ectoparasites of mammals andbirds. The species most fre3urntly parasiti4ing man, are cat and dog fleas (/tenocephalides felis

and /tenocephalides canis&, that is 1hy persons in contact 1ith cat and dog are fre3uentl y

bitten. Some attacks are e2perienced by individuals moving into long emptied d1ellings, but

previously occupied by pet cats and dogs. Bleas are ubi3uitous as are mos3uito and live by

attacking e2posed skin and e2tracting blood from the superficial capillaries for the purpose of

producing stimulant to lay eggs. >hen a flea bites for its blood meal, saliva (the

allergen& is injected into the skin to prevent blood clotting.

Cinica #icture

The clinical picture due to the bites of /.felis and /.canis involves a patient complaining

of itching 1ith multiple centrally e2coriated papules. The bites usually provoketypical

popular uriticaria often 1ith a haemorrhagic punctum in a sensiti4ed individual.

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or irregular clusters.(8,$"&

Dia!nosis

0esions in relation to cat and dog flea bites occur predominantly on the legs belo1 the

knees and are most profuse around the ankles, but they can also occur on the forearm

dependent on umprotected body parts. ;2amination of fleas collected from rooms 1ith a

vacuum cleaner or to visit the suspect premises is necessary. The presence of cat or dog in

and surrounding the patient?s d1elling may help the confirmation of flea bites diagnosis.

($"&

Treat$ent

Treatment of flea bites involves eradicating the fleas and symptomatic care of the pruritic

lesions. Spraying by concen trating on the sleeping places of cats and dogs 1ith 5aygone

inside the house or 1ith Malathion as outdoor spray is e2perienced to be most effective. The

pruritic skin lesions are best treated 1ith calamine lotion 1ith or 1ithout menthol ($@& and

phenol ($"@&, or a potent topical corticosteroid cream or gel. (8,&

Bedbu! Bites


5edbug belongs to the order hemiptera. The t1o most common members, /ime2

lectularius (the common bedbug& are primarily parasites of humans. /.hemipterus is resistricted

to tropical and subtropical regions including +ndia, Myanmar, Malaysia and +ndonesia.($&

5edbugs are 7-) mm in length, 1ith dorsoventrally flattened, oval

bodies, the fore1ings absent. The mouth part 1hich consists of mandibles and

ma2illae is used at night or under subdued light for feeding from blood vessels. uring

feeding the bedbug injects saliva containing an anticoagulant and anaesthetic. Aeactions to

bites are variable, depending on the allergic response.

Cinica #icture

The bites of the bedbug are usually painless seldom 1eaken the sleeper, and the attention of

the victim is only dra1n to the bites by the reaction they produce. The reaction evoked

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depends on the immunologic status of the host. 5edbug most often bites skin of the thigh,

buttock, neck, and arms, but may occasionally bite other parts of the body. +n the individual not

sensiti4ed by previous e2posure there ma y be no symptoms at any stage, and only a purpuric

macule indicates the site of the bite. +n sensiti4ed person intensely irritating oval or oblong

1heals often as large as 9 cm, or papules surmounted by haemorrhagic puncta are the

characteristic reaction. The bites are usually multiple and arranged in ro1s or clusters. +n some

cases 1here the reaction is severe, bullae predominate.(8,&

;2coriations fre3uently arranged in parallel tracks of t1o or three, as the 1heals are large

enough to reguire multidigit scratching for satisfaction. +n younger age groups, bedbug bites

may cause popular unticaria. Aepeated feedings of large numbers for iron deficiency in

infants.(8&

Dia!nosis

+n establishing a diagnosis, the time at 1hich lesions appear is an important consideration.

>hen a child retires at night 1ithout lesions and regularly a1akens, the presence of

/.hemipterus should al1ays be inspected.

Treat$ent

ntiprurutic lotions containing menthol or phenol could be used for treating bedbug bites.

Topical steroid creams are effective, and in e2tensive reaction systemic antihistaminics are

useful. (&

Bee Stin!s


5ees belong to the order ymenoptera. Bour families of ymenoptera of special

significance are ' pidae (the honey bee&, 5ombidae (the bumble bee&, Eepidae

(1asps, hornets, and yello1 jackets&, and Bormidae (ants&. These creatures have body

regions consisting of head, thora2, and abdomen. hen man is stung by a honey bee, the beeis

unable to remove the stinger. The stinger and venom apparatus are evulsed from the bee?s

abdomen in its strunggle, but the venom apparatus continues to function and pump in

more venom as this bee possesses a barbed stinger.

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an unbarbed stinger, and is therefore able to sting repeatedly.(8&

5ees insert the posteriorly

located stinger into the victim?s skin and may give rise to reactions varying from local

discomfort to fatal anaphyla2is.

Cinica #icture

oney bee?s venom contains polypeptide mellitin, phospholipase !, histamine,

hyaluronidase and apamin. oney bee (pis mellifera& sting, therefore, are dangerous

essentially for individuals 1ho are at risk. Systemic reactions from the sting may occur

through multiple stings. To2ic reactions due to honey bee stings include vomiting, diarrhea,

shock, and renal failure. Most fatalities due to the stings have follo1ed the occurrence of more

than )"" stings.(),8&

Dia!nosis

The first step in establishing the diagnosis is to kno1 1hich types of bees the patient is

allergic to. >hat usually occurs is a local reaction, paint at the site of the sting and may be a

small amount of s1elling and redness that subsides after a fe1 days. hen people have severe allergic reactions, they may be s1elling around

the ayes, lips, tongue or hand, and may feel like it is difficult breath get air and also have a

drop in blood pressure, feel faint, even lose consciousness.

Treat$ent

;arly removal of the stinger by simpl y s3uee4ing and or pulling out could be conducted

($@&, hyaluronidase, and lidocaine (!@& injected into the site provides immediate and often

lasting relief.(),8&

Bor patient 1ith anaphylactic reaction treatment could be made by

injecting (subcutaneousl y or intravenously, or by nebuli4er&, epinephrine, aminophylline,

antihistamines, corticosteroid, and generally accepted antishock measures the use of local ice

dnacks and tourni3uets is also common ()&

Concusion

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The cause of allergic reactions may be

due to the bites of mos3uitoes, lice, fleas, and bedbugs, or by 1ay of the stings of bees.

Symptoms of allergic reactions among other things include itching, hives, s1elling, vomiting,

diarrhea and shock. The diagnosis and treatment of allergic reactions are dependent on the

species of insects and the deseases involved.

Re%erences

$. James MT, ar1ood AB. erm?sMedical ;ntomology. 8th

ed. 0ondon' The

Macmillan /ompany# $%8%.p.$%- !9.

!. :erlman, B. ermatologic llergy' +mmunology, iagnosis Management.:hiladelphia' >5 Saunders /ompany# $%8.p.!!!-79.

9. ahl ME /linical +mmuno- dermatology. 0ondon' Fear 5ook Medical :ublishers#

$%*!.p.!9%-77.

7. oedojo. 5ionomics of nopheles barbirostris in several areas in +ndonesia.

Scientific Meeting of Malaysia Society of :arasitology and Tropical Medicine. :enang,

Malaysia#$%*!.

). enenhol4 , /rissey JT. /utaneous +nfestations. +n' Maldonado AA, :arish 0/, 5eare

JM. ;ds. Te2tbook of :ediatric ermatology. :hiladelphia' >5 Saunders /ompany#

$%*%.p.)))-8".

8. 5urnd . iseases /aused b y rthropods and other Go2ious nimals. +n'

/hampion A, 5urton J+, ;bling BJH.eds. Te2tbook of ermatology. Eo.!. )th

ed.

0ondon' 5lack1ell

Scientific :ublications, $%%9.p.$!8)-%9.

. rnold 0,5 Sauders /ompany,$%%",p )$! I ).

*. oedojo. /ases of :hthiriasis in Jakarta, +ndonesia. +nternastional Scientific Meeting on

:arsditology and Tropical Medinice. Manila, =niversity of the :hilippines# $%7.

%. >irt4 A, 4ad B. +njurious arthropods. +n' Srickland HT.ed. unter?s Tropical

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Medicine. th ed. :hiladelphia' >5 Saunders /ompany, $%%$.p.*%9-%.

$". oedojo, +dris, G. ermatitis due to cat flea?s (/.felis& bites. Maj edokt +ndon $%*"#

9"(7&'$"78.

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