1. Name – XYZ MRN No.- 0000000
Age - 4 Years Gender - Male
Nationality – Egypt Blood group – unknown
Date of Admission – 23-02-2021
Date of Examination- 24-02-2021
Informant – Mother
Reliability – High
Chief Complaint - Left facial swelling since one day.
History Of Presenting illness
The patient, a previously well child, was brought to the hospital on 23rd of February 2021 with a
sudden onset of swelling on the left cheek. The child had been hypoactive initially in the morning
when mother noticed the swelling first.She describes the swelling was diffuse associated with
moderate pain upon touching ,redness and itching .Mother said she tried topical treatment of
which no improvement was seen. No associated fever,weakness or rash on any other part of the
body was noticed.No recent dental procedures done or any ear infection.
SystemicReview
- Constitutional: No fevers, chills, sweats
- Eye: No recent visual problems
- ENMT: No ear pain, nasal congestion, sore throat
- Respiratory: No shortness of breath, cough
- Cardiovascular: No Chest pain, palpitations, syncope
- Gastrointestinal: No nausea, vomiting, diarrhea
- Genitourinary: No hematuria
- Hema/Lymph: Negative for bruising tendency, swollen lymph glands
- Endocrine: Negative for excessive thirst, excessive hunger
- Musculoskeletal: No back pain, neck pain, joint pain, muscle pain, decreased range of motion
- Integumentary: No rash, pruritus, abrasions.
- Neurologic: Alert & oriented X 4
- Psychiatric: No anxiety, depression
Pediatrichistory
Antenatal History
1st Trimester :
• Hyperemesis gravidarum
• No history of fever with rash, drug/radiation exposure, smoking/alcohol
consumption , trauma , bleeding
• No X-ray or history of irradiation
2nd Trimester :
2. • Quickening : 18 weeks onwards
• Mother had GDM , controlled by diet
• No infections during pregnancy was reported
• Normal anomaly scan
3rd Trimester :
• No bleeding , leaking
Natal History
• Mode of delivery : NVD (without any complication)
• At 39 weeks and 3 days of GA
• Weight : 3.1 Kgs
• Immediately cried and suckle after birth; No RDS.
• Passed urine and meconium appropriately.
• No abnormal bleeding or blood transfusion given.
Post Natal history
First cry immediately
No need for resuscitation, problem with respiration or sucking/swallowing
No Birth injury reported Convulsions, cyanosis, jaundice, fever, rash
NoProcedures like exchange transfusion, umbilical artery catheterization, drugs administered.
Immunization - Up to date; No severe reaction occurred after receiving the vaccines.
Developmental History
Childcan run,hop,throwand kickballs,climbing,andswingingwithease.CanStandon one footformore than9
seconds.Doa somersaultandhop
Nutritional history
Exclusive breast-feeding until 6 months of age.
Supplemented by formula milk then onwards
Currently included a neutral diet
Past medical history
No Similar complaints in the past
No congenital /genetic disorders
No history of blood transfusion
No allergies known
Past surgical history
3. Circumcision at the age of one-month .No complications associated.
Familyhistory
History of eczema since the last 2 years
No similar complaints among any of the family members
No consanguinity between the parents.
No history of asthma,genetic diseases, congenital anomalies or bleeding diseases.
Social history
He lives with his family(6 members) in a villa.
He does not attend any day care centre.
No pets
Exposure to Smoking from father
No history of recent travel
ARthpometry
PARAMETER PRESENT
Weight 15.3 Kgs
Length 103cm
Head circumference 50 cm
Chest circumference 61 cm
Data Analysis
Presence of reddish painful swelling on the left side of his cheek with itching.Has a History
of eczema since 2 years.
Genera Hypothesis :- Insect sting
Examination
Vitals
Pulse : 106beats per minute
Respiratory rate :28 breaths per minute
BP: 91/ 180 mmHg
Temp: 36.7 degree celcius
SPO2: 98%
4. General examination
He is alert,oriented ,active, well nourish and not in any distress. Not connected to any device
• Eye: PERRL, EOMI, normal conjunctiva.
• HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa, no
scleral icterus, no sinus tenderness.
• Neck: Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy.
• Lungs: Clear to auscultation and percussion, non-labored respiration.
• Heart: Normal rate, regular rhythm, no murmur, gallop or edema.
• Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses.
• Musculoskeletal: Normal range of motion and strength, no tenderness or swelling.
• Skin: 5 cm longitudinal ulcer in the left sole , dry clean edge
• Neurologic: Awake, alert, and oriented X3, CN II-XII intact.
• Psychiatric: Cooperative, appropriate mood and affect
Local examination:- Upon inspection, a diffuse unilateral swelling was present on the preauricular aspect of
the left cheek with about 5x6cm with reddness. There wasn’t any visible pus leaking out from the swelling or
had any punctum in the center . On palpation of the swelling, it was slightly hard as compared to the
surrounding area with pain and itchingness. No significant swelling or any enlarged lymphnide on the right
side of the face or neck region.
DIAGNOSIS: Insect sting
DIFFERENTIAL DIAGNOSIS:
Mumps:- A contagious disease that have fever, headache and malaise with bilateral swelling
over the parotid region and can cause puffy cheeks with swollen tender jaws
Cellulitis:- Inflammation over the skin with swelling and redness that tends to spread, fever
involved with red spots and blisters over the skin
Lymphadenitis:-Inflammationof one or two lymphnodes that result in increase sie and tender
lyphmnodes with red streaking of the skin above th enodes
Abcess -A smooth swelling under the skin with pain ,redness and warmth in the affected area
along with a visible build up of white or yellow pus under the skin ,patient also have high
temeperature and chills
Lab Investigation
6. FINAL DIAGNOSIS - Insect Sting
Treatment
- Treating local swelling is symptomatic and may include a combination of cold
compression, non-sedating antihistamines tablets, analgesics given or in case if the local
response be serious then a short course of oral corticosteroid.
- Any systemic response is treated with intramuscular epinephrine. For first-aid,
administration of anaphylaxis, an epinephrine dosage of 0.01 mg/kg is given
intramuscularly, within at least of 4 to 6 hours on reaching the emergency department.
Epinephrine is the life-saving mediation for systemic responses, where its action involves
acting as a vasoconstrictor to reduce hypotension. An Adjunct therapy with oral non-
sedating antihistamines are given but not as a substitute.
Course of Stay :-The childisactive andvitallystable now.
CASE DISCUSSION
Many patients oftenconfuse aninsectbite withastinganduse the term interchangeably.A bite is when
an insectusesitsmouthparts whenitisagitatedor to defenditself orwhenitseekstofeed .Itwould
rather cause itchingandno pain. Onthe otherside a stingngapparatusisusuallyasharp organof
defense oroffense,especially if itis connectedwithavenomousgland,andadaptedtoinflictwoundby
piercing.The stingeris usually locatedatthe rear of the animal.Animalswithastinger are bees,wasps,
and scorpions.
Pathogenesis
Once venomisintroducedintothe skin,the proteolyticenzymes startstodegrade the tissue
surroundingthe sting.Basophil activation andhistamine releasefrommastcellsinresponse tothe
venom, which causesvasodilationandthe inflammatoryresponsethatinclude pain,edema,erythema,
and warmtharoundthe site.
Clinical manifestations
- In a local reaction, the child may complain of mild to moderate pain ,have redness and
tenderness around the site of sting . In some cases it may also involve the neighboring
joints
- In a systemic reaction, the complain is usually , complaints incorporate generalized
erythema, urticaria, and pruritic edema.
In a systemicreaction,the patientmaycomplainof local symptomsaswellas those symptoms thatare
not contiguouswiththe location of the sting.Symptomscanrange frommildto fatal.
7. Early complaintstypicallyinclude:-
- generalized rash
- urticaria
- angioedema
- pruritus
- disorientation
- weakness cramping
- vomiting
- syncope
- dizziness
- hypotension
Management
Large local responses don't require an epinephrine auto-injector or referral for VIT.
Treatment of systemic responses is with intramuscular epinephrine.
Evaluation of insect sting responses that cause extreme anaphylaxis must include a serum
tryptase blood test.
Children with a history of systemic response except those with an already experienced
isolated systemic cutaneous reponse is given an epinephrine auto-injector,and assessed
by a pediatric allergist for venom immunotherapy (VIT)
Insectbite can cause the skinarea aroundthe bite to swell,turn red,anditch.To treat the swelling
aroundthe zone of the sting, we can:
●Wash the range withcleanserandcool water
●Keepthe zone cleanandattemptnotto scratch it
●Puta cold,moistwashclothonthe area
●Take a nonprescriptionmedicationforpain
REFERENCE
Canadian Paediatric Society (CPS): Practice point on stinging insect hypersensitivity –
Evaluation and management in children and youth (2018)
American Academy of Allergy, Asthma, and Immunology (AAAAI) and American College
of Allergy, Asthma, and Immunology (ACAAI):Stinging insect hypersensitivity – A
practice parameter update 2016 (published 2017)
Stinging insect hypersensitivity: A practice parameter update 2016
