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  3. Clinical entry: Caterpillars, moths and butterflies with urticating hairs and spines

Clinic: Caterpillars, moths and butterflies with urticating hairs and spines

Examine for venom effects

Autopharmacological / Allergic effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Arterial hypotension / hypovolaemic shock
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Haematological effects 

  • Clotting disturbances:
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia:
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera
    • Oliguria, anuria (arterial hypotension / AKI)
    • Neurological features of hypoglycaemia, or refractory shock (acute pituitary-adrenal insufficiency!)  

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

   Autopharma-
cological
effects1 		 Local
effects2
 		 Haematological effects
 Bleeding3  Coagulopathy4

Lonomia obliqua

 ?       

Megalopyge opercularis

        

Other effects

Lonomia obliqua
Acute renal failure 6/33 (however, this was probably secondary in the context of disseminated intravascular coagulation) (Duarte et al. 1993).

Megalopyge opercularis
Headache that commences within minutes and can persist for up to 24 h (626/2130); cerebral seizures (5/2130) (McGovern et al. 1961). 


1Autopharmacological effects
Megalopyge opercularis
Shock-like symptoms that occur within 2 h (autopharmacological reaction?) (104/2130) (McGovern et al. 1961).
Pulmonary symptoms caused by inhaled hairs (differential diagnosis allergic reaction – toxic).

2Local effect 
Lonomia obliqua 
Local pain 33/33 (Duarte et al. 1993).
Megalopyge opercularis
Local pain, urticarial skin lesions with pruritus and a local haemorrhagic lesion (Pinson and Morgan 1991).
Strong local pain (2093/2130), local swelling (1964/2130), regional lymphadenopathy within 1 h (679/2130) (McGovern et al. 1961).

Haematological effects

3Bleeding
Systemic bleeding 
Lonomia obliqua
Generalised ecchymosis 30/33, mucous membrane bleeding 22/33, haematuria 15/33, cerebral haemorrhage 4/33, pulmonary haemorrhage 1/33 (Duarte et al. 1993).
Multiple intracerebral haemorrhages (CCT) (Kowacs et al 2006).
4Coagulopathy
Type of haemostatic defect
Lonomia obliqua
Consumptive coagulopathy and secondary fibrinolysis (Arocha-Pinango et al. 1988).

Haemostatic parameters
PT and PTT ↑, fibrinogen and platelets ↓ (first reading 5th day (day of admission) after contact, max 7th day after contact (time of death)) (Kowacs et al 2006).

Case fatality rate

Megalopyge opercularis
0/2130 (McGovern et al. 1961).

Lonomia obliqua 
4/33. Cause of death: cerebral and pulmonary haemorrhage, acute renal failure (Duarte et al. 1993).
1/1. Cause of death: cerebral haemorrhage (Kowacs et al 2006). 

Publications reporting broadly on Caterpillars, moths and butterflies with urticating hairs and spines envenoming and treatment

Diaz (2005)

Species-specific publications 
see ‘References’ at the end of the file.

Clinical management

First aid

Toxic hemolymph and caterpillar hairs that have not yet penetrated the skin should immediately be removed: (1) soap-and-water washing, (2) no-touch drying of the sting site with a hair dryer (not a towel), stripping of the site with adhesive tape, rapidy trying fingernail polish, rubber cement or commercial facial peel solutions. These should then be allowed to dry under a hair dryer, and then peeled off the sting site. Removal of rings etc since the affected extremites may grossly swell. Ice packs to ease pain (McGovern et al. 1961, Diaz 2005).

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

ABCDE approach

WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured

Obey Caterpillars, moths and butterflies with urticating hairs and spines - specific features

see 'Species-specific envenoming pattern' above.

Key issues:

Supportive treatment including treatment of allergic complications (McGovern et al. 1961, Diaz 2005).

  • Rapid cardiovascular collapse, arterial hypotension, shock
  • Bleeding

Specific treatment (antivenoms)

A Lonomia Antivenom is produced by the Butantan Institute in Brazil.

Species-specific evidence

Lonomia obliqua

Brazil (Rio Grande do Sul)

  • Duarte et al. (1993) 
    33 patients of contact with L. obliqua. Identification criteria not specified, 11 cases 0–12 years old, 15 cases 13–50 years, 7 cases >50 years.
  • Kowacs et al. (2006) 
    1 patient. Identification: morphological.

Lonomia sp.

Brazil (Western Amazon)

  • Santos et al. (2017)
    1 patient; identification: morphological as Lonomia sp.


Megalopyge opercularis

USA

  • McGovern et al. (1961) 
    2,130 patients.
  • Pinson and Morgan (1991) 
    1 case. Identification: morphological. 

References

  • Diaz JH. The evolving global epidemiology, syndromic classification, management, and prevention of caterpillar envenoming. Am J Trop Med Hyg. 2005 Mar;72(3):347-57. PMID: 15772333.
  • Duarte, A., C. Duarte, E. Barros (1993) Acute renal failure in accidents caused by caterpillars (Lonomia obliqua Walker). Toxicon 31: 124
  • Kowaks, A., J. Cardoso, M. Entres, E. M. Novak, L. C. Werneck (2006)Fatal Intracranial hemorhage secondary to Lonomia obliqua carterpillar envenoming. Arq Neuropsiquiatr 64 (4): 1030-103
  • McGovern, J. P., G. D. Barkin, T. R. McElhenney, R. Wende (1961) Megalopyge opercularis. Observation of its life history, natural history of its sting to man, and report of an epidemic. J. Amer. Med. Ass. 175: 1155-1158
  • Pinson, R. T. (1991) Envenomation by the Puss carterpillar (Megalopyge opercularis). Ann. Emerg. Med. 20: 562-564
  • Santos JHA, Oliveira SS, Alves EC, Mendonça-da-Silva I, Sachett JAG, Tavares A, Ferreira LC, Fan HW, Lacerda MVG, Monteiro WM. Severe Hemorrhagic Syndrome After Lonomia Caterpillar Envenomation in the Western Brazilian Amazon: How Many More Cases Are There? Wilderness Environ Med. 2017 Mar;28(1):46-50. Epub 2017 Jan 10. PMID: 28087323. https://doi.org/10.1016/j.wem.2016.11.001
  • WHO ABCDE Approach. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139