systemic or diffuse cutaneous reaction ... deShazo RD, Feldlaufer MF, Mihm MC Jr, Goddard J. Bullous Reactions to Bedbug Bites Reflect Cutaneous Vasculitis.
A systemic and erythrodermic reaction following repeated exposure to bites from the Common bed bug, Cimex lectularius Rashi Minocha, Stephen Doggett, Cameron Webb, Kai Dang, Wenjun Bu, Pablo Fernández‐Peñas Patient two:
Introduction
Case report
Conclusion
Bed bugs (both the Common species, Cimex lectularius and the Tropical species, Cimex hemipterus) are haematophagus parasites that readily bite humans.1 In recent years, there has been an unexpected worldwide resurgence of bed bug infestations, with numerous reports especially from the more economically advantaged nations.2 Insecticide resistance appears to be the key factor for the resurgence.
A 28 year old male Chinese, PhD student in the Medical Entomology Department, fed a new shipment of 5‐6 C. lectularius on himself on the 24th of December 2013 to ensure survival of specimens, as rodent and artificial blood feeding devices were not available. He had previously been bitten in October 2013 and he had never experienced a systemic or diffuse cutaneous reaction systemic or diffuse cutaneous reaction. The student was otherwise healthy and his medical history was unremarkable.
Physical impacts of bed bug bites are of growing concern and there has been a surge of legal disputes throughout the United States in recent times. In the general community, there is still a high level of ignorance when it comes to recognizing bed bugs and thus infestations may be present for some time before the source of the mysterious bites are identified. Therefore, patients with systemic reactions may increasingly present to medical identified. Therefore, patients with systemic reactions may increasingly present to medical practitioners and bed bugs should be considered in the differential diagnosis for those with symptoms described herein.
In the late 1990’s several pest control organizations started to see an increase in bed bugs, with some groups seeing a six fold increase in infestations between 1997 and 2000 (Boase 2001). In greater London, calls to pesticide teams for bed bugs has grown 28.5% annually over 2000‐2006 (Richards et al. 2009). Initial reports around the world indicated that infestations with the modern resurgence were more common in the tourism accommodation sector. However, in the last few years, bed bugs have spread into the wider community and it has been low socio‐economic dwellings, such as homeless shelters that have been especially impacted.3 Previously, diffuse cutaneous and systemic manifestations have not been widely reported4 or have been presented as an ill‐defined syndrome.2 We present a case of a research student working in the field of bed bugs and previously exposed to bites from the insect, who developed an acute, erythrodermic and systemic reaction after voluntary exposure.
Figure 1. a) Bed bug infestation b) C imex Lectualrius (male on the left and fenale on the right)
a.
Bed bugs were placed on the proximal, right anterior forearm for approximately 15 minutes. Within one minute of the start of the bed bugs feeding, the student experienced a gradually increasing amount of pruritis over the bite area. Within five minutes of feeding the bite region was inflamed and erythematous with wheals (Figure. 2). Within 10 minutes the student developed intense pruritis over his face, scalp, buttocks and groin, and 20 minutes later became intensely erythrodermic (Figure. 3). He developed systemic symptoms of lethargy, dysphagia, chest tightness and dyspnoea. Forty‐five minutes after the bite his urticaria and erythroderma remained intense, despite being given an antihistamine and he was assessed in the Emergency Department (ED) approximately 25 minutes later.
1. Hildreth CJ, Burke AE, Glass RM. Bed Bugs. JAMA, 2009; 301(13): 1398 2. Doggett SL. Bed Bugs: Clinical relevance and Control options. Clinical microbiology reviews, 2012; 25(1):164 3. Goddard J, deShazo R. Bed Bugs (Cimex lectularius) and Clinical Consequences of Their bite. JAMA. 2009; 301(13): 1358‐1366 4. Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O. Bed bug infestation. BMJ, 2013; 346:f138 5. deShazo RD, Feldlaufer MF, Mihm MC Jr, Goddard J. Bullous Reactions to Bedbug Bites Reflect Cutaneous Vasculitis. Am J Med, 2012; 125:688‐694 6. Reinhardt K, Kempke D, Naylor RA, Siva‐Jothy MT. Sensitivity to bites by the bedbug, Cimex lectularius. Medical and Veterinary Entomology, 2009; DOI: 10.1111/j.1365‐ 2915.2008.00793.x 7. Goddard J, Hasenkampf N, Edwards KT, de Shazo R, Embers ME. Bed Bug Saliva causes release of monocytic inflammatory mediators: Plausible cause of cutaneous bite reactions. In Arch Allergy Immunol, 2013; 161: 127‐130 8. Stucki A, Ludwig R. Bedbug Bites. NEJM, 2008; 359:10 9. Aultman JM. Don’t let the begbugs bite: the Cimicidae debacle and the denial of healthcare and social justice. Med Health Care and Philos, 2012; DOI 10.1007/s11019‐012‐9404‐x / Acknowledgments The execution of this research adhered to the Western Sydney Local Health District Human Ethics Committee, Australia (HREC2012/5/4.5 (3510) AU RED HREC/12/WMEAD/137) Photos courtesy of Dr. Stephen Doggett
He displayed no obvious respiratory distress, drooling or stridor and had a normal cardiac and respiratory examination. He was treated with 200mg of IV hydrocortisone cardiac and respiratory examination He was treated with 200mg of IV hydrocortisone and 12.5mg of IV Phenergan. Blood samples taken during this time were unremarkable. Two and a half hours after the bites the student’s cutaneous and systemic symptoms had noticeably reduced and four hours after the onset of the bites they had almost resolved
Figure 2. 28 year old Chinese C ese stude student, t, after five minutes of bed bug (Cimex lectularius) feeding on the right, anterior forearm. The region was intensely edematous with surrounding erythema, consistent with the development of an acute urticarial reaction.
Discussion There are a limited number of published cases of systemic reactions to bed bugs. Consequently these reactions can create a diagnostic dilemma for health care professionals. A diverse number of dermatological differential diagnoses exist including erythema multiforme, Sweet’s syndrome and vasculitis.5
b.
Multiple bed bug bites are typically characterised by a cluster or linear distribution of erythematous macular lesions and can progress to wheals and widespread urticaria.6 Although rare, systemic reactions can involve widespread pruritis, asthma, anaphylaxis g pp p and fever.2 There is increasing evidence to support sensitization after initial exposure to bed bugs with the latency period between bed bug bite and cutaneous reaction decreasing substantially between subsequent bites.7 In this case, the student had been exposed to bed bug bites since November 2012 and has developed progressively more severe cutaneous reactions from each subsequent bite. The pathogenesis of reactions produced by bed bug bites may correlate with bed bug salivary extract, which has been shown to induce chemokines that recruit inflammatory mediators; eosinophils, macrophages, neutrophils, and other granulocytes and maintain their proliferation by stimulating the release of granulocyte colony stimulating factor 8 their proliferation by stimulating the release of granulocyte colony stimulating factor. The treatment of systemic reactions includes intramuscular epinephrine, antihistamines and oral and topical9 corticosteroids, dependent upon the severity of the allergic reaction. The student in this case noticed an improvement in his symptoms prior to the administration of these medications.
a.
b.
Figure 2. Development of an erythrodermic reaction twenty minutes after initiation of bed bug feeding over his a) head and neck with b) dispersed, hypopigmented macules over the neck region.
