Arthropod bites and stings

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Arthropod bites and stings
Other namesBug bite
Tick bite.jpg
Tick bite
Symptoms Swelling, itching, pain
Complications Anaphylaxis, envenomation, disease transmission

Many species of arthropods (insects, arachnids, millipedes and centipedes) can bite or sting human beings. These bites and stings generally occur as a defense mechanism or during normal arthropod feeding. While most cases cause self-limited irritation, medically relevant complications include envenomation, allergic reactions, and transmission of vector-borne diseases. [1]

Contents

Signs and symptoms

The left side of the image is showing the temperature increase caused by an insect bite after about 28 hours. Thermal effects of Insect bite by Volkan Yuksel IR001666.jpg
The left side of the image is showing the temperature increase caused by an insect bite after about 28 hours.

Most arthropod bites and stings cause self-limited redness, itchiness and/or pain around the site. Less commonly (around 10% of Hymenoptera sting reactions), a large local reaction occurs when the area of swelling is greater than 10 centimetres (4 in). Rarely (1-3% of Hymenoptera sting reactions), systemic reactions can affect multiple organs and pose a medical emergency, as in the case of anaphylactic shock. [2] [3]

Defensive and predatory bites and stings

Many arthropods bite or sting in order to immobilize their prey or deter potential predators as a defense mechanism. Stings containing venom are more likely to be painful. Less frequently, venomous spider bites are also associated with morbidity and mortality in humans.

Most arthropod stings involve Hymenoptera (ants, wasps, and bees). While the majority of Hymenoptera stings are locally painful, their associated venom rarely cause toxic reactions unless victims receive many stings at once. The low mortality (around 60 deaths per year in the US out of unreported millions of stings nationwide) associated with Hymenoptera is mostly due to anaphylaxis from venom hypersensitivity. [4]

Most scorpion stings also cause self-limited pain or paresthesias. Only certain species (from family Buthidae ) inject neurotoxic venom, responsible for most morbidity and mortality. Severe toxic reactions can occur resulting in progressive hemodynamic instability, neuromuscular dysfunction, cardiogenic shock, pulmonary edema, multi-organ failure, and death. Although robust epidemiological data is unavailable, global estimates of scorpion stings exceed 1.2 million resulting in more than 3000 deaths annually. [5]

Spider bites most often cause minor symptoms and resolve without intervention. Medically significant spider bites involve substantial envenomation from only certain species such as widow spiders and recluse spiders. Symptoms of latrodectism (from widow spiders) may include pain at the bite or involve the chest and abdomen, sweating, muscle cramps and vomiting among others. By comparison, loxoscelism (from recluse spiders) can present with local necrosis of the surrounding skin and widespread breakdown of red blood cells. Headaches, vomiting and a mild fever may also occur. [6]

Feeding bites

Feeding bites have characteristic patterns and symptoms that reflect feeding habits of the offending pest and the chemistry of its saliva. Feeding bites are less likely to be felt at the time of the bite, although there are some exceptions. Since feeding requires longer attachment to prey than envenomation, feeding bites are more often associated with vector transmission of disease. [7]

PestPreferred body partFelt at time of biteReaction
Mosquitoesexposed appendagesusually notLow raised welt, itches for several hours.
Midges and no-see-umsexposed appendagesusuallyItches for several hours.
Fleasprefer ankles and bare feetusuallyMay make red itchy welt; several days. Later bites are less severe.
Biting fliesany exposed skinpainful and immediatePainful welt, several hours.
Bed bugsappendages, neck, exposed skinusually notLow red itchy welts, usually several together resembling rash, slow to develop and can last weeks.
Hair Licepubic area or scalpusually notInfested area intensely itchy, with red welts at bite sites. See pediculosis.
Larval ticksAnywhere on body, but prefer covered skin, crevices.Usually not; may be scratched off before they are seen.Intensely itchy red welts lasting over a week.
Adult tickscovered skin, crevices, entire bodyusually notItchy welt, several days.
Mitesmainly on the trunk and extremitiesusually notIntensely itchy welts and papules that may last for days. See acariasis.

As vectors of disease

In addition to stings and bites causing discomfort in of themselves, bites can also spread secondary infections if the arthropod is carrying a virus, bacteria, or parasite. [8] The World Health Organization (WHO) estimates that 17% of all infectious diseases worldwide were transmitted by arthropod vectors, resulting in over 700,000 deaths annually. [9] The table below lists common arthropod vectors and their associated diseases. The figure below represents endemic areas of common vector-borne diseases.

VectorPathogen classDiseaseAnnual disease burden*
Mosquitoes

(Culicidae)

Arboviruses (Togavirus, Flavivirus, Bunyavirus)


Protozoa (Plasmodia)

Nematode (Wuchereriabancrofti)

Chikugunya, Zika, Yellow fever, Dengue, West Nile, California encephalitis, Japanese encephalitis, Equine encephalitis, Rift Valley fever

Malaria

Lymphatic filariasis

>300 million
Black flies

(Simuliidae)

Nematode (Onchocercavolvulus) River blindness >10 million
Assassin bug

(Reduviidae)

Protozoa (Trypanosomacruzi) Chagas disease >6 million
Sand fly

(Phlebotominae)

Protozoa (Leishmania) Cutaneous and visceral leishmaniasis >3 million
Ticks

(Ixodidae)

Arboviruses (Bunyavirus, Flavirus)


Bacteria (Rickettsia, Anaplasma, Ehrlichia, Borreliaburgdorferi, Coxiellaburnetti)

Protozoa (Babesia)

Heartland virus, Tick-borne encephalitis, Crimean-Congo hemorrhagic fever


Rocky Mountain spotted fever, anaplasmosis, ehrlichiosis, Lyme disease, Q fever


Babesiosis

>500,000
Tsetse flies

(Glossinidae)

Protozoa (Trypanosomagambiense, T. rhodesesiense) African sleeping sickness >10,000
Biting flies

(Tabanidae)

Nematode (Loa Loa) African eyeworm NA
Fleas

(Siphonaptera, Pulicidae)

Bacteria (Yersinia pestis, Bartonella henselae) Plague, Cat scratch fever NA
Lice

(Phthiraptera, Pediculidae)

Bacteria (Borrelia recurrentis, Rickettsia prowazekii, Bartonella quintana)Lice-borne relapsing fever, endemic typhus, Trench fever NA

*Estimated global number of cases annually according to WHO in 2017. [9] If a vector transmits multiple diseases, aggregate case numbers are listed. Rough estimates are only meant to provide a sense of scale. Unknown disease burden is listed as NA for not available.

Geographic distribution of major vector-borne diseases VBD GeoDist.jpg
Geographic distribution of major vector-borne diseases

Diagnosis

Low-magnification micrograph showing wedge-shaped perivascular inflammation (superficial dermal perivascular lymphoeosinophilic infiltrate), the histomorphologic appearance of an insect bite (H&E stain). Dermal perivascular lymphoeosinophilic infiltrate - very low mag.jpg
Low-magnification micrograph showing wedge-shaped perivascular inflammation (superficial dermal perivascular lymphoeosinophilic infiltrate), the histomorphologic appearance of an insect bite (H&E stain).

Most arthropod bites and stings do not require a specific diagnosis since they typically improve with supportive management alone. Certain bites and stings present with characteristic appearances and distributions. In general, however, dermoscopic findings of bitten or stung skin rarely aid in diagnosis. [11] Rather, patient history (recent travel to endemic areas, outdoor activities, and other risk factors) primarily guides the diagnostic approach, which can raise clinical suspicion for more serious complications like vector-borne diseases.

Microscopic appearance

Skin biopsies are not indicated for bites or stings, since the histomorphologic appearance is non-specific. Bites and stings as well as other conditions (e.g. drug reactions, urticarial reactions, and early bullous pemphigoid) can cause microscopic changes such as a wedge-shaped superficial dermal perivascular infiltrate consisting of abundant lymphocytes and scattered eosinophils, as shown in the adjacent figure: [12]

Prevention

Prevention strategies against arthropod bites and stings comprise measures for personal protection, travel advisories, public health and environmental concerns.

Personal protection

Travelers should seek to minimize outdoor activity during peak activity times and avoid high risk areas such as regions with known outbreaks or epidemics. Standing water and dense vegetation also commonly attract arthropods. Clothes covering most exposed skin can also provide a measure of physical protection, which may be augmented when the fabric is treated with pesticides such as Permethrin. Topical repellants such as N,N-diethyl-m-toluamide (DEET) is supported by a large body of evidence. [7]

Vaccines may also help prevent vector-borne diseases for eligible patients. For example, Japanese encephalitis, Yellow fever, and Dengue fever have FDA-approved vaccines available. Since they are relatively new vaccines, however, they are not standard of care as of 2023. Additionally, patients traveling to Malaria endemic regions are routinely prescribed Malaria chemoprophylaxis. [13]

Patients with a history of venom hypersensitivity may benefit from venom immunotherapy (VIT). Patients eligibile for VIT include those with a prior anaphylactic reaction to a venomous sting and who have IgE to venom allergens. VIT can help prevent future severe systemic reactions in select patients. [2]

Global health

International organizations such as WHO aim to reduce disease burdens of neglected tropical diseases, many of which are vector borne. [14] Such campaigns must incorporate multipronged approaches to consider global inequality, access to resources, and climate change.

Management

Most arthropod bites and stings require only supportive care. However, complications such as envenomation and severe allergic reactions can present as medical emergencies.

Supportive care

Local reactions to bites and stings are treated symptomatically. If a stinger is still embedded, manual removal can reduce further irritation. Washing the affected area with soap and water can help reduce risk of contamination. Oral antihistamines, calamine lotion, topical corticosteroids and cold compresses are common over the counter remedies to reduce itchiness and local inflammation. In more severe cases, such as large local reactions, systemic glucocorticoids are sometimes prescribed, although limited evidence supports their effectiveness. There are limited data to support one treatment over another. [15]

Medical emergencies

Systemic reactions from venom hypersensitivity can rapidly progress to a medical emergency. The mainstay of anaphylactic shock management is intramuscularly injected epinephrine. The patient should be stabilized and transferred to an intensive care unit. [2]

Toxic reactions to envenomation are similarly managed with medical stabilization and symptomatic treatment. Tetanus prophylaxis should be up to date but antibiotics are typically unnecessary unless a bacterial superinfection is suspected. Antivenom drugs have been created for certain species such as Centruroides scorpion stings, but these drugs are not yet widely available and so typically reserved for severe systemic toxicity. [15]

Several vector-borne diseases can present emergently.

Treatment of vector-borne diseases

After confirmation of diagnosis, antimicrobials are prescribed according to standard of care.

Biting and stinging arthropods

Aedes aegypti, the yellow fever mosquito, biting. Female mosquitoes feed on blood. This species is known for also transmitting yellow fever. Aedes aegypti biting human.jpg
Aedes aegypti , the yellow fever mosquito, biting. Female mosquitoes feed on blood. This species is known for also transmitting yellow fever.

A bite is defined as coming from the mouthparts of the arthropod. The bite consists of both the bite wound and the saliva. The saliva of the arthropod may contain anticoagulants, as in insects and arachnids which feed from blood. Feeding bites may also contain anaesthetic, to prevent the bite from being felt. Feeding bites may also contain digestive enzymes, as in spiders; spider bites have primarily evolved to paralyse and then digest prey. A sting comes from the abdomen; in most insects (which are all largely hymenopterans), the stinger is a modified ovipositor, [16] which protrudes from the abdomen. The sting consists of an insertion wound, and venom. The venom is evolved to cause pain to a predator, paralyse a prey item, or both. Because insect stingers evolved from ovipositors, in most hymenopterans only the female can sting. However, there are a few orders of wasp where the male has evolved a "pseudo sting" - the male genitalia has evolved two sharp protrusions which can deliver an insertion wound. However, they do not contain venom, so they are not considered a true sting. [17] In ants that bite instead of sting, such as the Formicinae, the bite causes the wound, but during the bite the abdomen bends forward to spray formic acid into the wound, causing additional pain. In arachnids that sting (all largely scorpians), the stinger is not a modified ovipositor, but instead a metasoma that bears a telson. [18] (Scorpians lack an ovipositor entirely and give birth to live young.)

Insects

The botfly lays its eggs in the wound after biting, causing an infection of parasitic maggots called Myiasis. Myiasis - Skin (51892436737).jpg
The botfly lays its eggs in the wound after biting, causing an infection of parasitic maggots called Myiasis.

Diptera (True flies)

Venom droplet from a wasp stinger. Wasp stings in humans can provoke a strong localised reaction, and rarely, anaphylaxis in those with a wasp sting allergy. Waspstinger1658-2.jpg
Venom droplet from a wasp stinger. Wasp stings in humans can provoke a strong localised reaction, and rarely, anaphylaxis in those with a wasp sting allergy.

Hymenoptera

Flea bites. Rarely, some species of fleas can also transmit secondary infections, such as flea-borne (murine) typhus. Fleabite.JPG
Flea bites. Rarely, some species of fleas can also transmit secondary infections, such as flea-borne (murine) typhus.

Siphonaptera (Fleas)

Louse bites. Lice do not carry disease. Fig.4.Louse bites.jpg
Louse bites. Lice do not carry disease.

Phthiraptera (Lice)

Other insects

Arachnids

White-tailed Spider bite WhiteTailedSpiderBite and spider.png
White-tailed Spider bite

Spiders

Mites

Scorpions

  • All species sting

Myriapoda

Related Research Articles

<span class="mw-page-title-main">Scorpion</span> Predatory order of arachnids

Scorpions are predatory arachnids of the order Scorpiones. They have eight legs, and are easily recognized by a pair of grasping pincers and a narrow, segmented tail, often carried in a characteristic forward curve over the back and always ending with a stinger. The evolutionary history of scorpions goes back 435 million years. They mainly live in deserts but have adapted to a wide range of environmental conditions, and can be found on all continents except Antarctica. There are over 2,500 described species, with 22 extant (living) families recognized to date. Their taxonomy is being revised to account for 21st-century genomic studies.

<span class="mw-page-title-main">Venom</span> Toxin secreted by an animal

Venom or zootoxin is a type of toxin produced by an animal that is actively delivered through a wound by means of a bite, sting, or similar action. The toxin is delivered through a specially evolved venom apparatus, such as fangs or a stinger, in a process called envenomation. Venom is often distinguished from poison, which is a toxin that is passively delivered by being ingested, inhaled, or absorbed through the skin, and toxungen, which is actively transferred to the external surface of another animal via a physical delivery mechanism.

<span class="mw-page-title-main">Chelicerata</span> Subphylum of arthropods

The subphylum Chelicerata constitutes one of the major subdivisions of the phylum Arthropoda. It contains the sea spiders, horseshoe crabs, and arachnids, as well as a number of extinct lineages, such as the eurypterids and chasmataspidids.

<span class="mw-page-title-main">Mutillidae</span> Family of wasps

The Mutillidae are a family of more than 7,000 species of wasps whose wingless females resemble large, hairy ants. Their common name velvet ant refers to their dense pile of hair, which most often is bright scarlet or orange, but may also be black, white, silver, or gold. Their bright colors serve as aposematic signals. They are known for their extremely painful stings,, and has resulted in the common name "cow killer" or "cow ant" being applied to the species Dasymutilla occidentalis. However, mutillids are not aggressive and sting only in defense. In addition, the actual toxicity of their venom is much lower than that of honey bees or harvester ants. Unlike true ants, they are solitary, and lack complex social systems.

<span class="mw-page-title-main">Fire ant</span> Genus of red ants

Fire ants are several species of ants in the genus Solenopsis, which includes over 200 species. Solenopsis are stinging ants, and most of their common names reflect this, for example, ginger ants and tropical fire ants. Many of the names shared by this genus are often used interchangeably to refer to other species of ant, such as the term red ant, mostly because of their similar coloration despite not being in the genus Solenopsis. Both Myrmica rubra and Pogonomyrmex barbatus are common examples of non-Solenopsis ants being termed red ants.

<span class="mw-page-title-main">Antivenom</span> Medical treatment for venomous bites and stings

Antivenom, also known as antivenin, venom antiserum, and antivenom immunoglobulin, is a specific treatment for envenomation. It is composed of antibodies and used to treat certain venomous bites and stings. Antivenoms are recommended only if there is significant toxicity or a high risk of toxicity. The specific antivenom needed depends on the species involved. It is given by injection.

<span class="mw-page-title-main">Apocrita</span> Suborder of insects containing wasps, bees, and ants

Apocrita is a suborder of insects in the order Hymenoptera. It includes wasps, bees, and ants, and consists of many families. It contains the most advanced hymenopterans and is distinguished from Symphyta by the narrow "waist" (petiole) formed between the first two segments of the actual abdomen; the first abdominal segment is fused to the thorax, and is called the propodeum. Therefore, it is general practice, when discussing the body of an apocritan in a technical sense, to refer to the mesosoma and metasoma rather than the "thorax" and "abdomen", respectively. The evolution of a constricted waist was an important adaption for the parasitoid lifestyle of the ancestral apocritan, allowing more maneuverability of the female's ovipositor. The ovipositor either extends freely or is retracted, and may be developed into a stinger for both defense and paralyzing prey. Larvae are legless and blind, and either feed inside a host or in a nest cell provisioned by their mothers.

<span class="mw-page-title-main">Stinger</span> Sharp organ found in various animals capable of injecting venom

A stinger is a sharp organ found in various animals capable of injecting venom, usually by piercing the epidermis of another animal.

<span class="mw-page-title-main">Jack jumper ant</span> Species of ant

The jack jumper ant, also known as the jack jumper, jumping jack, hopper ant, or jumper ant, is a species of venomous ant native to Australia. Most frequently found in Tasmania and southeast mainland Australia, it is a member of the genus Myrmecia, subfamily Myrmeciinae, and was formally described and named by British entomologist Frederick Smith in 1858. This species is known for its ability to jump long distances. These ants are large; workers and males are about the same size: 12 to 14 mm for workers, and 11 to 12 mm for males. The queen measures roughly 14 to 16 mm long and is similar in appearance to workers, whereas males are identifiable by their perceptibly smaller mandibles.

<span class="mw-page-title-main">Bee sting</span> Puncture wound caused by a bees stinger

A bee sting is the wound and pain caused by the stinger of a female bee puncturing skin. Bee stings differ from insect bites, with the venom of stinging insects having considerable chemical variation. The reaction of a person to a bee sting may vary according to the bee species. While bee stinger venom is slightly acidic and causes only mild pain in most people, allergic reactions may occur in people with allergies to venom components.

<span class="mw-page-title-main">Medical entomology</span> Study of insect impacts on human health

The discipline of medical entomology, or public health entomology, and also veterinary entomology is focused upon insects and arthropods that impact human health. Veterinary entomology is included in this category, because many animal diseases can "jump species" and become a human health threat, for example, bovine encephalitis. Medical entomology also includes scientific research on the behavior, ecology, and epidemiology of arthropod disease vectors, and involves a tremendous outreach to the public, including local and state officials and other stake holders in the interest of public safety.

<span class="mw-page-title-main">Wasp</span> Clade of insects

A wasp is any insect of the narrow-waisted suborder Apocrita of the order Hymenoptera which is neither a bee nor an ant; this excludes the broad-waisted sawflies (Symphyta), which look somewhat like wasps, but are in a separate suborder. The wasps do not constitute a clade, a complete natural group with a single ancestor, as bees and ants are deeply nested within the wasps, having evolved from wasp ancestors. Wasps that are members of the clade Aculeata can sting their prey.

<span class="mw-page-title-main">Centipede bite</span> Medical condition

A centipede bite is an injury resulting from the action of a centipede's forcipules, stinger-like appendages that pierce the skin and inject venom into the wound. Such a wound is not strictly speaking a bite, as the forcipules are a modified first pair of legs rather than true mouthparts. Clinically, the wound is viewed as a cutaneous condition characterized by paired hemorrhagic marks that form a chevron shape caused by the paired forcipules.

<span class="mw-page-title-main">Scorpion sting</span> Medical condition

A scorpion sting is an injury caused by the stinger of a scorpion resulting in the medical condition known as scorpionism, which may vary in severity. The anatomical part of the scorpion that delivers the sting is called a "telson". In typical cases, scorpion stings usually result in pain, paresthesia, and variable swelling. In serious cases, scorpion stings may involve the envenomation of humans by toxic scorpions, which may result in extreme pain, serious illness, or even death depending on the toxicity of the venom.

<span class="mw-page-title-main">Insects in medicine</span>

Insects have long been used in medicine, both traditional and modern, sometimes with little evidence of their effectiveness.

The toxicology of fire ant venom is relatively well studied. The venom plays a central role in the biology of Red imported fire ants, such as in capturing prey, and in defending itself from competitors, assailants, and diseases. Some 14 million people are stung annually in the United States, suffering reactions that vary from mild discomfort, to pustule formation, swelling, and in rare cases, systemic reactions followed by anaphylactic shock. Fire ant venoms are mainly composed (>95%) of a complex mixture of insoluble alkaloids added to a watery solution of toxic proteins. For the Red imported fire ant Solenopsis invicta Buren there are currently 46 described proteins, of which four are well-characterised as potent allergens.

<span class="mw-page-title-main">Biting</span> Behaviour of opening and closing the jaw found in many animals

Biting is a common zoological behavior involving the active, rapid closing of the jaw around an object. This behavior is found in toothed animals such as mammals, reptiles, amphibians and fish, but can also exist in arthropods. Myocytic contraction of the muscles of mastication is responsible for generating the force that initiates the preparatory jaw abduction (opening), then rapidly adducts (closes) the jaw and moves the top and bottom teeth towards each other, resulting in the forceful action of a bite.

<i>Leiurus abdullahbayrami</i> Species of scorpion

Leiurus abdullahbayrami is a species of scorpion in the family Buthidae. Its venom is highly toxic to humans, but can be used in medical development.

<i>Hemiscorpius lepturus</i> Species of scorpion

Hemiscorpius lepturus is a species of scorpion in the family Hemiscorpiidae. It is found in deserts of the Middle East, especially in southern Iraq and Iran. These scorpions have long, thin tails and wide bodies and grow to 8 cm in males and 5.5 cm in females, allowing them to live in tight rock crevices. They are fairly solitary creatures. H. lepturus has mainly been studied to discover the components and effects of its venom, which is highly lethal and is responsible for most deaths due to scorpion sting in the Iran area. H. lepturus is the only scorpion not in the family Buthidae that is potentially lethal to humans; the Buthidae family is the largest and most abundant family of scorpions, containing many highly venomous species.

References

  1. Powers J, McDowell RH (2022). "Insect Bites". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   30725920 . Retrieved 2023-02-09.
  2. 1 2 3 Golden DB, Demain J, Freeman T, Graft D, Tankersley M, Tracy J, et al. (January 2017). "Stinging insect hypersensitivity: A practice parameter update 2016". Annals of Allergy, Asthma & Immunology. 118 (1): 28–54. doi:10.1016/j.anai.2016.10.031. PMID   28007086.
  3. Goddard J (2002). Physician's guide to arthropods of medical importance . Boca Raton: CRC Press. pp.  14. ISBN   978-0-8493-1387-5.
  4. Reed H, Landolt PJ (January 2019). "Chapter 22 - Ants, Wasps, and Bees (Hymenoptera)". In Mullen GR, Durden LA (eds.). Medical and Veterinary Entomology (Third ed.). Academic Press. pp. 459–488. doi:10.1016/b978-0-12-814043-7.00022-4. ISBN   978-0-12-814043-7. S2CID   239396551.
  5. Chippaux JP, Goyffon M (August 2008). "Epidemiology of scorpionism: a global appraisal". Acta Tropica. 107 (2): 71–79. doi:10.1016/j.actatropica.2008.05.021. PMID   18579104.
  6. Braitberg G, Segal L (November 2009). "Spider bites - Assessment and management". Australian Family Physician. 38 (11): 862–867. PMID   19893831.
  7. 1 2 Herness J, Snyder MJ, Newman RS. Arthropod bites and stings. American family physician. 2022 Aug;106(2):137-47.
  8. Schorderet-Weber S, Noack S, Selzer PM, Kaminsky R (April 2017). "Blocking transmission of vector-borne diseases". International Journal for Parasitology. Drugs and Drug Resistance. 7 (1): 90–109. doi:10.1016/j.ijpddr.2017.01.004. PMC   5302141 . PMID   28189117.
  9. 1 2 Global vector control response 2017–2030. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO.
  10. Marselle, Melissa R.; Stadler, Jutta; Korn, Horst; Irvine, Katherine N.; Bonn, Aletta, eds. (2019). Biodiversity and Health in the Face of Climate Change. doi:10.1007/978-3-030-02318-8. ISBN   978-3-030-02317-1. S2CID   199491437.
  11. Chauhan P, Jindal R, Errichetti E (October 2022). "Dermoscopy of skin parasitoses, bites and stings: a systematic review of the literature". Journal of the European Academy of Dermatology and Venereology. 36 (10): 1722–1734. doi:10.1111/jdv.18352. PMID   35735046. S2CID   249955855.
  12. Alsaad KO, Ghazarian D (December 2005). "My approach to superficial inflammatory dermatoses". Journal of Clinical Pathology. 58 (12): 1233–1241. doi:10.1136/jcp.2005.027151. PMC   1770784 . PMID   16311340.
  13. Murray HW (August 2020). "The Pretravel Consultation: Recent Updates". The American Journal of Medicine. 133 (8): 916–923.e2. doi:10.1016/j.amjmed.2020.02.005. PMID   32179056. S2CID   212741346.
  14. Global report on neglected tropical diseases 2023. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.
  15. 1 2 Erickson TB, Cheema N (May 2017). "Arthropod Envenomation in North America". Emergency Medicine Clinics of North America. Wilderness and Environmental Medicine. 35 (2): 355–375. doi:10.1016/j.emc.2017.01.001. PMID   28411932.
  16. Gwaltney-Brant SM, Dunayer E, Youssef H (2018). "Terrestrial Zootoxins". In Gupta RC (ed.). Veterinary Toxicology. Elsevier. pp. 781–801. doi:10.1016/b978-0-12-811410-0.00058-1. ISBN   978-0-12-811410-0.
  17. Sugiura S, Tsujii M (December 2022). "Male wasp genitalia as an anti-predator defense". Current Biology. 32 (24): R1336–R1337. doi: 10.1016/j.cub.2022.11.030 . PMID   36538881. S2CID   254874084.
  18. van der Meijden A, Kleinteich T (April 2017). "A biomechanical view on stinger diversity in scorpions". Journal of Anatomy. 230 (4): 497–509. doi:10.1111/joa.12582. PMC   5345679 . PMID   28028798.