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Emergency Medicine > ENVIRONMENTAL
Millipede Envenomation
Article Last Updated: Jan 4, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Robert Norris, MD, Chief, Associate Professor, Department of Surgery, Division of Emergency Medicine, Stanford University Medical Center
Robert Norris is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, and Wilderness Medical Society
Editors: James Li, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine; John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital; Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Scott H Plantz, MD, FAAEM, Assistant Professor, Research Director, Department of Emergency Medicine, Mount Sinai School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
millipede envenomations, Diplopoda, Arthropoda, millipede exposure
Background
Millipedes are elongated cylindrical creatures that bear 2 pairs of legs per body segment and are found in a wide variety of habitats. They are generally very slow-moving creatures and are relatively innocuous. Falling into the class Diplopoda and the phylum Arthropoda, millipedes comprise some 7000 species.
Pathophysiology
Millipedes do not have biting mouthparts or fangs. Their medical importance comes from their ability to secrete an irritating defensive liquid from pores along their sides. Such secretions contain benzoquinones, aldehydes, hydrocyanic acid, phenols, terpenoids, nitroethylbenzenes, and other substances.
Some species are capable of squirting these liquids to distances of up to 25 cm.
Mortality/Morbidity
No deaths have been documented from millipede exposures, and it is unlikely that such an exposure could be fatal, even to a small child.
History
The history may indicate that a patient was handling a millipede. On occasion, the history of a patient (eg, a sleeping victim, small child) may be obscure.
- Skin irritation
- Pain
- Brown staining at the site of contact
- Slight blistering
- Eye irritation and pain
Physical
- Local erythema
- Mild edema
- Vesicles
- Occasionally, cracked skin that may slough and then heal
- Conjunctivitis, which may lead to ulceration of the conjunctiva and cornea
Centipede Envenomations
Lab Studies
- No lab studies are required.
Prehospital Care
- Any millepede secretions on the patient's skin should be washed away with soap and water.
- If the eyes are involved, they should be copiously washed with water as soon as possible.
Emergency Department Care
- The exposed skin should be washed thoroughly with soap and water.
- Eye exposure should prompt immediate instillation of local anesthetic drops, followed by copious irrigation with saline solution or water.
- Adequate tetanus immunization status should be ensured.
- Topical steroid creams may be beneficial for local skin irritation.
Severe conjunctivitis or dermatitis, resulting from toxic secretions of a millepede, can be treated. To reduce this type of inflammation, topical and ophthalmic steroids may be administered.
Drug Category: Ophthalmic agents
These agents prevent further ulcerations of the cornea and should be given in consultation with an ophthalmologist.
| Drug Name | Prednisolone, ophthalmic (Pred Forte) |
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| Description | Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. |
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| Adult Dose | Solution: 1-2 gtt into conjunctival sac qh during day and q2h during night; once desired response is obtained, use 1 gtt q4h; may reduce to 1 gtt tid/qid to control symptoms
Suspension: Shake well before using, instill 1-2 gtt into conjunctival sac 2-4 times qd; may increase dosing frequency during initial 1-2 d prn |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin lesions |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in hypertension; known to cause cataract formation with chronic use; in prolonged use, withdraw treatment by gradually decreasing frequency of applications to avoid adrenal insufficiency |
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| Drug Name | Sulfacetamide sodium and prednisolone (Isopto) |
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| Description | Treats steroid-responsive inflammatory ocular conditions that have a risk of infection. |
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| Adult Dose | Solution: Instill 1-3 gtt q2-3h while awake and hs until favorable response
Ointment: Apply 0.5-inch ribbon into lower conjunctival sac 1-4 times qd and once hs |
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| Pediatric Dose | <2 months: Not established
>2 months: Administer as in adults |
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| Contraindications | Documented hypersensitivity; mycobacterial infection |
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| Interactions | Decreases effects of silver compounds and gentamicin |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in severe dried eyes; ointment may retard corneal epithelial healing |
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Drug Category: Corticosteroids
Used to treat erythema and skin irritation that result from chemical insults. Prevent further ulcerations of the skin.
| Drug Name | Triamcinolone (Triderm, Aristocort) |
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| Description | Treats inflammatory dermatitis that is responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. |
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| Adult Dose | Apply thin film bid/tid until favorable response |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; fungal, viral, and bacterial skin infections |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Do not use in patients diagnosed with decreased skin circulation |
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| Drug Name | Hydrocortisone (Westcort) |
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| Description | Treats inflammatory dermatitis responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. |
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| Adult Dose | Apply thin film to affected area tid/qid until favorable response |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Prolonged use, applying over large surface areas, application of potent steroids, and occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria |
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Further Outpatient Care
- Follow-up care is generally unnecessary unless local complications ensue or the eyes are involved.
- In ocular cases, the patient should be examined daily until the eye is healed.
Deterrence/Prevention
- Beyond avoidance of handling these creatures, little deterrence is required.
Complications
- Cutaneous exposures generally heal without complications.
- Conjunctivitis or corneal ulcerations can complicate eye exposures.
Prognosis
- Millipede envenomations are usually self-limited.
Medical/Legal Pitfalls
- Failure to refer a patient suffering from eye exposure to an ophthalmologist for follow-up care could lead to a worse outcome.
| Media file 1:
The desert millipede, Orthoporus ornatus. Photo by Robert Norris, MD. |
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Media type: Photo
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| Media file 2:
The desert millipede, Orthoporus ornatus. Photo by Robert Norris, MD. |
 | View Full Size Image | |
Media type: Photo
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| Media file 3:
Millipede contact injury on day 3 following exposure. |
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Media type: Photo
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Millipede Envenomation excerpt Article Last Updated: Jan 4, 2007
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