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Plants and Creatures of Dermatologic Significance 459

14 Plants and Creatures of Dermatologic Significance

Jennifer B. Perone, MD

C o n t e n t s

14.1 Plant Dermatoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461

14.2 Dermatologic Diseases Caused by Creatures . . 466

14.3 Lice, Spiders, Bugs, and Other Creatures . . . . . . 469

14.4 Ticks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

14.5 Mites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

14.6 Exotic Pets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478

14.7 Skin Eruptions Caused by Marine Life . . . . . . . . . . 479

14.8 Medications Derived from Plants and Creatures . . .481

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14.1 PLANT DERMATOSESContact Urticaria

Contact urticaria occurs after direct contact, and can be immunologic (IgE) or non-immuno-logic (toxin-mediated).1 It is a transient eruption characterized by wheals, erythema, and pruritus with burning or stinging caused by direct contact with proteins.

Type I hypersensitivity, or IgE mediated reactions, require previ-ous sensitization. Vasoactive mediators are released and lead to local, or systemic (called “contact urticaria syndrome”) involvement usu-ally within 30 minutes. Urticants include vegetables, fruits, and many other plants. Celery (Apium graveolens) is more likely than other causes to lead to a systemic reaction or anaphylaxis.3 Frequent causes of immunologic eruptions such as latex proteins (Hevea brasiliensis) may cross react with other plants.4 Processing or cooking of foods reduces their allergenicity.5

Nonimmunologic urticaria occurs without previous sensitization in any host. Plants such as stinging nettles (Urtica dioica, Urticaceae family) lead to the release of histamine from mast cells. Toxin urticaria is usually short-lived.6 Sharp hairs on the plants contain toxins (histamine, serotonin and acetylcholine), which are released into the skin causing rapid edema, pruritus and burning.7 One human (and many equine) deaths have been reported from Australian sting-ing nettles (Dendrocnide spp.).8 Other common causes are Euphorbiaceas (spurge nettle) and Hydrophyllaceae (water-leaf family) found in the tropical Americas.

Irritant DermatitisIrritant dermatitis can be caused by several mechanisms including mechanical and chemi-

cal factors. There is a direct toxic effect of the irritant on the skin without involvement of an immune response. Environmental factors such as humidity and temperature, and host factors such as atopy, fissures, sweating and dryness impact the severity of the irritant effect. Clinically, the response is varied ranging from erythema to bullae and even necrosis. Pathologic appearance parallels the clinical appearance from spongiosis, vesicles and karyorrexis or necrosis.9

Mechanical irritant dermatitis can be caused by direct effects of thorns and barbs. Small glo-chids (barbed hairs or bristles) or large thorns (on cacti for example) can become imbedded into the skin causing injury and resultant dermatitis. Secondary infection can be caused by microor-ganism inoculation (see Table 14-1).

Table 14-1. Microorganism Inoculation (adapted from 8)

Vector Organism

Spines Clostridium tetani

Blackthorns Staphylococcus aureus

Grasses, sphagnum moss, rose thorns Sporothrix schenckii

Blackberries Mycobacterium kansasii

Cactus spines M. marinum

Spiky tropical vegetation M. ulcerans

uTIPa Atopics and food-handlers are

often susceptible to contact urticaria2

uTIPa Immunologic (IgE mediated) requires prior sensitization

aNonimmunologic occurs without prior exposure

462 2011/2012 Dermatology In-Review l Committed to Your Future

Many plant families contain chemicals that cause chemical irritant dermatitis. One of the most common irritants is calcium oxalate; however, a wide range of chemicals exist within plants.10 Calcium oxalate itself is an irritant, and is synergistic with other chemicals, thereby increasing their irritancy. Pineapples contain bromelin, a proteolytic enzyme, which is granted access to dermal vessels by calcium oxalate induced fissures.11 The most common cause of irritant dermatitis in florists is from oxalate alkaloids in the sap of daffodils (Narcissus spp.) present in the stems and bulbs leading to “daffodil itch.”12 (Figure 14-1) Other plants such as hyacinth and tulips can cause a similar dermatitis, usually manifested by xerosis, erythema and fissures on the fingertips, hands and arms. Patients may try an at-home remedy for onychomycosis by applying garlic cloves to the nails but this may cause irritant dermatitis from thiocyanates in the garlic. (Figure 14-2, 14-3, Table 2)

Figure 14-1. Narcissus Spp.Photo courtesy of Britton, NL and Brown A 1913

USDA-NRCS PLANTS Database

Figure 14-2. Buttercup (Ranunculaceae) Figure 14-3. Pointsettia (Euphorbiaceae)Photo courtesy of Jennifer Anderson

USDA-NRCS PLANTS Database


Table 14-2. Causes of Plant Irritant Dermatitis (adapted from 7)

Family or Binomial Name Common Name Irritant

Euphorbiaceae Spurges, crotons, poinsettas, machineel tree

Phorbol esters, latex

Ranunculaceae Buttercup Ranunculin

Solanaceae Chili pepper Capsaicin

Opuntia vulgaris Prickly pear

Alliaceae Garlic Thiocyanates

Narcissus spp. Daffodil Calcium oxalate

Brassicaceae Mustard, radish Thiocyanates

Ananas comosus Pineapple Bromelin, calcium oxalate

Lilaceae Hyacinth Calcium oxalate

Allergic Contact DermatitisWhen the skin mounts a specific immune response to an

allergen, the result is an allergic contact dermatitis (ACD). Langerhans cells in the epidermis present the antigen to primed CD4+ T lymphocytes and there is a resultant local dermati-tis or a type IV, cell-mediated delayed hypersensitivity reac-tion. Histopathologically, an acute spongiotic dermatitis that may have vesicles containing Langerhans cells and a predominantly lymphohistiocytic infiltrate is seen.13 A variable number of eosinophils may be seen.

Many plants are causes of allergic contact dermatitis. Some of the most common include car-riers of the rhus antigen pentadecacatechol (found in poison ivy, oak and sumac) and sesquiter-pene lactones in the Compositae family.14 (Figures 14-4, 14-5, 14-6; Table 3) Rhus antigen causes an acute, often streaky or linear reaction with an erythematous and edematous possibly vesicular dermatitis. In contrast, tuliposide A (in Alstroemeria) causes a hyperkeratotic or lichenified plaque in the area of contact, usually the finger. (Figure 14-7) Sensitization to sesquiterpene lactones may occur after use of compositae-containing products and cosmetics such as tea-tree oil.15 (Figures 14-8, 14-9)

Figure 14-4. Poison Ivy Figure 14-5. Poison Oak Photo courtesy of Robert H. Mohlenbrock Photo courtesy of Robert H. Mohlenbrock USDA-NRCS PLANTS Database/USDA SCS. 1991 USDA-NRCS PLANTS Database/USDA SCS. 1991

uTIPaSkin mounts specific immune response to an allergen

aType IV cell-mediated delayed hypersensitivity


Figure 14-6. Poison Sumac Figure 14-7. Alstromeria Photo courtesy of Robert H. Mohlenbrock USDA-NRCS PLANTS Database/USDA SCS. 1991

Figure 14-8. Primrose Figure 14-9. Ragweed Photo courtesy of Bob Moseley Photo courtesy of Robert H. Mohlenbrock USDA-NRCS PLANTS Database/USDA NRCS USDA-NRCS PLANTS Database / USDA SCS. 1989

Table 14-3. Allergic Contact Dermatitis

Family Sensitizer Sources Cross Reactions

Anacardiacea (Toxicodendron genus)

Pentadecylcatechol in oleoresin (urushiol)

Poison ivy, oak and sumac

Mango (peel), cashew, gingko, Japanese lacquer tree, Brazilian pepper tree

Alstroemeriaceae and Liliaceae

Tuliposide A (a glycoside)

Peruvian lily (Alstromeria)

Balsam of Peru Myroxylon balsamum Turpentine, colophony,benzoin, wood tars,spices (cinnamon, clove, vanilla, curry)

Colophony Pinus palustris tree Rosin, medications,mascara, adhesives,bandages, varnish, wax,paper products, dentalcement

Ginkgo fruit pulp Ginkgo Rhus, cashew


Family Sensitizer Sources Cross Reactions

Asteraceae (Compositae)

Sesquiterpene lactones Ragweed, pyrethrum, chrysanthemum, weeds, feverfew, artichoke

Alliaceae Diallyl disulfide (also allylpropyl disulfide,allicin)

Onions, garlic, chive

Primulaceae Primin Primrose(Primula obconica)

PhytophotodermatitisMany plants containing furocoumarins with a combi-

nation of indirect damage by photons cause phototoxic eruptions, or phytophotodermatitis. Photoallergic reactions are more frequently caused by other, non-plant sources. Furocoumarins, such as 5-methoxypsoralen (5-MOP) or 8-methoxypsoralen (8-MOP), cause a phototoxic reaction after contact with the skin, followed by exposure to ultraviolet light in the UVA range (320 to 400 nm).16 The photoactive psoralens can be exploited by dermatologists when treating patients with PUVA phototherapy.

Clinically, phytophotodermatitis presents itself with acute erythema and/or vesiculation fol-lowed by delayed hyperpigmentation (up to weeks later). The eruption is usually painful, and non-pruritic. The diagnosis can be recognized by peculiar formations to the pigment, such as from drips of lime juice, or sharp linear and angular streaks of pigment in sun exposed areas.17 (Figure 14-10, 14-11) Use of a weed-whacker may result in a spray of weeds (such as cow parsley, wild chervil, hogweed) leading to “strimmer dermatitis” on exposed areas such as the chest and arms. Vitiligo patients have been known to exploit the hyperpigmentation in an effort to reduce the appearance of their disease; in India Psoralea corylifolia is the most commonly used. The Apiaceae family causes the majority of phytophotodermatitis. (see Table 4)

Berloque dermatitis is caused by the phototoxic compound bergamot oil from the rind of a small orange citrus bergamia. It was used in cologne and artificial tanning applications and led to hyperpigmentation in the neck area.18 Currently, an artificial oil of bergamot is used.

Figure 14-10. Hyperpigmentation Seen in Figure 14-11. Phytophotodermatitis Phytophotodermatitis from Lime Juice Photo courtesy of John C. Murray, Duke University on Bottleneck of a Beer Bottle Photo courtesy of John C. Murray, Duke University

uTIP a Remember: Unlike photoallergic reactions,

which involve the immune system (type IV or delayed hypersensitivity), phytophoto-dermatitis is non-immunologic

Table 14-3. Allergic Contact Dermatitis (cont.)


Table 14-4. Causes of Phytophotodermatitis

Family Pertinent Members

Apiaceae (formerly Umbelliferae) Parsley, celery, parsnip, hogweed, fennel

Rutaceae Lime, rue, burning bush, bergamot orange, Hawaiian lei flowers

Moraceae Fig tree (Ficus carica)

Fabaceae (Leguminosae) Bavachee or scurf-pea

Occupational Plant DermatitisObviously, those occupations that expose workers to plants have a higher incidence of plant

dermatoses. Grocery workers handling parsley and celery, and bartenders squeezing limes may be at higher risk of phytophotodermatitis. Outdoor workers increase the likelihood of exposure to toxicodendron. Florists and floral designers may have reactions to primin, sesquiterpene lactones and tuliposide A in flowers and their bulbs. One of the most common causes of irritant dermatitis in florists is from the stems of daffodils (Narcissus spp).19 Nursery workers in Angers, France (a center for plant and flower cultivation) have been shown to have allergic contact dermatitis to hydrangea.20

14 .2 DERMATOLOGIC DISEASES CAUSED BY CREATURESOrf

Orf, also known as ecthyma contagiosum or infectious pustular dermatitis, is transmitted to humans by a parapoxvirus in sheep, goats and reindeer. The virus is very sturdy and survives many months in cold weather. Clinically, a nodule develops with possible crusting, pustule formation, or localized lymphadenopathy. This is a self-limited condition with an excellent prognosis lasting approximately 6 weeks. Lesion mor-phology changes through a series of six stages: papular (red, elevated) → target (nodule with red center, white middle ring, red periphery) → acute (red, weeping) → regenerative (thin, dry crust overlying lesion) → papillomatous → regressive.

Milkers’ NoduleMilkers’ nodule is caused by the paravaccinia virus (a parapoxvirus, and related to the orf

virus), which infects cows and can be transmitted to dairy workers and others who work with cattle or meat. It is also known as pseudocowpox. These are often targetoid lesions on the hands or distal upper extremities. Crusting or central ulceration often is a hallmark; local lymphadenopa-thy can be seen. This is a self-limited condition lasting approximately 6 weeks. Lesions progress through a similar morphology as the orf lesion.

Butcher’s WartsMeat (as well as fish and poultry) handlers often suffer with hand and finger verruca. These

are usually caused by human papilloma virus (HPV) 2 and 7.

uTIPa�Orf:

Animal and meat handlers develop lesions on their fingers

The animals often have perioral lesions, or second-ary lesions on udders from nursing their young


Erysipeloid (of Rosenbach)This should not be confused with erysipelas. Erysipeloid is an

infection with Erysipelothrix insidiosa or Erysipelothrix rhusiopathiae,

a gram-positive rod that can colonize many animals, most com-monly causing disease in pigs. A distinctive feature is sharply mar-ginated and polygonal patches of bluish erythema. Edema often accompanies the cutaneous changes. Usually patients develop a solitary violaceous and tender nodule that may vesicu-late. Systemic antibiotics are required as occasional septicemia and endocarditis may result. Treat with erythromycin or penicillin.

Cutaneous AnthraxHumans may acquire this disease from handling animal carcasses and animal products leading

to the form called “woolsorter’s disease.” Bacillus anthracis (rod-shaped, gram positive) has been used as an agent of bioterrorism and may cause three other types of infection: pulmonary, gas-trointestinal (acquired by ingestion of spores) and oropharyngeal. The majority (95%) of naturally occurring cases are the cutaneous form, from direct contact with the carcasses of dead sheep, cows, goats and horses. The so-called “malignant pustule” (which, in fact, is not a pustule) begins as a vesicular lesion and formation of a central eschar ensues. There is frequently surrounding edema. After notifying the local health department, cultures (with Dacron or rayon swabs, not cotton tips), punch biopsy and other appropriate diag-nostic tests should be performed.

Virulence Factors: 1.) polyglutamate capsule that inhibits phagocytosis; 2.) edema toxin, comprised of edema factor and protective factor; 3.) lethal toxin, comprised of lethal factor and protective factor. Untreated, 20% of cutaneous cases are fatal. Treat with ciprofloxacin, doxycycline, or penicillin.

Cat-Scratch DiseaseThis is an infection caused by the gram-negative rod Bartonella hensalae. Approximately

90% of patients can recall a preceding cat bite or scratch.23 Afipia felis causes a small number of cases. A small papule will occur at the site of inoculation after 3 to 5 days. Regional lymph-adenopathy with swelling of the overlying skin develops. The primary lesion is usually a papule. Most commonly, this is a self-limited, local infection, usually resolving with several weeks to months. Less commonly, systemic manifestations may occur including encephalopathy, osteo-lytic lesions, and thrombocytopenic purpura.24 The oculoglandular syndrome of Parinaud is the combination of granulomatous conjunctivitis and preauricular lymphadenopathy. Other cutane-ous manifestations include a morbilliform eruption, erythema nodosum, erythema marginatum, leukocytoclastic vasculitis, and erythema multiforme.25,26

Bacillary AngiomatosisBacillary angiomatosis, while also caused by Bartonella hensalae, is less commonly associated

with contact with cats (approximately 20% of cases) and occurs in patients with AIDS (often with CD4 < 50). Clinically, smooth papules or nodules, occasionally with a collarette of scale, occur. Vascular proliferation is seen on biopsy and it may be confused with pyogenic granuloma in the case of a single lesion or Kaposi’s sarcoma with multiple lesions. Visceral lesions may occur in any organ.27 Hepatic lesions are seen in peliosis hepatitis. Treat with a macrolide antibiotic or doxycy-cline. A Jarisch-Herxheimer reaction may ensue after initiating treatment.

uTIPa Importantly, this lesion is painless; but patients

may develop painful regional lymphadenopa-thy.21 In inhalational anthrax – acquired by the inhalation of anthrax spores – a helpful clue on chest x-ray is a widened mediastinum and hemorrhagic lymph nodes on chest CT22

a“Malignant pustule” is actually painless, and vesicul with central eschar; lymphadenopathy can be painful

uTIPa Farmers, meat handlers, fish

handlers and veterinarians are most frequently afflicted


BrucellosisAlso known as Malta fever, this infection is caused by ingesting raw goat milk and unpasteur-

ized goat cheese infected with Brucellae (gram-negative rod). It is infrequent in the U.S., occur-ring mainly in veterinarians and farmers. Acute brucellosis has very nonspecific features and presents as a flu-like illness. Skin lesions are infrequent (20% of cases) but are usually violaceous papulonodules on the trunk and lower extremities.28 Treatment is with doxycycline or rifampin.

Glanders/FarcyThe gram-negative rod Pseudomonas mallei most frequently infects horses, donkeys and

mules. Occasionally, humans can also be infected. At the inoculation site, an edematous nodule, pustule or vesicle can be seen. Nodules are often present along the lymphatic drainage route called “farcy buds.” Importantly, nasal ulceration and septum perforation can be caused by glan-ders. A chronic form leads to deep, painful abscesses. Treat with surgical excision of the lesion followed by streptomycin combined with tetracycline.

DermatophytesMany forms of dermatophytosis are zoophilic. (Figure 14-12, 14-13, 14-14, 14-15)

Figure 14-12. Canine M. Canis Figure 14-13. Feline M. Felis Photo courtesy of D. Morris, University of Pennsylvania Cats are the Usual Reservoir Host, USDA-NRCS PLANTS Database/USDA SCS. 1991 Rather Than Dogs Photo courtesy of D. Morris, University of Pennsylvania

Figure 14-14. Bovine Ringworm Figure 14-15. Veterinarian Student with Photo courtesy of P. Habecker, Tinea Corporis from Bovine Source University of Pennsylvania Photo courtesy of P. Habecker, University of Pennsylvania

uTIPa�Consider any pets and ask about

hobbies and occupations as a possible source of pathogen


Dog, Cat, and Human BitesIn areas where vaccination is not uniform, rabies can be a concern following bites from dogs

and cats. Indeed, even in the United States, many owners do not vaccinate their pets. Local infection and cellulitis, however, is a more common concern following routine domes-

ticated animal bites, such as from a family pet. Cat bites most frequently result in Pasteurella multocida while dog bites result in Pasteurella canis; however, most bites are polymicrobial with mixed aerobes and anaerobes. Infrequently systemic infections may result in brain or lung abscess, endocarditis or sepsis.29,30,31 Sepsis is more frequent in an immunocompromised victim and may be due to Capnocytophaga or Pasteurella.32

Antibiotic coverage is usually employed in all but the most minor wounds. Any wound to the hand, or penetrating bone or tendon should be empirically treated. An antibiotic such as amoxi-cilin with a beta-lactamase inhibitor (Augmentin) is the first line treatment.

Human bites result in infection with Eikenella corrodens, a gram-negative bacillus that is part of the normal flora of the human mouth. This infection can also follow fist fights with blows to the mouth.

Snake BitesSymptoms of snake bites are dependent on the species and venom dosage injected. Two

main snake families are Crotalidae (including rattlesnakes, and copperheads) and Elapidae (including coral snakes). Pain and edema are immediate responses, while necrosis and hemor-rhage commonly follow. Systemic symptoms such as hypotension, respiratory distress, and neu-romuscular blockade may occur. Observation of the victim is crucial as the syndrome may prog-ress despite an apparently minor initial reaction. Even delayed antivenin administration, derived from horse antibody, can be of benefit.

14.3 LICE, SPIDERS, BUGS, AND OTHER CREATURESSpiders

The ability to identify spiders from their photographs is important for the kodachrome section of the board exam. (Figure 14-16; Table 5)

Black WidowLactrodectus mactans, the most common black widow, is a large,

black, shiny spider with an hourglass shaped white marking on the abdomen. (Figure 14-17) Bites are acutely painful, and may swell but do not cause necrosis; the venom contains neurotoxins. Within hours: chills, vomiting, violent cramps, paralysis, spasms, and abdominal rigidity; symptoms mimicking an acute abdomen. Antivenin may be helpful up to 90 hours after the bite.33

Figure 14-16. Spider Bite Figure 14-17. Black Widow Spider Photo courtesy of N. Sidhu-Malik, Duke University Photo courtesy of Clyde S. Gorsuch, Clemson University - USDA Cooperative Extension Slide Series

uTIPa�Black widow spider bites, in

distinction with brown recluse and hobo spider bites, do not cause necrosis


Figure 14-18. Male and Female Figure 14-19. Necrotic Spider Bite Brown Recluse Spiders Photo courtesy of N. Sidhu-Malik, Duke University Photo courtesy of N. Sidhu-Malik, Duke University

Wolf SpiderThe Lycosidae family (or wolf spiders) consist of three genera: Lycosa, Pardosa, and Arctosa.

(Figure 14-20) Bites can be exceedingly painful and may lead to lymphangitis or eschar.

Green Lynx SpiderPeucetia viridans is common in the southern United States. This spider is bright green with red

spots; the legs have black spines. (Figure 14-21) The bite is painful, with tenderness and pruritus.

Table 14-5. Spiders and Active Venom Components

Common Name Scientific Name Venom Contents

Black widow Lactrodectus Alpha lactrotoxin

Brown recluse Loxosceles Sphingomyelinase-D

Wolf spider Lycosidae Histamine

Jumping spider Hidippus Hyaluronidase

Sac spider Chiracanthium Lipase

Brown RecluseLoxosceles reclusa is a tan spider, with a violin-shaped marking

on the abdomen. (Figure 14-18) Necrotic lesions involve extensive gan-grene. Systemic reactions (viscerocutaneous loxoscelism) may occur and can be severe in children: fever, chills, vomiting, joint pain, hema-turia, hemolytic anemia, thrombocytopenia, with possible shock and death. The venom contains several toxins, however sphingomyelinase D seems to be causative of the necrosis and hemolysis. Ice, rather than heat, should be immediately applied. Treatments have been disappointing; dapsone, steroids, aspirin and anti-venom therapies have had variable results. Surgery should be avoided.

Hobo SpiderTegenaria agrestis is the leading cause of necrotic arachnidism in several states of the

Pacific Northwest.35 (Figure 14-19) These spiders are relatively large, with a herringbone-striped pattern on the abdomen. Spider bites may be painless with fast-onset induration, erythema and numbness. A necrotic eschar will often form with slowed healing. Systemic reactions can con-sist of headache, with visual disturbances; hemodynamic changes can also occur as well.

uTIPa�The bite may be painless, how-

ever the patient may develop erythema, a vesicle and even-tual necrosis. This may result in the “red, white and blue sign” or erythema, ischemia and thrombosis34


Figure 14-20. Wolf Spider Figure 14-21. Lynx Spider Photo courtesy of R. Bessin Photo courtesy of Alden M. Johnson University of Kentucky Department of Entomology © California Academy of Sciences

Figure 14-22. Jumping Spider Photo courtesy of R. Bessin

University of Kentucky Department of Entomology

Jumping SpiderPhidippus formosus is an aggressive spider with dark body hairs and various white pat-

terns depending on the species. (Figure 14-22) They are the most common biting spiders in the United States and are found mainly in the south. No systemic symptoms are known, but the bite is particularly painful with toxic venom.

TarantulasTheraphosidae are large, brown to black, hairy spiders frequently found in the southwest.

They are of dermatologic importance due to the urticating hairs. Tarantula bites generally do not produce any systemic toxicity. The spider releases hairs in the direction of the perceived attacker; hairs can penetrate the skin as deeply as the reticular dermis.36 If they injure the cor-nea, they can cause a chronic granulomatous reaction (ophthalmia nodosa) and loss of vision.37

Other CreaturesScorpionsScorpion stings can produce cardiovascular complications. Centruroides sculpturatus and

C. gertschi are the primary species in U.S. The injected venom acts as a neurotoxin.Scorpion stings produce both local and systemic effects: sensation of sharp burning pain at

site, associated with numbness beyond site. Regional swelling may occur. Sometimes ecchymo-sis and lymphangitis may accompany. Neurologic sequelae include convulsions, coma, hemiple-gia, hyper/hypothermia, tremor, restlessness, and irritability. Cardiopulmonary sequelae include arrhythmias, pulmonary edema, and hypertension.


Therapy for stings is local wound care, ice packs, and antihistamines; local injections of anes-thetics may relieve pain, and systemic antihypertensives and anticonvulsants address systemic complications. The antivenom is only available in Arizona, and has questionable efficacy.

Caterpillars (Lepidoptera)The ability to identify caterpillars from their photographs

is also important for the kodachrome section of the board exam. Clinical reactions are similar, usually causing urticaria after contact with hairs on the caterpillar body. Erythematous papules, hemorrhage or purpura (in a classic “tram-track” pattern) and pruritus are frequent fea-tures following contact with the pests. If hairs get into the patient’s eye, a similar response to that of a tarantula hair is seen. One of the most widespread causes of caterpillar dermatitis is from Megalopyge opercularis (puss caterpillar), which can cause immediate pain.38 Two excellent web-sites are referenced with photos to study.39,40 (Figures 14-23 through 14-27)

Figure 14-23. Io Caterpillar Figure 14-24. Hag Moth Caterpillar Photo courtesy of R. Bessin Photo © 1998-2003 Troy Bartlett University of Kentucky Department of Entomology

Figure 14-25. Puss Caterpillar Figure 14-26. Saddleback Caterpillar Photo © 1998-2003 Troy Bartlett Photo © 1998-2003 Troy Bartlett

Figure 14-27. Woolybear CaterpillarPhoto courtesy of R. Bessin

University of Kentucky Department of Entomology

Hymenoptera (Bees, Wasps, Hornets and Ants)The honeybee leaves a barbed ovipositor and paired venom sacs impaled into victim; the

method of removal is less important than speed of removal. The honeybee dies after stinging, but other hymenoptera do not. A minority of those stung (0.5 %) have severe systemic reactions:

uTIPa�Caterpillar photos worth recognizing

would be the brown-tail moth, puss caterpillar, and saddleback caterpillar


angioedema or generalized urticaria, respiratory insufficiency, or shock. The venom from honey-bee contains phospholipase A. Cutaneous reactions may be managed by ice and local injection of lidocaine. Systemic reactions require epinephrine.

Fire AntsSolenopsis inject a venom that contains a hemolytic factor, solenopsin D, a piperidine

derivative, that causes a release of histamine and other vasoactive amines from mast cell; the bite becomes a sterile pustule. Imported fire ants (S. invicta) attack in groups; there is no spe-cific therapy for ant stings, and bites should be treated symptomatically.

FliesBlack flies are also blood suckers. The initial bite is painless, but later becomes extremely

painful with itching, pruritus, edema, and erythema. Black flies are vectors for onchocerciasis and tularemia. Sand flies transmit Dipetalonema perstans; bites produce immediate pain and erythema and 2-3 mm papulovesicles, followed by indurated nodules lasting many months. The tabandae family includes ferocious blood suckers, such as horseflies, deerflies, clegs, breeze flies, greenheads, and mango flies, which transmit loiasis and tularemia. Bites are painful and may bleed vigorously, and are a particular problem to campers in the spring and summer.

MosquitoesAnopheles causes malaria. Aedes causes yellow fever and dengue. The cutaneous reaction is

due to the female inserting her blood tube, injecting irritating salivary secretions that anticoagu-late blood, and subsequently cause edema, pruritus, and papules. Mosquitoes prefer black skin, young skin, warm to cool skin, and scented skin. They also prefer bright colors and elevated car-bon dioxide concentrations.

BedbugsCimicidae are flat with broad bodies. Their bites are asymptomatic, initially. Bedbugs are noc-

turnal feeders and travel great distances. Their bites form linear purpuric macules.

FleasFlea bites are most frequent on the lower legs, and present as extremely pruritic erythema-

tous papules, often with superficial erosions secondary to excoriation. (Figure 14-28) The human flea, Pulex irritans, can also be seen on dogs. More frequent infestations on domestic animals are by Ctenocephalides felis and canis (on cats and dogs respectively). Fleas can be vectors of many diseases from typhus to plague.

Reduviid bugsAlso known as “kissing” or “assassin” bugs, these are members of the Triatoma species and

are “true bugs” of the order Hemiptera. Posterior to the head, where the wings join together, the characteristic triangular shape can be seen. They are bloodsuckers, and importantly, they transmit Chagas’ disease by carrying Trypanosoma cruzi. Romana’s sign is unilateral eyelid swelling at the site of the bite of the assassin bug.

BeetlesLytta vesicatoria, or the spanish fly is a blister beetle from which cantharadin is derived. This

is further discussed in the Medications Derived from Plants and Creatures secion. The beetles do not sting, or bite however cantharidin produces vesicles after contact with the skin. The larvae of carpet beetles (Attagenus megatoma and Anthrenus scrophulariae) can cause an allergic contact dermatitis after contact.


Figure 14-28. An Unusual Distribution of Flea Bites Photo courtesy of N. Sidhu-Malik, Duke University

MyiasisBotfly larvae penetrate into the skin to cause cutaneous myiasis. Callitroga americana is the

most important in the U.S. Dermatobia hominis causes pyogenic furuncle, but will not respond to antibiotics. Phlebotomid sandflies transmit Leishmanial parasites like L. donovani and L. trop-ica. Glossina, the tsetse fly, produces minimal cutaneous disease but transmits trypanosomes and sleeping sickness.

Centipedes and MillipedesChilopoda: Centipedes. These are nocturnal carnivores that produce painful wounds by dis-

charging venom. The wound is accompanied by severe pain, localized sweating, edema, second-ary infection, and ulceration. Scolopendra is a species found in Hawaii.

Diplopoda: Millipedes. These are harmless vegetarians. When disturbed or threatened they emit a toxic substance that may produce burning, blistering, and pigmentation of the skin, and severe inflammation of the eye.

Head LiceHead lice are frequently found on children in school outbreaks, however adults can be infest-

ed as well. Direct contact and fomites cause spread from person to person. Pediculus capitis is visible with the naked eye, as are their nits (eggs) and infestation is usually limited to the scalp. It has six legs, and a long narrow body as compared with the body louse. The louse lives for approximately one month, feeding every few hours, and lays eggs daily. Differential diagnosis includes white piedra and hair casts. Treatment recommendations include two applications of a pediculicide, one week apart. Resistance patterns have led to decreased efficacy of permethrin 5% cream, pyrethrins, and lindane. Malathion 0.5% continues to be effective.

Pubic (Crab) LicePthirus pubis (crab lice) are shorter and squatter than either the head or body louse. (Figure

14-29) Infestation is usually in the pubic area where hairs are farther apart than on the scalp, thereby matching the arm-span of the louse. (Figure 14-30) Lice and eggs can be seen on the host, sometimes with perifollicular erythema. (Figure 14-31) In advanced infestations, lice can be seen on the trunk and in the eyelashes. Maculae cerulea can be seen in severe cases. Pruritus is the prevailing symptom. Patients should be counseled and tested for other sexually transmitted diseases as appropriate.


Figure 14-29. Pthirus Pubis Figure 14-30. Crab Lice and Eggs Photo courtesy of N. Sidhu-Malik, Duke University in Pubic Area of the Host Photo courtesy of N. Sidhu-Malik, Duke University

Figure 14-31. Eyelash Involvement in anExtensive Case of Pediculosis

Photo courtesy of N. Sidhu-Malik, Duke University

Body LicePediculus humanus var. corporis, or body lice, live in the folds of clothing, not directly on the

host. Therefore, papules with crust and excoriations are often found at the waist, on the back and shoulders. They can be vectors of diseases; treatment involves decontamination or disposal of the clothing and avoiding potential infested upholstered furniture and sheets.

14.4 TICKSTicks are divided into Argasidae (soft tick) and Ixodidae (hard tick) families, with Ixodidae

responsible for most diseases. Ticks tear open the epidermis and insert the barbed hypostome; during insertion a cement-like substance is secreted which hardens, firmly anchoring the hypo-stome to the skin. Ticks feed for 7 days, then fall off to continue their life cycle.

Bites occur in spring and summer. All stages of the life cycle—egg, larva, nymph, and adult—require a blood meal.

United States Ticks• Ixodes scapularis (same as I. dammini)• I. Pacificus• Amblyomma americanum• Dermacentor andersoni• Dermacentor variabilisTick bites may or may not be painful, and only a red papule may be left, which may prog-

ress to local swelling, erythema, blistering, pruritus, and ecchymosis, necrosis, and ulceration. Persistent papules respond to IL steroids.


Lyme Disease: Caused by the spirochete Borrelia bergdorferi, via the Ixodes ticks, and named after Lyme, Connecticut where a group of children developed arthritis in 1977. Most cases in the U.S. are in the Northeast and Mid-Atlantic States although it has occurred elsewhere. Approximately 7 to 14 days incubation occur prior to the onset of the classic erythema migrans eruption. Early disseminated infection (involving nervous, musculoskeletal and cardiovascular systems) occurs shortly thereafter (days to weeks). Late disseminated disease occurs weeks to months subsequent to initial exposure.

Southern Tick-Associated Rash Illness: Associated with the bite of the lone-star tick, Amblyomma americanum, patients residing in or traveling through southeastern and south-central states develop a rash similar to that of Lyme disease. A candidate spirochete has been detected by DNA analysis and has been named Borrelia lonestari.

Tick Paralysis: Believed to be caused by a toxin secreted in the saliva of ticks; most commonly, caused by Dermacentor; lower motor neuron paralysis occurring 4–7 days after attachment, and removing tick causes rapid disappearance of symptoms; treatment may require respiratory support.

Babesiosis: Caused by intracellular RBC parasite, Babesia microti; transmitted by larvae of I. dammini. This disease is endemic in eastern Long Island, Martha’s Vineyard, and Nantucket, and carries an increased risk in those with T-cell depression or after splenectomy. The condition is associated with fever, drenching sweats, myalgia, hemolytic anemia.

Ehrlichiosis: Comes in two forms: monocytic, caused by E. chaffeensis, which invades mono-nuclear WBCs, and granulocytic, which is caused by organisms related to E. phagocytophila and E. equi. Peripheral PMNs show intracytoplasmic inclusions. Patients present with fever, chills, HA, myalgias, along with leukopenia, anemia, and thrombocytopenia. I. scapularis appears to be a vector for HE.

Treat with doxycycline or tetracycline.

Table 14-6. Summary of Tick-Borne Diseases

Disease Pathogenic Organism Vector

Lyme Borreliosis Borrelia burgdorferi Ixodes dammini, I. pacificus, Amblyomma americanum

Relapsing Fever Borrelia duttonii, B. hermsii, B. turicatae

Ornithodoros moubata

Rocky Mountain Spotted Fever Rickettsia rickettsii Dermacentor andersoni, D. variabilis, A. americanum

Babesiosis Babesia microti I. dammini

Tularemia Francisella tularensis Dermacentor andersoni, D. variabilis

Ehrlichiosis Ehrlichia canis, Ehrlichia, sennetsu

Rhipicephalus sanguineus

14.5 MITESScabies

Sarcoptes scabiei var. hominis can complete its entire 30-day life cycle on the human host, therefore it is not a self-limited disease and must be treated. The female mite has eight short legs and an ovoid, flat body, laying up to 100 eggs. (Figure 14-32)


The adult mite burrows within the stratum corneum resting in the upper granular layer. (Figure 14-33) Clinically, erythematous papules and burrows are seen in finger and toe web-spaces, nipples, axilla, male genitalia and the umbilicus. (Figure 14-34) They are intensely pruritic leading to many linear erosions due to excoriation. Skin scrapings with mineral oil preparation can demonstrate mites, eggs or feces. (Figure 14-35)

Crusted scabies (or Norwegian scabies) is seen in immuno-compromised hosts (the elderly, HIV or transplant patients). (Figure 14-37) While regular scabies involves only a few mites (usually less than 100), crusted scabies patients are infested with innumerable mites. Mites can survive up to a week off the patient, leading to easy transmission of the infestation, particularly in areas of overcrowding.

Treatment includes permethrin (Elimite), lindane (Kwell), crotamiton (Eurax) and precipitated sulfur in petrolatum. Lindane has become unavailable due to concerns regarding neurotoxic-ity, particularly in pediatric populations, as well as increasing resistance patterns. Permethrin is currently the recommended first-line agent; with two applications one week apart. Crotamiton requires daily use for approximately five days, and may cause irritation. Malathion, or a single dose of oral ivermectin can be given as well.

Figure 14-32. Scabies Mite Figure 14-33. Histopathologic Section Photo courtesy of A. Kaplan, Duke University Highlighting Stratum Corneum Location of Scabies Mite Photo courtesy of N. Sidhu-Malik, Duke University

Figure 14-34. Finger Web Spaces are a Common Figure 14-35. Scabies Egg Casings Area of Involvement in Scabies Infestation from a Skin Scraping Photo courtesy of N. Sidhu-Malik, Duke University Photo courtesy of A. Kaplan, Duke University

Figure 14-36. Demodex Folliculorum from a Mineral Oil Preparation Slide Photo courtesy of N. Sidhu-Malik, Duke University

Figure 14-37. Crusted Scabies Photo courtesy of N. Sidhu-Malik, Duke University


Other MitesDemodex folliculorum is a mite that can live within the sebaceous glands of hair follicles. It

may be important in some subsets of patients with acne rosacea, as well as patients with HIV infection and folliculitis. A glass slide preparation with mineral oil can easily demonstrate these mites on infected patients. (Figure 14-36) Treatment of the mites with permethrin has led to vary-ing clinical responses.

Food mites infest foodstuffs. Examples include the grain mite, Acarus, cheese mite, Glyciphagus, and grocery mite, Tyrophagus. These creatures produce papular urticaria or vesico-papular eruptions.

Fowl mites bother office workers, homemakers, and bird fanciers affected by mites that infest birds. Dermanyssus is the most common class. Ornithonyssus sylviarum can induce human skin lesions and Western equine encephalomyelitis virus.

Grain mites: Pyemotes, the straw itch mite—a parasite of insect larvae that feed on grain; dis-tribution worldwide. The mites infest both animals and humans. Affected patients have systemic symptoms such as fever, diarrhea, anorexia, and malaise.

Harvest mites: Also known as the chigger, of the class Trombicula. Contact occurs during summer and fall. Frequently, the only sign of exposure is intense pruritus on ankles, legs, or belt line. In sensitized individuals, papular urticaria, vesiculation, or a granulomatous reaction with fever and lymphadenopathy may occur.

Animal mites: Two important species: Ornithonyssus bacoti (tropical rat mite), and Allodermanyssus sanguineus (housemouse mite), the vector of rickettsial pox.

O. bacoti, a vector of murine typhus, travels widely to get blood meal; affects persons work-ing where rats live. Cheyletiellid mites harbored by dogs and cats; pet is asymptomatic, but per-son holding pet experiences marked pruritus when mites feed on skin. Diagnosed by microscopic examination of cellophane tape applied to pet’s skin. The pet must be treated by a veterinarian.

Table 14-7. Summary of Mite-Induced Diseases (adapted from 58)

Mite Disease

Acarus (grain mite) Baker’s itch

Allodermanyssus sanguineus (house mouse mite) Rickettsial pox

Cheyletiella Walking dandruff in dogs, cats

Demodex Rosacea (controversial)

Dermanyssus (fowl mite) Equine encephalitis

Dermatophagoides (dust mite) Allergic reactions

Glyciphagus (cheese mite) Grocer’s itch

Ornithonyssus (fowl mite) Western equine encephalitis

Trombicula alfreddugesi (Chigger mite) Dermatitis; carry scrub typhus in some areas

Trombicula Scrub typhus

14.6 EXOTIC PETSSome exotic pets can cause unique dermatoses. Hedgehogs, particularly the African pygmy hedgehog, are a popular pet. Quills on the ani-

mal may lead to Trichophyton mentagrophytes infection in the form of tinea corporis or capitis.41 Urticaria may result from contact with the saliva. Also, humans who have contact with the African pygmy hedgehog have been known to contract salmonella via an unclear mechanism; this is par-


ticularly important for immunocompromised pet owners. European hedgehogs may transmit M. marinum or M. avium-intracellulare.

The flying squirrel, while thought of as a friendly pet, can be a carrier of many infections including Toxoplasma gondii, Staphylococcus sp., and Rickettsia prowazekii (via the body louse, causing epidemic typhus).42

An iguana is an inexpensive and easily contained pet when young. However, it can grow to very large sizes, up to 6 feet in length. (Figure 14-38) Many potential pathogens have been cul-tured from various species of iguana; one case of Serratia marcescens led to cellulitis with severe systemic manifestations.43 It may also be a potential carrier of a herpes-type virus and may also cause a human allergic reaction. The iguana is another transmitter of salmonella to pet owners usually resulting in gastrointestinal manifestations (diarrhea) and a few cases of meningitis. A generalized papular exanthem may be seen as well.

Figure 14-38. Iguana Figure 14-39. Sea Urchin Photo © 1998-2003 Troy Bartlett Photo courtesy of Gerald and Buff Corsi © California Academy of Sciences

A chinchilla is a small, furry pet. Their fur and skin are frequently colonized with Trychophyton mentagrophytes and Microsporum gypseum, which may lead to owner dermatophytosis. Immunocompromised people should be aware that they may also contract gram-negative infec-tions such as Klebsiella pneumoniae and Pseudomonas aeruginosa from these pets.44

Beautiful birds are also coveted pets, and the cockatoo is one of the most popular. Cryptococcus neoformans can be transmitted by the cockatoo and the pigeon, a less likely pet choice. The bird does not appear ill but transmits the fungus in its feces, leading to air-borne pathogen. This is critical information for immunosuppressed hosts, as at least one case of an organ transplant patient contracting Cryptococcus has been reported in the literature.45 Avian mites can also be carried by the cockatoo, but this is not unique to the species as the mites can be found in most bird types. Avian mite infestation is self-limited in bird owners because their life cycle cannot be completed in the human host.

14.7 SKIN ERUPTIONS CAUSED BY MARINE LIFE Many different eruptions including swimming pool granuloma, clam digger’s itch, and sea-

bather’s eruption may result following exposure to water. Additionally, many marine creatures can lead to dermatologic manifestations.

Fishtank GranulomaAlso called swimming pool granuloma, this is a centrally ulcerated nodule or papule, which

may result from contact with infected fish or fishtank water. This can become chronic and appear more verrucous with hyperkeratosis. The infection is caused by Mycobacterium marinum and should be treated with systemic antibiotics such as trimethoprim-sulfamethoxazole, clarithromy-cin or doxycycline.


LeechesLeeches can be exploited for medical use, such as coaxing survival of skin flaps, due to par-

ticular features of their bites. They prevent coagulation partly due to the presence of inhibitors of platelet aggregation in their saliva.46

Sea UrchinSpines on the sea urchin easily break off once they have penetrated the skin – frequently

after a diver inadvertently steps on the creature. (Figure 14-39) Only a small fraction of sea urchin species have spines with venom toxic to humans.47 However, the spines themselves can cause a foreign body reaction if not completely removed. Most frequent areas of involvement are the feet and ankles and result in pink papules. Immersion in hot water with vinegar can provide instant pain relief as well as inactivating any toxins present.

Sea CucumberSea cucumbers are cucumber-shaped bottom-dwellers that can cause conjunctivitis due to

release of a toxin called holothurin to which nearby swimmers can be exposed. Vigorous cleans-ing of exposed eyes is important as well as ophthalmologic consultation.48

Seabather’s EruptionSeabather’s eruption (or sea lice) can be either sporadic, or part of an outbreak. Clinically, it

appears as dermatitis beneath areas covered by swim suits. The geographic distribution is most frequent from the Caribbean to Bermuda, however there have been three outbreaks at Long Island, NY beaches.49 A variety of cnidarian larvae can cause this eruption including thimble jelly fish (Linuche unguiculata) and sea anemone (Edwardsiella lineate).50 Quick removal of bathing suits and rinsing can help with prevention. Symptom relief is the mainstay of therapy.

Swimmer’s ItchIn contrast to seabather’s eruption, swimmer’s itch (or cercarial dermatitis) is more frequently

seen in fresh and brackish water bathers and is caused by avian schistosomes (usually ducks and other waterfowl are the hosts). This is a self-limited eruption that will clear without treatment within several weeks.

Figure 14-40. Jellyfish Figure 14-41. Hookworm Infection in a Patient Photo courtesy of Gerald and Buff Corsi Who Just Returned from a Vacation in Jamaica © California Academy of Sciences

CnidariansCnidarians are aquatic organisms and include the jellyfish, Portuguese man of war, sea anem-

ones, coral and hydroids.51 Jellyfish (scyphozoan) are translucent, bell-shaped marine creatures with stingers (nematocysts) capable of breaking the skin surface causing immediate pain and possible further symptoms. (Figure 14-40)


Stings from Chironex fleckeri (box jellyfish) are extremely toxic and stings may lead to shock particularly in small adults and children. Death may occur within only a few minutes.

Portuguese man of war (hydrozoa) are common in the southern Atlantic Ocean and the sting is more painful than that of a typical jellyfish. Stings may result in hemorrhagic lesions with vesicu-lation; rarely systemic manifestations occur.

Sea anemone stings can be highly variable. Erythematous wheals may vesiculate and ulcerate. Sponge diver dermatitis is actually caused by sea anemones that are attached to sea sponges and can lead to headache, nausea, vomiting, fever and chills.52

The nematocysts contain a toxin that can lead to systemic symptoms.53 The toxin acts directly on many different tissues including myocardium, nervous tissues and renal and hepatic struc-tures. Erythematous wheals will frequently develop locally in the shape of the stingers. Treatment involves irrigation, immobilization and removal of stingers. If systemic symptoms are severe, including nausea, vomiting, fever, chills, shortness of breath and unresponsiveness, cardiopulmo-nary resuscitation may be necessary. Importantly, the nematocysts continue to contain toxin and are active even after washing up on shore. Pouring vinegar on jellyfish and Portuguese man of war will fix the nematocysts and prevent further firing and toxin release.

Cutaneous Larvae MigransWhile not caused directly by marine life, this infestation is usually acquired on sandy beaches.

These hookworms can penetrate human skin, usually through the foot, when the larvae are deposited by dogs (Ancylostoma caninum) and cats (A. braziliense) via feces on the beach.54 A serpiginous inflammatory reaction can be seen highlighting the burrow of the larvae in the skin. (Figure 14-41) This is a self-limited reaction, however pruritus can be significant, therefore oral treatment with thiabendazole or ivermectin is often given. Topical application of 10% thiabenda-zole also is effective.

14.8 MEDICATIONS DERIVED FROM PLANTS AND CREATURESAnthralin: Derived from Goa powder, extracted from the Vouacopoua araroba tree. It is used

to stimulate an inflammatory response for treatment of psoriasis and off-label treatment of alo-pecia areata. Side effects include purple staining and irritancy.

Antimalarials: Originals were derived from Cinchona officinalis in Lojan rainforests. The bark was dried and had a bitter taste. Quinine was determined to be the active substance in the bark of Cinchona species. Modern antimalarials are synthetically derived.

Cantharadin: Derived from Lytta vesicatoria (blister beetle).55 The blister beetle is often found in alfalfa fields, and in the southern United States in flower beds. Application of the agent is done painlessly, and as the name implies, leads to vesiculation, or blistering within 1 to 2 days due to disruption of desmosomal plaques.56 It is used in physicians offices for treatment of verruca vul-garis without risk of scarring.

Capsaicin: Agent responsible for the “hot and spicy” flavor of chili pepper (the Solanaceae family).57 Capsaicin is formulated as a topical agent that is utilized as an anesthetic and analge-sic. It causes the release of substance P. Substance P release causes unmyelinated C-fibers to be excited, which leads to the pain response. With repeated application, substance P is depleted and the pain response is reduced. FDA-approved uses include postherpetic neuralgia and diabetic neuropathy.

Pyrethrin: Derived from the chrysanthemum flower (Compositae family). Patients who have a chrysanthemum or ragweed allergy may experience allergic symptoms including respiratory wheezing, and rhinitis. This drug is now synthetically produced.


MORE FIGURES

Acarus ΩAlstroemeria (1) Amblyomma Americanum

Female

Aedes (1) Alstroemeria (2)Anopheles (1)

Aedes (2)Amblyomma Americanum Male

Anopheles (2)

Black Widow (1) Cimex (bedbug) (1)

Dermacentor Variabilis Male

Black Widow (2) Cimex (bedbug) (2)

Fire Ant (1)


Brown Recluse (1)Cimex (bedbug) (2)

Fire Ant (2)

Brown Recluse (2)Copperhead

Glossina

Browntailed Caterpillar Coral Snake Hagmoth Caterpillar

Dermacentor Variabilis Female

Io Caterpillar

Ixodes Scapularus Engorged

Ornithonyssus

Pulex Flea

Pediculosus Humans Capitus

Rattlesnake (1)Ixodes Scapularus Female Pediculus Humans 1


Ixodes Scapularus Male Phthirus Pubis Rattlesnake (2)

Leptotrombidium (chigger)Primrose (1)

Reduvid (1)

LutzomyiaPrimrose (2) Reduviid (2)

Sea UrchinSimulium (1)

Xenopsylla

Tabanid Simulium (2) Wolf Spider


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NOTES


NOTES