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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 23-25

Stellate ganglion blockade as a treatment modality in ischemia and gangrene following insect bite

1 Aditya Pain and Spine Centre, Assam Medical College, Dibrugarh, Assam, India
2 Department of Anesthesiology and Critical Care, Assam Medical College, Dibrugarh, Assam, India

Date of Submission26-Nov-2020
Date of Acceptance10-Dec-2020
Date of Web Publication08-Mar-2021

Correspondence Address:
Bhaben Chandra Boro
Aditya Pain and Spine Centre, Dibrugarh, Assam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_13_20

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We describe the case of a 34-year-old female patient who had ischemia of the hand and fingers following insect bite and underwent stellate ganglion block as treatment. She was otherwise fit without any significant past history. We recommend an early recognition of such cases with prompt treatment for a better outcome.

Keywords: Complex regional pain syndrome, insect bite, stellate ganglion block

How to cite this article:
Boro BC, Sahoo P. Stellate ganglion blockade as a treatment modality in ischemia and gangrene following insect bite. J Recent Adv Pain 2020;6:23-5

How to cite this URL:
Boro BC, Sahoo P. Stellate ganglion blockade as a treatment modality in ischemia and gangrene following insect bite. J Recent Adv Pain [serial online] 2020 [cited 2022 Aug 13];6:23-5. Available from: http://www.jorapain.com/text.asp?2020/6/2/23/310951

  Introduction Top

Insect bite is one of the common reasons for patients to seek medical advice. The assessment is based on clinical experiences by using a combination of clinical features and risk factors. The clinical presentation usually varies from minor itch to septicemia. The incidence of insect bite is exactly not known as most are not reported. Study data recorded about 5.4/100,000 patients of insect bites per week on an average by general practitioners of England and Wales.[1] Similarly, in India, the prevalence of papular urticaria in the dermatology outpatient clinic of Pondicherry was 5.3% in children <14 years of age and in Calcutta was 10.6% in children <5 years of age.[2]

Stellate ganglion block at the C6 level is a technically simple procedure with readily identifiable landmarks with short recovery periods.[3] It is a very effective interventional technique for the management of complex regional pain syndrome (CRPS) type I of upper extremities.[4]

Background and aims

The objective is to report the use of stellate ganglion block in a patient with ischemia, gangrene, and CRPS-like symptoms in the right upper limb following insect bite.

  Case Report/Methods Top

A 34-year-old woman was evaluated at our clinic with pain in the right hand. There were pain, swelling, as well as discoloration of index, middle, and ring fingers of the right hand following bite of an unknown insect on the dorsum of the right hand [Figure 1]. The symptoms developed within an hour and the patient visited our clinic on the 4th day following the bite. Pain was severe in intensity and radiating to her right arm. There were no aggravating or relieving factors. She had no significant past medical and surgical history. Her family history was unremarkable. She denied the use of alcohol, cigarettes, or recreational drugs. On physical examination, our patient exhibited hyperreflexia (pain score of 8/10) and bluish discoloration of three fingers in the right upper limb. Motor strength and sensations were normal. Color Doppler study of the right upper limb revealed reduced blood flow in the digital arteries of index, middle, and ring fingers. Fluoroscopy-guided right stellate ganglion block was given using 7 ml of 0.25% bupivacaine and 2 ml of depomedrol [Figure 2].
Figure 1: Clinical presentation of our patient

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Figure 2: Radiological images during the procedure

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Stellate ganglion block which was given on day 4 of insect bite resulted in immediate relief of pain (from pain score of 8/10 to 2/10) and disappearance of discoloration within 12 h in index, middle, and ring fingers of the right hand. No immediate or late adverse effects were noted following the procedure.

  Results Top

Stellate ganglion block which was given on day 4 of insect bite resulted in immediate relief of pain (from pain score of 8/10 to 2/10) and disappearance of discoloration within 12 h in index, middle, and ring fingers of the right hand.

  Conclusion Top

Stellate ganglion block relieves the pain caused by ischemia of the upper limb following insect bite. Hence, timely intervention is very important to prevent risk of gangrene and amputation as soon as there is sign of ischemia.

  Discussion Top

The incidence of CRPS has been reported to range from 5.5 to 26.2 per 100 000 persons per year, resulting from minor to major trauma.[5] It is a clinical disorder that is characterized by severe, continuous pain, sensory, vasomotor, sudomotor/edema, and motor/trophic changes of the affected extremity.[6] Our patient fulfills the criteria of CRPS as she had symptoms of spontaneous excessive continuous pain on light touch as well as swelling of the hand along with discoloration and raised temperature. There is also a possibility of insect venom-induced vasospasm which got relieved by vasodilatory effect of stellate ganglion block.

Stellate ganglion block using local anesthetic drugs is one of the most effective blocks widely used for vascular insufficiency of the upper extremities, CRPS, etc. A successful block may cause sympathetic blockade of the ipsilateral face and arm, Horner's Syndrome, increased temperature of face and arm, slightly blurred vision, hoarseness, hematoma, etc.[7]

The mechanism of occurrence of CRPS following insect bite is not known, but it may be due to direct bite trauma or envenomation. In 2012, CRPS following snake bite was reported by Ergan et al.[8] In January 2016, CRPS following viper bite was reported by Kleggetveit et al.[9] Moreover, similarly, in July 2020, CRPS following a centipede bite was reported by Thumtecho et al.[10]

The primary cause in this case is not known, but awareness is important for early diagnosis and appropriate management in such cases.


Written informed consent was taken from the patient for publication of this case report and accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wilcock J, Etherington C, Hawthorne K, Brown G. Insect bites. Bmj 2020;370:m2856.  Back to cited text no. 1
Singh S, Mann BK. Insect bite reactions. Indian J Dermatol Venereol Leprol 2013;79:151.  Back to cited text no. 2
  [Full text]  
Carron HA, Litwiller RO. Stellate ganglion block. Anesthesia and analgesia. 1975;54:567-70.  Back to cited text no. 3
Toshniwal G, Sunder R, Thomas R, Dureja GP. Management of complex regional pain syndrome type I in upper extremity—Evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: A pilot study. Pain Med 2012;13:96-106.  Back to cited text no. 4
de Mos M, de Bruijn AG, Huygen FJ, Dieleman JP, Stricker BH, Sturkenboom MC. The incidence of complex regional pain syndrome: A population-based study. Pain 2007;129:12-20.  Back to cited text no. 5
Harden RN, Bruehl S, Perez RS, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the 'Budapest Criteria') for complex regional pain syndrome. Pain 2010;150:268-74.  Back to cited text no. 6
Benzon H, Rathmell J, Christopher L. Wu, Dennis Turk, Charles Argoff; Raj's Practical Management of Pain. 4th ed. 2008. p. 339-850.  Back to cited text no. 7
Ergan SA, Yoleri Ö, Yavaşi S, Ölmez N, Memiş A. Complex regional pain syndrome caused by snake bite: A case report. Turk J Phys Med Rehabil 2012;58:69-71.  Back to cited text no. 8
Kleggetveit IP, Skulberg PK, Jørum E. Complex regional pain syndrome following viper-bite. Scandinavian J Pain 2016;10:15-8.  Back to cited text no. 9
Thumtecho S, Schimmel J, Trakulsrichai S. Complex regional pain syndrome following a centipede bite: A case report. Clin Toxicol 2020;58:777-9.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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