Stinging insects and ticks can cause problems for athletes who participate in outdoor sports or activities. At the very least, these stings or bites can lead to itchy and irritating skin conditions. On the more extreme end, these stings or bites may lead to serious anaphylactic reactions or Lyme disease. Therefore, it is important for sports medicine practitioners to recognize the potential conditions and dangers that may come from these insect bites and stings, and know how to institute appropriate treatment. Stinging insects belong to the order Hymenoptera, which includes bees, wasps and stinging ants, just to name a few. Hymenoptera stings reportedly cause anywhere from 40 to 150 deaths a year in the United States, with the vast majority of the deaths due to anaphylactic reactions. Approximately one in every 200 people is dangerously allergic to Hymenoptera venom. Those who participate in sports and other outdoor athletic activities are especially vulnerable to Hymenoptera stings. Yellow jackets and honeybees are often drawn to sports drink refreshment coolers, which athletes count on to stay hydrated during games. Yellow jackets and fire ants (which are especially problematic in the southern United States) can also sting athletes on practice fields. Key Treatment Recommendations For Varying Reactions To Bee Stings When a nonallergic athlete suffers a Hymenoptera sting, he or she may present with moderate to severe pain, a localized wheal, erythema, pruritis and edema. The honeybee has a barbed stinger and leaves its stinger and venom sac in the wound. (Other insects in this group do not have barbed stingers and may sting multiple times.) Since the honeybee leaves its barbed stinger imbedded in the skin, the first step in treatment is removing the stinger. One should scrape away the stinger with a fingernail, the edge of a credit card or a knife (if available). Do not use forceps or tweezers. If you grasp or handle the venom sac, it will compress and inject additional venom into the skin, causing a more severe sting. In some patients, more extensive local reactions may result and include severe pain, prolonged edema and intense erythema. These symptoms can last up to a week and may progress to infection and cellulitis. Insect stings can also result in systemic allergic reactions that range from mild to severe. Moderate reactions may include malaise, nausea, vomiting and wheezing. The most severe systemic reaction is anaphylaxis, resulting in hypotension, bronchospasm and laryngeal edema. Use cool compresses or ice for localized stings in nonallergic athletes. You would treat localized reactions in allergic patients the same way but administer antihistamines as well to reduce the inflammatory component of the reaction. In delayed local reactions that appear after 24 hours, one should consider a five-day course of prednisone. In the case of a severe allergic reaction, one should promptly administer subcutaneous injections of aqueous epinephrine 1:1000 in a dosage of 0.3 to 0.5 ml. You can repeat this injection in 20-minute intervals for a total of three injections. Ensure that the victim is in a supine position with his or her legs elevated. Contact emergency medical services as soon as possible. Aggressive resuscitation of the patient may be necessary in the event of respiratory or cardiac arrest. From a proactive standpoint, it is a good idea for coaches and team physicians to ask athletes if they have had severe reactions to insect stings so they can take the appropriate precautions. What You Should Know About Fire Ant Stings In the southern United States, particularly the Gulf region, the imported fire ants, Solenopsis richteri and S. invicta, account for many thousands of stings each year. As much as 40 percent of the population in infested urban areas may be stung each year and at least 30 deaths have been attributed to these insects. The fire ant grasps the skin with its jaws while it pivots and stings repeatedly with its abdominal stinger in a circular fashion. You may see two red puncta at the center of the stings. Immediate pain results but it quickly resolves. Small red wheals form and convert to vesicles within three to four hours. After 24 hours, the lesions typically become pustules with an erythematous rim. These pustules resolve in about 10 days. Multiple ant stings may cause a more serious systemic allergic reaction similar to those caused by other Hymenoptera species. These ants commonly bite the feet and lower legs. One should treat the bite area with cool compresses, antipruritic lotions and oral antihistamines, and scrupulously clean the area to prevent secondary bacterial infection. Recognizing The Symptoms Of Tick Bites Ticks are blood-sucking ectoparasites that typically live in grass, brush and wooded areas. Athletes are usually infested on the legs and feet while hiking or jogging through heavy grass or in the woods. The tick bite is usually inconsequential by itself, but the tick may act as a carrier of several organisms that may cause rickettsial, spirochetal, bacterial and parasitic infections. The tick bite itself is usually painless and may go unnoticed until the patient discovers a lump or notices a local reaction of an urticarial wheal or the formation of a pruritic area around an embedded tick. Some of the more important conditions that might affect the outdoor athlete include Rocky Mountain spotted fever and Lyme disease. Rocky Mountain spotted fever occurs in many parts of the United States but is prevalent in Oklahoma, Texas and the South Atlantic states. This condition is caused by Rickettsia rickettsii transmitted in the tick bite. The infection is seasonal. Most cases are reported between April 1 and Sept. 30, which corresponds to the increased activity of ticks. The principal vector in the western states is the wood tick Dermacentor andersoni. In the eastern states, it is the dog tick Dermacentor variabilis. In the south central states, it is the Lone Star tick Amblyomma americanum. The tick will transmit the disease after it has been attached for at least six hours. The incubation period ranges from three to 12 days. The onset of early symptoms is abrupt with fever, chills, headache, myalgia, arthralgia and generalized rash. The rash usually appears first on the wrists and ankles. The forearms, palms and soles become involved within hours at which time the symptoms become generalized. A Guide To Treating Tick Bites Treatment involves immediately removing the tick once it has been identified. Tick removal requires care and should not be performed with the fingers because of the danger of contracting a rickettsial infection. The proper technique for tick removal is to use forceps, tweezers or a thread attached as close as possible and pull upward with steady even pressure for several minutes until the tick is removed. Take care not to squeeze the tick’s body, which will cause infectious fluids to enter the skin. Do not rotate or twist the tweezers during the removal process because this may allow the forepart of the tick to break off within the skin. If the mouth parts do not come away or portions are left in the skin, remove them with a small punch biopsy. Do not apply hot water or heat packs since heat tends to induce the tick to regurgitate infected fluids into the skin. If the mouth parts are left below the skin surface, they may produce a nodule known as a tick bite granuloma. Once the tick has been removed, cleanse the area well with warm water and soap and disinfect it with isopropyl alcohol. Additional treatment should include doxicycline (except for pregnant women) or chloramphenicol for pregnant women. Continue therapy for at least three days after fever subsides. Diagnosing And Treating Lyme Disease Lyme disease is a multi-systemic condition that involves the skin, nervous system, joints and heart. It is caused by a tick born spirochete, Borrelia burgdorferi. The principal vector is the deer tick Ixodes scapularis. This malady is named for Lyme, Conn., where the first cases were reported in children. Lyme disease is now recognized on six continents and in at least 20 countries. It equally affects both sexes and people of all ages. The clinical picture is one of headache, stiff neck, myalgia and fever. Lyme disease has three primary stages. Stage 1 (flu-like stage) is the early infection phase with erythema chronicum migrans (85 percent of cases) at the site of the tick bite. Stage 2 (the cardiac and neurological stage) is the disseminated infection phase with characteristic signs and symptoms in the cutaneous system, nervous system and musculoskeletal sites. Stage 3 (chronic arthritis and neurological syndrome stage) is the late persistent infection phase with severe progressive arthritis, chronic encephalomyelitis, chronic fatigue syndrome, ataxic gait, spastic paresis and polyradiculopathy. One frequently makes the diagnosis solely on the knowledge that the individual was bitten by a tick and subsequently developed a skin lesion in the general area. The skin lesion, erythema chronicum migrans, is therefore the characteristic finding in Lyme disease. The skin lesion begins as a small vesicle or papule at the tick bite site that slowly enlarges and forms an erythematous ring or oval with a gradually clearing central area. Over the next few days, the erythematous lesion expands rapidly away from the bite area to form a single or double, broad, round-to-oval area of erythema. During the early stage with the skin lesion present, patients may develop fever and minor constitutional symptoms. The lesions usually disappear within four weeks of the infection. When treating Lyme disease and erythema chronicum migrans, the key is early administration of oral doxicycline for three weeks. Amoxicillin is recommended for younger children and for pregnant or lactating women. When treating patients who are allergic to the penicillins, using erythromycin for 30 days is recommended. Athletes can best prevent tick bites by wearing protective socks and boots with pant cuffs tucked into the socks while they are outdoors in tick country. They should also inspect all skin areas regularly for ticks and treat their socks and other outer clothing with repellents such as permethrin. Dr. Caselli is an Adjunct Professor in the Department of Orthopedic Services at the New York College of Podiatric Medicine. He is also a staff podiatrist at the VA Hudson Valley Health Care System and a Fellow of the American College of Sports Medicine.
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