4-57
Assesment: Diagnose based on the history of millipede handling or identification of the specimen.
Differential Diagnosis: Centipede bite and caterpillar (Lepidoptera) “sting” (see topics in this chapter
and on CD-ROM).
Plan:
Treatment
- Irrigate exposed eye promptly with copious amounts of water or saline to dilute toxin. If conjunctival ulcer
is noted, see Symptom: Eye Problems: Eye Injuries. - Wash exposed skin thoroughly with soap and water to remove any remaining toxin.
- Apply topical steroid cream (1% hydrocortisone) as needed to skin. Do not use steroids in the eye.
- Supportive therapy with ice/cold; acetaminophen or NSAIDs (see Symptom: Joint Pain for NSAIDs doses)
may be comforting.
Patient Education
Prevention: Avoid handling millipedes. Use caution when turning soil and when picking up or climbing
over rocks.
No Improvement/Deterioration: Return promptly for continuing eye pain or deteriorating vision.
Follow-Up Actions
Return Evaluation: Examine involved eye(s) daily until healed. No further exams needed for skin lesions.
Evacuation/Consultation criteria: Evacuation not necessary unless conjunctival ulcer is large or does not
heal in 24-48 hours. Consult ophthalmologist or primary care physician, or entomologist as needed.
Skin: Hymenoptera Stings
(bees, wasps, hornets, yellowjackets, and ants)
COL Roland J. Weisser, Jr., MC, USAIntroduction: The stinging insects of the order Hymenoptera include bees, wasps, hornets, yellow jackets
and ants. Hymenoptera stings are a nuisance for most victims who usually recover without sequelae. One
study reports 17-56% have a local reaction, 1-2% have a generalized reaction, and 5% seek medical care.
However, because the Hymenoptera are so ubiquitous and live in such close proximity to humans, they are
responsible for more human deaths each year than all other venomous animals combined. 50% of fatalities
occur within the first hour, and 75% occur within four hours after the sting. The venom load from 30 wasp or
200 honeybee stings may be sufficient to cause death. Alternately, a single sting may provoke a generalized
anaphylactic reaction (the proteinaceous venom is a potent activator of the immune system) and death in
a sensitized individual, particularly if there was an earlier, milder generalized reaction. The shorter the
time interval since the previous challenge, the more likely a severe subsequent reaction. Additionally, cross-
reactions to the venoms of various members of the Hymenoptera family have been reported. For example, an
individual who suffers an anaphylactic reaction to a wasp bite may also simultaneously develop anaphylaxis
to ant bites. Hymenoptera are social insects that live in colonies or hives located in caves, hollow trees or in
the ground. They are most often found among flowers and fruit where they feed, and are probably attracted
by bright colors, perfumes and colognes.
Bees have a stinger with a specialized tip that not only penetrates the skin and delivers venom, but
possesses a barb that anchors the stinger in the skin. The bee is able to sting only one time, because the
barbed stinging apparatus remains in the victim when the bee flies away causing evisceration and death of
the insect. The so-called “killer bees” are hybrids of species (e.g., European bees and African bees) that
evolved under different environmental conditions. While the individual venom and sting are no different from
other species, “killer bees” tend to be overtly aggressive, are prone to “gang up” on victims, and may chase
intruders up to 150 meters.
Wasps, hornets, and yellow jackets are generally more aggressive than bees, and have a barbless stinger