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Erythema, swelling after insect sting in a 3-year-old female
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A few years ago, a 3-year-old female came running into her house one May evening, crying to her mother that a bee had stung her on her left foot. The mother did not see a stinger or anything else unusual, but the next morning, the child’s foot and ankle were mildly swollen, accompanied by a blush of erythema.
The mother immediately took the child to a local weekend urgent care clinic, where the patient was diagnosed with cellulitis and prescribed Augmentin (amoxicillin-clavulanate, Dr. Reddy’s Laboratories Ltd.). Later the same day, the mother saw me in my driveway, having lived across the street, and brought the child over for me to examine her left foot. I looked at the right foot also. She stated that she did not want to bother me earlier that morning, but before filling the prescription, she wanted my opinion (I assumed that bothering me now was OK). I got more history; the child has had no fever, is not limping, and is playful — one of the best signs of wellness we have. She has, however, been noted to be occasionally scratching her ankle.
James H. Brien
The examination in my driveway revealed a healthy and happy-appearing child, with mild swelling of her left foot, especially when compared with her right foot (Figure 1). Since toddlers can sometimes have chubby feet, comparison helps. She also had mild erythema of her left ankle and foot (Figures 2-3). Additionally, there was a papular lesion on the anterior part of the ankle (Figure 4), with no discharge or underlying fluctuance felt, and no stinger was seen.
A happy child is seen in Figure 1 with mild swelling of her left foot, especially when compared with her right foot. She also had mild erythema of her left ankle (Figure 2).
Source: Brien JH
She also had mild erythema of her left foot (Figure 3). Additionally, there was a papular lesion on the anterior part of the ankle (Figure 4)
Case Discussion
My answer is to relax and, if anything, administer some Benadryl (B) for the minimal itching, and perhaps apply an ice pack if the swelling of her ankle and foot is bothersome. However, this is not a problem for this child, and you really don’t have to do anything for a ‘non-problem.’ This problem is only bothering the mother, so, treat the child, not the mother.
I offered to help her watch the problem through the weekend, which is really all the mother needed to hear. By the next day, there was nothing left but a papule where the presumed wasp had stung her. How do I know it was a wasp? I don’t, but usually, when bees sting, especially honey bees, the stinger detaches and is retained in the skin due to its barbed-tip configuration, and in the process, lethally eviscerates the bee (Figure 5). Of course, in this child, the stinger could have been scratched off before being examined. Also, wasp stings (at least where I live) are much more common. They need very little provocation to attack, whereas honey bees will usually leave you alone unless you really disturb or threaten them. It is almost as if they know that they only get one sting in their life, and they are not going to waste it on someone who just happens to be walking by. However, if you get close to a wasp nest, they could come after you for very little disturbance.
When bees sting, especially honey bees, the stinger detaches and is retained in the skin due to its barbed-tip configuration, and in the process, lethally eviscerates the bee (Figure 5). For example, when Dr. Brien was about 10 years of age, he lived in the house in Figure 6.
Source (Figure 5): Shutterstock/Tyler Olson
For example, when I was about 10 years of age, I lived in the house in Figure 6. One day, I came running out the front door (shown in Figure 7), and there was a yellow jacket nest in the eave of the porch, in the same location as shown in Figures 8 and 9. Apparently, the process of swinging the door open was enough to disturb them, and I received multiple stings to my face and neck. Also, I think I must give off some sort of scent that sends them into combat-mode, since I got stung a lot when I was young, which is why I had my wife pose in that location (plus, somebody had to take the picture). In addition, wasps don’t sacrifice their lives and lose their stingers when they use them, as shown in Figure 10, a dead wasp showing the needle-like stinger.
One day, he came running out the front door (shown in Figure 7), and there was a yellow jacket nest in the eave of the porch, in the same location as shown in Figure 8.
There was a yellow jacket nest in the eave of the porch, in the same location as shown in Figure 9. Wasps don’t sacrifice their lives and lose their stingers when they use them, as shown in Figure 10.
The case presented is not an infection, so no antimicrobial therapy is needed. The question of cellulitis, and therefore the need for antimicrobial therapy, and/or incision and drainage, can be answered by the history and exam. Cellulitis is painful, and progressive, and will often suppurate, as shown in the foot of a child with Staphylococcus aureus cellulitis with an abscess (Figures 11 and 12).
Note that if a soft-tissue infection has a rapid onset and rapid progression, as shown in Figure 13 of a patient who had a minor injury to the face 36 hours earlier, think group A streptococcus (GAS), also known as Streptococcus pyogenes (G. for pus producing). But remember, S. aureus statistically leads the list of injury-related soft-tissue infections at approximately 85%.
Cellulitis is painful, and progressive, and will often suppurate, as shown in the foot of a child with Staphylococcus aureus cellulitis with an abscess (Figures 11 and 12).
If you cannot be sure, especially if the child is febrile or acting sick, or the infection is located about the head and neck area, do not rely on a sulfonamide antibiotic alone. It will not work in the case of a GAS infection, and will allow for the unchecked progression of the infection, as demonstrated in Figure 14, a patient with GAS cellulitis that progressed to sepsis and severe cellulitis overnight while being treated with trimethoprim-sulfamethoxazole (TMP-SMX) for presumed S. aureus cellulitis. Those uncertain cases may need a second antimicrobial, such as a beta-lactam, to cover the possibility of GAS.
If a soft-tissue infection has a rapid onset and rapid progression, as shown in Figure 13 of a patient who had a minor injury to the face 36 hours earlier, think group A streptococcus (GAS), also known as Streptococcus pyogenes (G. for pus producing). It will not work in the case of a GAS infection, and will allow for the unchecked progression of the infection, as demonstrated in Figure 14.
We used to use clindamycin as a single empiric agent to cover for both organisms, but our local MRSA rate of resistance to clindamycin has risen in recent years and become a bit too unreliable, with resistance rates as high as 30%. In some places, it has become even higher. However, virtually all MRSA isolates in our lab are sensitive to TMP/SMX or Septra (oral trimethoprim/sulfamethoxazole, Monarch Pharms). If you are sure that a relatively mild, soft-tissue infection is caused by S. aureus, TMP/SMX is not a bad choice. However, a word of caution: Be sure to ask about sulfonamide allergy, as this is one of the most common causes of severe cutaneous drug reactions, like toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome.
Lastly, at this moment in medical history, with the rapidly rising rates of antimicrobial resistance, the proper use of these agents has never been more critical. Therefore, it is very important to take the time to think through the history and use common sense when evaluating our patients. They will almost always tell you the answer, directly or indirectly, but only if you ask. Not all lungs that wheeze have asthma. Likewise, not all tissues that are red and swollen have infection.
At the risk of sounding arrogant — and please believe me, I’m not — if we make the correct diagnosis, we not only do the right thing for the patient, but we can also save the parents the expense of a co-pay for the prescription, the insurance company their cost for the drug, and most importantly, deny that additional pressure for organisms to develop resistance. However, this can be very challenging in a clinic that has to see patients at 10- to 15-minute intervals. I don’t have a solution for that, but I will always be willing to give free advice to parents or their providers.
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James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.