Bites and Stings english

Bites and Stings

Most bites and stings in the Nordic region are benign and only cause mild to moderate symptoms. Some stings can lead to more serious symptoms, and the number of health-related cases can reach thousands every summer. Deaths are very rare, but occasional cases occur each year, primarily in the form of allergic reactions following bee stings, resulting in anaphylactic shock, with an estimated 2-3 deaths per year. Deaths from snake bites occur only sporadically, around one case per decade in Sweden.

A number of diseases transmitted from insects to humans (zoonoses) can cause very serious symptoms. Below is a brief summary of bites and stings from various causes.

SYMPTOMS (insect bites)

• Pain
• Swelling
• Redness
• Itching
• Discoloration
• Moderate general symptoms

TREATMENT

• Clean the bite area with soap and water
• Apply cooling and decongestant local treatment, such as an ice pack. Alternatively, you can apply a cooling gel or special insect gel (e.g., Mygga – contains menthol and eucalyptus oil).
• Avoid scratching the bite area.
• Remove any remaining stinger or mouthparts with tweezers if possible. Avoid crushing the bee’s stinger.
• Topical anesthetics in ointment form relieve itching, e.g., Xylocain ointment 5%.
• Oral antihistamines, e.g., desloratadine (Aerius) or cetirizine (Zyrlex) 10 mg orally (not for children < 6 years) or loratadine (Clarityn) 10 mg x 1. For children over 2 years with a body weight under 30 kg, give 5 mg x 1. For children under 30 kg, Clarityn syrup (loratadine) 1 mg/ml is recommended rather than tablets.
• Hydrocortisone cream locally, e.g., Hydrocortisone CCS or Mildison for swelling.
• Antiseptic cream locally, e.g., LHP 1%, which contains hydrogen peroxide.

Mosquito Bites

Mosquito bites are common every summer, particularly in humid and warm conditions, especially in the evenings and at night in wooded areas or near bodies of water. There are more than 30,000 different types of mosquitoes, about 2,000 of which are found in Sweden. Primarily, two types of mosquitoes are found: forest mosquitoes (Aedes communis) and floodwater mosquitoes (Aedes sticticus). Only the female mosquito sucks blood. Local outbreaks of mosquito infestations often lead to nicknames such as “subway mosquitoes,” “kamikaze mosquitoes,” or “Majorna mosquitoes.”

In exotic countries, mosquitoes often spread serious diseases such as malaria, yellow fever, dengue fever, Japanese encephalitis, chikungunya virus infection, equine encephalitis, Rift Valley fever, West Nile fever, Wuchereria, and Zika virus. Vaccines are available for Japanese encephalitis, yellow fever, and partially for dengue fever (not registered in Sweden). Yellow fever is a viral disease transmitted by mosquitoes and is found in parts of Africa and South America. It is a life-threatening disease with high mortality rates.

Forest Mosquitoes

• Forest mosquitoes are primarily active at dawn and dusk. They take their time before biting and can fly up to two kilometers from their breeding grounds. Only the females bite to suck blood. The mosquitoes can live for up to two months.
• Forest mosquitoes lay their eggs in puddles and areas with significant snowmelt.
• Most bites occur peripherally on the extremities, i.e., around the ankles and wrists.
• Mosquitoes are active from June, peak around midsummer, and decrease in numbers during July.

Floodwater Mosquitoes

• Floodwater mosquitoes are active throughout the daylight hours and can bite even in midday sunshine.
• Floodwater mosquitoes are more aggressive and bite immediately upon contact with humans.
• They can fly up to 20 kilometers from their breeding grounds and remain active until September.
• Floodwater mosquitoes lay their eggs on moist ground, and the eggs can survive for many years.
• Several generations of floodwater mosquitoes can develop over the course of a summer, causing significant mosquito problems.

General Information

• Different people attract mosquitoes to varying degrees, but they are primarily drawn to warm and sweaty skin. Alcohol consumption, which increases blood flow, raises the risk of bites. People’s odors and sweat tendencies play some role, while blood type plays a lesser role. According to a Japanese study on tiger mosquitoes, these mosquitoes prefer people with blood type O.
• Mosquito bites swell and redden but rarely become infected unless the skin is scratched and torn, allowing bacteria from the skin flora to enter the wound.
• When bitten by a mosquito, let it finish sucking to allow it to aspirate its saliva at the end, which may leave less itching behind.
• Mosquito bites can be somewhat prevented by wearing light, cool clothing or by applying mosquito-repellent creams or gels (“repellents” – spray or gel). Repellents contain ingredients such as DEET (N,N-diethyl-meta-toluamide). Modern repellents are often highly effective and lead to fewer mosquito bites than various mosquito traps in gardens. Examples of effective repellents include “Smidge,” “Care Plus Anti-Insect Deet,” and “Halley.”
• Symptoms after mosquito bites can be relieved with cold applications, such as an ice pack or cooling balm. A range of home remedies of varying quality are described, such as applying yogurt or lime to the skin. For medical treatment, see above.
• Mosquito bites in Sweden rarely cause serious illnesses. Cases of mosquito-borne tularemia (rabbit fever) do occur. Tularemia is caused by the bacterium Francisella tularensis. Horseflies, ticks, and blackflies can also spread this bacterium. Tularemia can cause high fever, nausea, and headache. A pus-filled sore develops after the mosquito bite, and the lymph nodes become tender and swollen. The infection is treated with antibiotics, such as doxycycline or streptomycin.
• Ockelbo disease, previously called berry-pickers disease or Pogosta disease, is caused by a virus called Sindbis virus, transmitted by mosquitoes. Symptoms include rash, joint pain, fatigue, and fever. Symptoms are usually mild and transient, but joint pain has become prolonged in some cases. The disease is most common in late summer and early autumn. The rash is fine-spotted, and pain has been described in areas such as the hands and feet.
• Ingåvirus has mainly occurred in Finland. The disease is caused by a virus called Bunyavirus, spread by mosquitoes. The infection is usually subclinical but can present with meningitis.
• In 2015 and 2016, global alerts were issued about the dangerous Zika virus, which can be transmitted by mosquitoes. The disease occurs in South and Central America, Southeast Asia, and Africa. The severity is due to suspected serious neurological malformations in fetuses if the infection is transmitted during early pregnancy. Several children have been born with microcephaly. The course of the disease itself has been relatively benign with mild flu-like symptoms, sometimes entirely asymptomatic. The disease may present with a maculopapular rash, itching, joint pain, conjunctival injection, and lymphadenopathy. Suspicions of connections to fetal death, placental insufficiency, growth restriction, and Guillain-Barré syndrome also exist.
• Several serious diseases can be spread by mosquitoes in exotic countries. These include malaria, West Nile virus, yellow fever, dengue fever, Japanese encephalitis, equine encephalitis, chikungunya virus, Zika virus, and visceral leishmaniasis.

Dengue Fever

Dengue Fever has spread rapidly in recent years, with hundreds of thousands of cases across several continents. In Southeast Asia, dengue fever is common, but chikungunya fever and Japanese encephalitis also occur. For most mosquito-borne diseases, there is neither a vaccine nor specific treatment, but a vaccine with partial efficacy now exists for dengue fever. Vaccines are also available for yellow fever and Japanese encephalitis. Specific treatment is lacking and consists only of symptomatic relief, such as with paracetamol.

Dengue fever is spread via mosquitoes and is present in many countries in Africa, Asia, and Central and South America. The disease can become severe and require hospital treatment. Severe symptoms typically develop only after the second exposure to dengue. Symptoms resemble the flu, with fever, headache, back, muscle, and joint pain, and bloodshot eyes. Over 400 million people contract dengue fever each year worldwide. Many of them are Swedes who contract the disease while traveling, mainly in Thailand. If you have previously had dengue fever, your body has developed resistance to that particular strain of the virus. However, since the virus exists in four different variants, you can contract the disease again with one of the other types, which then leads to aggravated symptoms.

There is a registered vaccine for dengue fever, Dengvaxia, which is commercially available in several countries but not in Sweden. Dengvaxia is estimated to provide approximately 60% protection and is not generally recommended for tourists.

Blackflies (biting midges)

• Blackflies (Simuliidae) are a type of small fly (2-5 mm) with a rounded back and wide, fly-like wings. There are about 35 different species in Sweden. Blackflies bite, hence their colloquial name “biting midges.” Blackfly bites, like mosquito bites, primarily occur in the summer, especially in northern Sweden and at higher altitudes, such as in the mountain ranges.
• Blackfly attacks often result in a large number of bites at once.
• Like mosquitoes, blackflies are attracted to warm and moist skin. Blackfly bites cause the same symptoms as ordinary mosquito bites, but the bite itself can be painful.
• Avoid hiking in the mountains with exposed skin, avoid wearing short sleeves and shorts. Treatment is the same as for mosquito bites.

Horseflies/Deerflies

• Horsefly/deerfly is a type of two-winged fly that can bite humans and suck blood. Note that horseflies do not sting; they bite. “Deerfly” is a colloquial name that comes from the fly’s apparent lack of awareness when one tries to swat it away. Horseflies resemble flies but are usually slightly larger and bulkier. Horseflies fly silently and surprise their victims by landing suddenly on exposed skin. They primarily irritate horses and cows grazing in fields but also bite humans.
• There are no chemicals that protect against horseflies. Bites often result in a larger affected area of skin compared to mosquito bites. Redness with bruising (ecchymoses) causes the formation of a bruise, which can become as large as a hand. The bruising occurs because the horsefly injects coagulation-inhibiting enzymes into the skin when it bites.
• Treatment is primarily symptomatic, using anti-itch creams and cooling and disinfecting solutions, such as rubbing alcohol.

Moose Flies/Moose Lice

• The moose fly is a 5-7 mm long louse fly (Lipoptena cervi) that can bite humans. Normally, it bites and sucks blood from moose and other fur-bearing deer. The fly has claw-like feet that it uses to cling after landing, making it difficult to remove. Once attached, it sheds its wings, bites, and sucks blood. Moose flies are most common in late summer and early autumn in forested areas.
• Perfumes and other human scents can deter moose flies. When they land on humans, bites from up to twenty flies can occur simultaneously.
• Bites cause itching and swelling. Normally, it does not transmit diseases but may carry bacteria such as Bartonella schoenbuchensis.
• Treatment is mainly symptomatic with anti-itch creams and cooling, disinfecting solutions, such as rubbing alcohol.

Spider Bites

There are approximately 42,000 known species of spiders, around 600 of which are found in Sweden. Most are completely harmless to humans, but spiders still evoke strong discomfort and fear in some people. Common spiders in Sweden include the house spider, wolf spider, cross spider, cellar spider, harlequin spider, sector spider, and fat spider. Spiders vary in size and color but can be recognized by their eight legs arranged in four pairs.

All spiders are predators and can bite, but bites on humans are rare. The cross spider’s bite can cause local redness and swelling, but it is harmless, and the symptoms usually disappear quickly. A mildly venomous species found in southern Sweden is the hobo spider (Tegenaria agrestis). A spider that can cause more discomfort with its bite is the larger yellow sac spider (Cheiracanthium punctorium); its bite causes symptoms roughly on par with a wasp sting. The larger yellow sac spider is mainly found on Öland.

Exotic Spiders

• In other parts of the world, mainly in Africa, South America, and Australia, there are several venomous species, some of which can even be deadly to humans.
• The most famous venomous spider is the black widow (Latrodectus mactans), where the female has a characteristic red hourglass shape on her back. The black widow carries a potent venom, latrotoxin. However, the amount of venom injected is so small that its effects on humans are rarely serious, and deaths are extremely rare. The bite is painful, and the pain intensifies after a few days before subsiding. The black widow is primarily found in the southern and central USA, but relatives of the black widow are found in many parts of the world.

• In Australia, there are several venomous spiders that can cause serious reactions in humans. Among the most dangerous is the redback spider (Redback spider, Latrodectus hasselti), a type of widow spider that moves relatively slowly. The most dangerous spider is the Sydney Funnel-Web Spider (Atrax robustus), a type of funnel web spider. The spider is relatively large (about 3 cm long) and easily becomes aggressive. It often hides in shoes! The spider is equipped with two strong jaws and can inject a significant amount of venom, which can be dangerous to humans. Antivenom is available in Australia for bites from both the redback spider and the Sydney funnel-web spider, and it is administered to patients who develop systemic symptoms after a bite. Deaths occur sporadically among humans but are extremely rare. Since antivenom was developed in 1981, no fatalities have been recorded in Australia.

Bee Stings and Wasp Stings

• There are more than 100,000 species within the order Hymenoptera.
• Bee stings typically cause local pain and swelling, which usually subsides within a few days. A bee sting is significantly more painful than a mosquito bite. Bees and wasps generally sting only in self-defense when they feel threatened.
• Allergy to bee stings can develop at any age, typically after several harmless stings.
• Children are often stung more frequently than adults, but systemic reactions occur in only about 1% of children. A few people react more severely to these stings and may develop systemic symptoms, including general malaise, anxiety, and difficulty breathing.
• Bees inject more venom than wasps, which makes their sting more irritating. A bee’s sting has barbs, while a wasp’s sting does not. The bee’s sting is more likely to get stuck in the skin. Try to remove any remaining sting by scraping it off without squeezing it.

• Bee stings can cause anaphylactic shock, which can be life-threatening. Stings in sensitive areas, such as the tongue and throat, can also be life-threatening due to swelling and should be treated with intravenous or intramuscular corticosteroids to prevent airway obstruction.
• An uncomplicated bee sting can be treated locally with a cooling ice pack or cold compress, followed by an anti-itch or topical anesthetic, such as hydrocortisone cream or Xylocain ointment 5% 10g.
• A peripheral venous catheter (PVC) is inserted, and fluids in the form of crystalloid solution are administered for systemic symptoms, such as Ringer-Acetate 1000 ml.
• Systemic reactions should be treated with antihistamines and corticosteroids.
• Antihistamines, e.g., T. Aerius (desloratidin) 10 mg orally, or loratidin (Clarityn) 10 mg orally.

• A severe anaphylactic reaction must be treated with adrenaline, epinephrine (e.g., Epipen) 500/300/150 µg intramuscularly in the outer thigh.
  • For adults over 60 kg, 500 µg is recommended intramuscularly.
  • For adults and children between 20 and 60 kg, 300 µg is recommended intramuscularly.
  • For children weighing 10-20 kg, 150 µg is recommended intramuscularly.
• Beta-agonists (e.g., salbutamol) are administered by inhalation in cases of bronchial obstruction.

• Anaphylaxis should be treated and monitored in a hospital. See also Anaphylaxis – Adults and Anaphylaxis – Children.

One should avoid attracting bees and wasps by leaving food and sweets (especially juice) out in the open near their nests or colonies. When bees or wasps are nearby, avoid swatting or attacking them, as this can provoke them to sting. If attacked by a swarm, running away is the best option. Tobacco smoke and other smoke containing carbon monoxide can significantly reduce bee activity.

The image shows common wasps at the top and hornets at the bottom.

Tick Bites

• Tick bites are common after walking bare-legged in wooded or meadow areas, especially in tall grass. The tick species found in Sweden (Ixodes ricinus) bites into the skin unnoticed and then grows as it sucks blood, from a few millimeters to about 10 mm in size.

• Tick bites usually do not cause significant discomfort on their own, but they can transmit dangerous diseases, such as Borrelia, Rickettsia, TBE (Tick-Borne Encephalitis), and Anaplasmosis (Ehrlichia). In recent years, other pathogens such as neoehrlichia (Candidatus neoehrlichia mikurensis) have been discovered following tick bites.
• Neoehrlichia can cause complications such as thrombosis in the legs or blood vessels of the head. Other typical symptoms include fever, muscle pain, and joint pain.
• Ticks can carry multiple species of pathogenic microorganisms.
• If a tick is found on the skin, it should be removed as soon as possible by grasping the tick around the head with fine-tipped tweezers (or a special tick removal tool) and pulling it straight out. Care should be taken to remove all parts of the insect. Applying fat around the tick’s head is no longer recommended. The bite area should be washed with soap and water or rubbing alcohol after the tick is removed.
• If a single red spot (erythema migrans) larger than a Swedish five-krona coin appears, it should be treated with antibiotics such as phenoxymethylpenicillin (PcV), e.g., Kåvepenin (1 g x 3 for 10 days). The spread of redness should be treated with antibiotics with better CNS penetration, such as doxycycline 200 mg x 1 for 10 days. Redness smaller than a five-krona coin does not need to be treated with antibiotics unless general symptoms are present. If symptoms indicating TBE appear, the patient should be referred to an infectious disease specialist.

Borrelia (Lyme borreliosis)

• Borrelia is caused by a group of bacteria (Borrelia burgdorferi) spread by ticks. Ticks often acquire the bacteria from infected small rodents. The infection is rarer north of the Dalälven river.
• The incubation period varies from three days to up to a month. Approximately 10,000 people are estimated to contract Borrelia each year in Sweden. The highest risk is in southern and central Sweden, as well as along coasts and near lakes.
• Most people affected by Borrelia develop only local symptoms, such as redness and mild swelling around the bite site. The redness is usually rounded and ring-shaped but can also be asymmetrical. Typically, the redness spreads in a ring pattern outward from the bite site and fades centrally.
• Borrelia should be treated with antibiotics such as PcV or tetracyclines (doxycycline) for 10-21 days. Doxycycline is chosen if neurological symptoms are present. A vaccine is not yet available. Misdiagnosis of Borrelia is common.
• Untreated Borrelia can cause encephalitis with severe symptoms such as general malaise, fever, decreased consciousness, and weakness.
• See the separate treatment overview on Borrelia.

TBE (Tick-Borne Encephalitis)

• TBE is caused by a flavivirus spread by ticks. Every year, 150-200 cases are reported in Sweden. TBE primarily occurs in the southern and central parts of the country and is most common in the eastern regions around Lake Mälaren, in Uppland, and Södermanland.
• TBE manifests as encephalitis with high fever, severe headache, and sometimes seizures, as well as the development of peripheral neuropathy with numbness, tingling, and loss of function. Most affected individuals fully recover, but about 30% experience prolonged or permanent symptoms, such as chronic fatigue, weakness, and memory disturbances.
• There is no specific treatment for flavivirus, and the treatment is primarily symptomatic.
• TBE can be prevented through vaccination. Vaccination is recommended for certain high-risk groups, such as people who live permanently in high-risk areas and individuals who frequently get tick bites.
• See the separate treatment overview on TBE.

Rickettsiosis

• Rickettsioses are caused by bacteria transmitted by ticks, body lice, fleas, and mites. Rickettsiae are small Gram-negative bacteria that replicate intracellularly. Today, there are about twenty known species of rickettsiae, two of which are found in Sweden. Among these, Rickettsia helvetica (spread by ticks) is the more studied. Its significance as a pathogen is not yet fully understood.
• Symptoms include high fever, headache, muscle pain, sweating, skin rash, hearing loss, and in severe cases, myocarditis. Fatal cases due to myocarditis have been described.
• Treat with doxycycline (T Doxyferm) 100 mg 2 x 1 for 10 days.
• See the separate treatment overview on rickettsioses.

Anaplasmosis

• Also called tick fever. Previously referred to as Ehrlichia.
• Symptoms include fever, chills, and night sweats, as well as headache, myalgia, fatigue, malaise, nausea, and vomiting.
• See the separate treatment overview on Anaplasmosis.
• Treat with doxycycline (T Doxyferm) 100 mg 2 x 1 for 10 days.
• The disease is relatively common in animals bitten by ticks, such as dogs and cats.

Jellyfish

In Sweden, jellyfish stings are usually caused by lion’s mane jellyfish (Cyanea capillata), but compass jellyfish (Chrysaora hysoscella) can also cause stings, sometimes accompanied by redness and swelling. The red lion’s mane jellyfish is common along the west coast from June and throughout the summer. Symptoms of a lion’s mane jellyfish sting include persistent itching and burning. Jellyfish are cnidarians, and the injury is caused by millions of nematocysts in the jellyfish’s stinging tentacles.

See the separate treatment overview on jellyfish stings.

Treatment of Jellyfish Stings

• Rinse the affected skin areas thoroughly with seawater from a bucket.
• Avoid contact with fresh water initially, and avoid showering.
• Apply a cold pack over the skin, such as ice cubes in a bag. Do not apply ice directly to the skin.
• Avoid rubbing or scrubbing the skin, for example with a towel.
• Try to remove any remaining jellyfish tentacles by scraping the skin with a credit card or shaving the skin with a razor and shaving foam.
• If a pronounced reaction occurs, try immersing the affected body part in hot water (about 45°C) for 20-30 minutes.
• Apply a mild hydrocortisone cream or Xylocain ointment 5% 10 g.

Snake Bites

Snake bites in Sweden are usually caused by adders during the summer months, particularly in coastal areas. Bites from tropical snakes are rarer but occur when snakes are handled carelessly in private or public terrariums. Adder venom is necrotizing and hemorrhagic.

See separate treatment overview on snake bites.

Symptoms

• Pain
• Swelling
• Discoloration (hemorrhages)
• Numbness
• Paralysis
• Paresthesia
• Necrosis
• Bleeding, ecchymosis
• Compartment syndrome

Treatment

• All snake bite patients should be treated in a hospital.
• Insert at least one IV catheter (PVK). Take blood tests for Hb, LPK, platelets, PK/INR, APTT, and urinalysis. If necessary, administer fluids such as Ringer’s acetate.
• Admit all children and patients with systemic symptoms for at least 24 hours.
• Patients without symptoms should be observed for at least 6-8 hours.
• Corticosteroids (e.g., Solu-Cortef 100-200 mg x 1-3 IV or IM). Scientific evidence for steroid treatment in snake bites is limited but is a well-established routine, especially recommended for allergic reactions or after serum treatment prepared from horses. It is also likely beneficial in cases of significant inflammatory reactions.
• Antihistamines (e.g., Tavegyl 1 mg IV x 1-2).
• Consider serum treatment in cases of systemic symptoms. Antivenom is the most important treatment for severe snake bites. The best effect is achieved within four hours of the bite, but it can be given later if systemic symptoms are present.
• Immobilize the affected limb, preferably in an elevated position. If the hand is bitten, suspend the arm in a sling, high above the bedpost or a similar structure.
• Morphine/Ketogan (5-10 mg IV) for pain relief.
• Administer tetanus prophylaxis. Previously, it was recommended that anyone who had not been vaccinated in the past five years should receive a tetanus booster. This recommendation has weak scientific support but is based on the potential for tetanus bacteria from underground burrows in prey (such as voles) to be carried by the snake (0.5 ml diTeBooster IM x 1).
• For allergic or anaphylactic reactions or bronchospasm, administer adrenaline (1 mg/ml, 0.3-0.5 ml IM into the outer thigh) and corticosteroids.
• In cases of circulatory shock, 0.1-0.5 mg of adrenaline can be administered IV, titrated according to blood pressure.
• Ensure adequate fluid replacement, e.g., Ringer’s acetate.
• If dextran is not administered, consider alternative thrombosis prophylaxis, e.g., Fragmin in low doses (5000 units SC) or Klexane 40 mg SC regardless of weight.
• Inotropic support and other shock treatments should be given based on standard indications for circulatory failure, e.g., infusion with norepinephrine.
• Provide oxygen via nasal cannula or nasal catheter.
• In severe cases, monitor Hb, LPK, platelets, CRP, myoglobin, PTK/APTT, S-haptoglobin, creatinine, liver enzymes, TNT, and LD.

ICD-10

• Non-venomous insect bite, unspecified T14.0D
• Venomous insect bite, unspecified T63.4X
• Toxic effect of spider venom T63.3
• Wasp or bee sting T63.4A
• Toxic effect of contact with other marine animals T63.6
• Toxic effect of snake venom T63.0

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