I was bitten by insects while traveling in the Dominican Republic; how should I manage the bites and what signs of infection or complications should I watch for?

Management of Insect Bites in the Dominican Republic

For insect bites acquired in the Dominican Republic, provide symptomatic treatment with topical corticosteroids and oral antihistamines for local reactions, while monitoring closely for fever developing 3–14 days post-exposure that would indicate dengue or chikungunya requiring immediate medical evaluation. 1

Immediate Bite Management

Local Reactions

• Apply cold compresses to reduce pain and swelling at the bite site 2
• Use topical corticosteroids for localized pruritus and inflammation 1
• Administer oral antihistamines to reduce itching 2
• Consider oral analgesics (acetaminophen preferred) for pain relief 2
• Avoid antibiotics unless clear signs of secondary bacterial infection develop, as initial swelling is inflammatory, not infectious 2

Large Local Reactions

• If extensive swelling develops over 24–48 hours (>10 cm diameter), consider a short course of oral corticosteroids 2
• These reactions typically resolve in 5–10 days 2
• Keep any vesicles or pustules intact and clean to prevent secondary infection 2

Critical Warning Signs Requiring Immediate Evaluation

Dengue Fever (High Risk in Dominican Republic)

Any fever developing 3–14 days after mosquito exposure requires immediate medical evaluation, even without rash 1. The Dominican Republic has significant dengue transmission, with Aedes mosquitoes responsible for approximately 5% of febrile illnesses in returning travelers 1.

Key dengue symptoms to monitor:

• Fever with severe headache and retro-orbital pain 1
• Severe myalgia and arthralgia (often back pain) 1
• Maculopapular rash 1
• Warning signs of hemorrhagic complications: thrombocytopenia, plasma leakage, bleeding 1

Critical management point: Avoid NSAIDs completely if dengue is suspected due to hemorrhagic risk; use only acetaminophen for fever and pain 1

Chikungunya (Endemic in Dominican Republic)

The Dominican Republic experienced a major chikungunya epidemic starting in 2014, with attack rates exceeding 40% among travelers 3, 4. Monitor for:

• Fever with severe joint pain 3
• Rash (present in 90% of cases) 3
• Symptoms typically appear within the dengue incubation window 3

Systemic Allergic Reactions

Watch for symptoms not contiguous with the bite site 2:

• Urticaria or angioedema distant from bite 2
• Respiratory symptoms, bronchospasm, or throat swelling 2
• Hypotension, dizziness, or cardiovascular symptoms 2
• Gastrointestinal symptoms (nausea, vomiting, diarrhea) 2

If systemic allergic symptoms develop: Administer epinephrine 0.3–0.5 mg intramuscularly in the anterolateral thigh immediately and transport to emergency department 2

Rickettsial Infection (Tick-Borne)

If tick exposure occurred, monitor for 1:

• Fever, headache, and myalgia developing after >24 hours of tick attachment 1
• Inoculation eschar at bite site 1
• Rash (present in <50% of cases) 1

Empiric doxycycline must be started immediately without awaiting laboratory confirmation, as untreated mortality reaches 32% 1

Diagnostic Approach

When to Seek Medical Testing

• Fever 3–14 days post-travel: Obtain dengue PCR if ≤5–7 days from symptom onset, or IgM ELISA if >5–7 days 1
• Suspected tick-borne illness: Start empiric doxycycline immediately; do not delay for serology 1
• Systemic allergic reaction history: Consider referral to allergist for venom-specific IgE testing 2

Common Pitfalls to Avoid

• Never use NSAIDs for post-travel fever until dengue is excluded; hemorrhagic complications can be fatal 1
• Do not prescribe antibiotics for initial bite swelling; this represents allergic inflammation, not infection 2
• Do not delay epinephrine in systemic reactions; fatal outcomes are associated with delayed administration 2
• Do not dismiss fever without rash; dengue and rickettsial infections frequently present without cutaneous findings initially 1
• Do not wait for laboratory confirmation to treat suspected rickettsial infection; mortality increases with treatment delay 1

When to Refer

Refer to an allergist-immunologist if 2:

• Systemic allergic reaction occurred (beyond local swelling)
• Patient needs education on emergency epinephrine use
• Coexisting conditions complicate epinephrine use (β-blockers, cardiac disease)
• Venom immunotherapy may be indicated

Prevention for Future Travel

• Apply DEET 20–50% to exposed skin during outdoor activities 1
• Wear long sleeves and pants during dawn/dusk (though dengue vectors bite during daylight) 1
• Treat clothing with permethrin for additional protection 1
• Use pyrethroid-containing indoor spray in sleeping areas 1