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Targetoid Lesions in the Emergency Department—Diagnosis

Targetoid Lesions in the Emergency Department—Diagnosis Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Findings from a histopathologic examination were remarkable for spongiosis, papillary dermal edema, dermal hemorrhage, and a dense superficial and deep perivascular and interstitial inflammatory cell infiltrate, including numerous eosinophils, lymphocytes, and neutrophils consistent with a hypersensitivity reaction. The patient was treated with topical clobetasol propionate, 0.05%, ointment and oral antihistamines and responded to this treatment within 24 hours. On detailed history, it was revealed that the patient had recently moved into new housing, and given the clinical concern for arthropod bites, an exterminator was sent to her apartment complex, where an extensive bed bug infestation was identified. The patient was seen in clinic 10 days after the initial eruption, and her lesions had resolved. Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Bed bug (Cimex lectularius) infestations are increasing worldwide owing to increased travel and resistance to insecticides. Bed bugs usually feed every 3 to 5 days for 4 to 10 minutes; however, their ability to survive for up to 1 year without a meal makes bed bug eradication and control a challenging endeavor.1,2 The most common cutaneous manifestations include no reaction, barely visible punctums, morbilliform eruption, or urticarial-like eruptions in a linear or grouped pattern. More extensive reactions have also been reported, including bullae and anaphylaxis.3,4 Severe reactions may be related to patients' immunocompetence and previous exposure to bed bugs, suggesting that repeated exposure may lead to a more complex, exuberant and pruritic eruption.5 This hypersensitivity to C letularius may be driven by an IgE-mediated immune response to bed bug salivary antigen nitrophorin.6 The intense reaction that our patient experienced suggests that she may have had repeated prior exposures, leading to a more intense response. Given the wide variability of presentations, diagnostic clues to bed bug bites include new lesions in the morning, or presence of blood or feces on the linen.1 With classic bed bug bites, other arthropod bites, such as scabies and fleas, various papulovesicular eruptions, and dermatitis herpetiformis, also are in the differential diagnosis.2 Our patient's targetoid and edematous lesions initially suggested a more serious diagnosis, including erythema multiforme or Sweet syndrome. Treatment for bed bug bites includes supportive and symptomatic control with antihistimines and topical steroids. Because of increasing rates of resistance to insecticides, eradication should be performed by an experienced exterminator. Return to Quiz Case References 1. Kolb A, Needham GR, Neyman KM, High WA. Bedbugs. Dermatol Ther. 2009;22(4):347-35219580578PubMedGoogle ScholarCrossref 2. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-43315186224PubMedGoogle ScholarCrossref 3. Goddard J, deShazo RD. Bed bugs (Cimex lectularius) and clinical consequences of their bites. JAMA. 2009;301(13):1358-136619336711PubMedGoogle ScholarCrossref 4. Scarupa MD, Economides A. Bedbug bites masquerading as urticaria. J Allergy Clin Immunol. 2006;117(6):1508-150916751024PubMedGoogle ScholarCrossref 5. Sansom JE, Reynolds NJ, Peachey RD. Delayed reaction to bed bug bites. Arch Dermatol. 1992;128(2):272-2731739312PubMedGoogle ScholarCrossref 6. Leverkus M, Jochim RC, Schäd S, et al. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. J Invest Dermatol. 2006;126(1):91-9616417223PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Targetoid Lesions in the Emergency Department—Diagnosis

JAMA Dermatology , Volume 149 (6) – Jun 1, 2013

Targetoid Lesions in the Emergency Department—Diagnosis

Abstract

Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Findings from a histopathologic examination were remarkable for spongiosis, papillary dermal edema, dermal hemorrhage, and a dense superficial and deep perivascular and interstitial inflammatory cell infiltrate, including numerous eosinophils, lymphocytes, and neutrophils consistent with a hypersensitivity...
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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.3314e
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Findings from a histopathologic examination were remarkable for spongiosis, papillary dermal edema, dermal hemorrhage, and a dense superficial and deep perivascular and interstitial inflammatory cell infiltrate, including numerous eosinophils, lymphocytes, and neutrophils consistent with a hypersensitivity reaction. The patient was treated with topical clobetasol propionate, 0.05%, ointment and oral antihistamines and responded to this treatment within 24 hours. On detailed history, it was revealed that the patient had recently moved into new housing, and given the clinical concern for arthropod bites, an exterminator was sent to her apartment complex, where an extensive bed bug infestation was identified. The patient was seen in clinic 10 days after the initial eruption, and her lesions had resolved. Diagnosis: Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. Bed bug (Cimex lectularius) infestations are increasing worldwide owing to increased travel and resistance to insecticides. Bed bugs usually feed every 3 to 5 days for 4 to 10 minutes; however, their ability to survive for up to 1 year without a meal makes bed bug eradication and control a challenging endeavor.1,2 The most common cutaneous manifestations include no reaction, barely visible punctums, morbilliform eruption, or urticarial-like eruptions in a linear or grouped pattern. More extensive reactions have also been reported, including bullae and anaphylaxis.3,4 Severe reactions may be related to patients' immunocompetence and previous exposure to bed bugs, suggesting that repeated exposure may lead to a more complex, exuberant and pruritic eruption.5 This hypersensitivity to C letularius may be driven by an IgE-mediated immune response to bed bug salivary antigen nitrophorin.6 The intense reaction that our patient experienced suggests that she may have had repeated prior exposures, leading to a more intense response. Given the wide variability of presentations, diagnostic clues to bed bug bites include new lesions in the morning, or presence of blood or feces on the linen.1 With classic bed bug bites, other arthropod bites, such as scabies and fleas, various papulovesicular eruptions, and dermatitis herpetiformis, also are in the differential diagnosis.2 Our patient's targetoid and edematous lesions initially suggested a more serious diagnosis, including erythema multiforme or Sweet syndrome. Treatment for bed bug bites includes supportive and symptomatic control with antihistimines and topical steroids. Because of increasing rates of resistance to insecticides, eradication should be performed by an experienced exterminator. Return to Quiz Case References 1. Kolb A, Needham GR, Neyman KM, High WA. Bedbugs. Dermatol Ther. 2009;22(4):347-35219580578PubMedGoogle ScholarCrossref 2. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-43315186224PubMedGoogle ScholarCrossref 3. Goddard J, deShazo RD. Bed bugs (Cimex lectularius) and clinical consequences of their bites. JAMA. 2009;301(13):1358-136619336711PubMedGoogle ScholarCrossref 4. Scarupa MD, Economides A. Bedbug bites masquerading as urticaria. J Allergy Clin Immunol. 2006;117(6):1508-150916751024PubMedGoogle ScholarCrossref 5. Sansom JE, Reynolds NJ, Peachey RD. Delayed reaction to bed bug bites. Arch Dermatol. 1992;128(2):272-2731739312PubMedGoogle ScholarCrossref 6. Leverkus M, Jochim RC, Schäd S, et al. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. J Invest Dermatol. 2006;126(1):91-9616417223PubMedGoogle ScholarCrossref

Journal

JAMA DermatologyAmerican Medical Association

Published: Jun 1, 2013

Keywords: emergency service, hospital,bedbugs

References