Letters to the Editor
539
3 Skinner BA, Greist MC, Norins AL. The keratitis, ichthyosis, and deafness (KID) syndrome. Arch Dermatol 1981; 117: 285–289. 4 Caceres-Rios H, Tamayo-Sanchez L, Duran-Mckinster C, de la Luz Orozco M, Ruiz-Maldonado R. Keratitis, ichthyosis, and deafness (KID syndrome): review of the literature and proposal of a new terminology. Pediatr Dermatol 1996; 13: 105–113. 5 Rycroft RJ, Moynahan EJ, Wells RS. Atypical ichthyosiform erythrodernam deafness and keratitis. A report of two cases. Br J Dermatol 1976; 94: 211–217. 6 Messmer EM, Kenyon KR, Rittinger O, Janecke AR, Kampik A. Ocular manifestations of keratitis-ichthyosis-deafness (KID) syndrome. Ophthalmology 2005; 112: e1–e6. 7 Kenneson A, Van Naarden Braun K, Boyle C. GJB2 (connexin 26) variants and nonsyndromic sensorineural hearing loss: a HuGE review. Genetics in medicine : official journal of the American College of Medical. Genetics 2002; 4: 258–274. 8 Coggshall K, Farsani T, Ruben B et al. Keratitis, ichthyosis, and deafness syndrome: a review of infectious and neoplastic complications. J Am Acad Dermatol 2013; 69: 127–134. 9 Bondeson ML, Nystrom AM, Gunnarsson U, Vahlquist A. Connexin 26 (GJB2) mutations in two Swedish patients with atypical Vohwinkel (mutilating keratoderma plus deafness) and KID syndrome both extensively treated with acitretin. Acta Derm Venereol 2006; 86: 503–508. 10 Sahoo B, Handa S, Kaur I, Radotra BD, Kumar B. KID syndrome: response to acitretin. J Dermatol 2002; 29: 499–502. DOI: 10.1111/jdv.12936
Dermoscopy is useful for bed bug (Cimex lectularius) bites Editor Bed bugs (Cimex lectularius) are blood-feeding insects that are uncommon in developed countries. However, outbreaks of bed bugs have recently been reported in developed countries.1,2
Nowadays, many travellers from outbreak-countries visit whole over the world every year, and the risk of bed bug bites is increasing in developed countries. Indeed, reports to the health centres are increasing in Japan. However, there are no case reports of bed bug bites from Japan. Here, we report a case of bed bug bites in a Japanese female. In our case, dermoscopic findings clearly showed the bite spots, which were also histologically identified as haemorrhage. A 66-year-old woman was referred with red papules on the whole body that had been seen for 6 months. Physical examination revealed exudative erythema (Fig. 1a), maculopapules associated with slight induration (Fig. 1b) distributed on the trunk and extremities. The eruptions were seen on the back usually covered with clothes (Fig. 1c). She reported severe itchiness during sleeping in bed sometimes. Dermoscopic findings showed telangiectasia (Fig. 2a) and haemorrhage (Fig. 2b), which were regarded as bite spot. Antinuclear antibody and anti-CCP antibody were positive. Total IgE level was elevated, at 3974.4 IU/mL. The skin biopsy revealed vacuolar degeneration at the dermal–epidermal junction and perivascular infiltration with lymphocytes and some eosinophils in the dermis (Fig. 2c, d). The extravasation of erythrocytes was also seen, but neither vasculitis nor thrombosis was observed. On further questioning, she remembered her symptoms as having started after stays at several hotels around Japan. She carefully cleaned her house and found lots of bed bugs and faecal spots behind the bed, the sofa and other furniture (Fig. 1d). She was diagnosed with bed bug bites and was cured after intensive cleaning of her house. Bed bugs are insects of approximately 5 mm in length in the order Hemiptera. They feed on mammal hosts, including humans. Bed bugs hide in dark spaces during the daytime and are active at night, when they feed. Although they are big enough to be visible to the human eye, previous reports have noted that
(a)
(c)
(b)
(d)
Figure 1 (a) Targeted exudative erythema are seen on her thigh. (b) Maculopapules and pigmentation are distributed on the upper extremities. (c) Eruptions are seen on the back, which is usually covered by clothes. (d) Bed bugs and their faecal spots are seen behind the sofa.
JEADV 2016, 30, 446–556
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
540
(a)
(b)
(c)
(d)
most patients do not see them.3 This is because bed bugs have a strong aversion to light. At night, they are attracted by CO2 exhalations.4 The clinical manifestations of bed bug bite vary, typically showing maculopapules with central haemorrhagic punctum corresponding to the bite site, associated with severe itchiness.2 In some cases, targetoid lesions are seen.5 Although there are no reports, dermoscopy is valuable tool to observe the bite spots. The tiny haemorrhage spots are clearly observed by dermoscopy. Histological features of bed bug bites are little known,5,6 because skin biopsy is not often performed in case of bed bug bites. Bullous lesions associated with erythema are also seen, due to hypersensitivity to bed bugs mediated by IgE against salivary nitrophorin.6,7 The present patient demonstrated high level of total IgE, which might be associated with hypersensitivity reaction. When seeing a patient suspected of having bed bug bites, dermoscopy is easy and convenient examination to observe haemorrhagic bite spots. T. Shirato, H. Iwata,* N. Yoshimoto, Y. Nomura, N. Yamane, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan *Correspondence: H. Iwata. E-mail: [email protected]
References 1 Anderson AL, Leffler K. Bedbug infestations in the news: a picture of an emerging public health problem in the United States. J Environ Health 2008; 70: 24–27, 52–53. 2 Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O. Bed bug infestation. BMJ 2013; 346: f138.
JEADV 2016, 30, 446–556
Figure 2 (a) Dermoscopy shows diffuse telangiectasia (in the red line). (b) Haemorrhage, which is regarded as a bite site, is also clearly observed (black arrow). (c) Histologically, vacuolar degeneration at the dermal–epidermal junction and perivascular infiltration are seen. (d) In the dermis, lymphocytes and some eosinophils infiltrates associated with erythrocyte extravasation are observed.
3 Reinhardt K, Harder A, Holland S et al. Who knows the bed bug? Knowledge of adult bed bug appearance increases with people’s age in three counties of Great Britain. J Med Entomol 2008; 45: 956–958. 4 Anderson JF, Ferrandino FJ, McKnight S et al. A carbon dioxide, heat and chemical lure trap for the bedbug, Cimex lectularius. Med Vet Entomol 2009; 23: 99–105. 5 Melnick L, Samimi S, Elder D et al. Targetoid lesions in the emergency department. Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. JAMA Dermatol 2013; 149: 751–756. 6 de Shazo RD, Feldlaufer MF, Mihm MC, Goddard J. Bullous reactions to bedbug bites reflect cutaneous vasculitis. Am J Med 2012; 125: 688–694. 7 Leverkus M, Jochim RC, Sch€ad S et al. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. J Invest Dermatol 2006; 126: 91–96. DOI: 10.1111/jdv.12938
Pemphigus herpetiformis: six additional cases with an emphasis on eczema-like features and the diagnostic utility of Tzanck smears Editor Pemphigus herpetiformis (PH) is a rare variant of pemphigus that is clinically characterized by pruritic herpetiform vesicles, bullae and papules, which often appear in a grouped pattern.1 Given that only approximately 100 cases have been reported in
© 2014 European Academy of Dermatology and Venereology
539
3 Skinner BA, Greist MC, Norins AL. The keratitis, ichthyosis, and deafness (KID) syndrome. Arch Dermatol 1981; 117: 285–289. 4 Caceres-Rios H, Tamayo-Sanchez L, Duran-Mckinster C, de la Luz Orozco M, Ruiz-Maldonado R. Keratitis, ichthyosis, and deafness (KID syndrome): review of the literature and proposal of a new terminology. Pediatr Dermatol 1996; 13: 105–113. 5 Rycroft RJ, Moynahan EJ, Wells RS. Atypical ichthyosiform erythrodernam deafness and keratitis. A report of two cases. Br J Dermatol 1976; 94: 211–217. 6 Messmer EM, Kenyon KR, Rittinger O, Janecke AR, Kampik A. Ocular manifestations of keratitis-ichthyosis-deafness (KID) syndrome. Ophthalmology 2005; 112: e1–e6. 7 Kenneson A, Van Naarden Braun K, Boyle C. GJB2 (connexin 26) variants and nonsyndromic sensorineural hearing loss: a HuGE review. Genetics in medicine : official journal of the American College of Medical. Genetics 2002; 4: 258–274. 8 Coggshall K, Farsani T, Ruben B et al. Keratitis, ichthyosis, and deafness syndrome: a review of infectious and neoplastic complications. J Am Acad Dermatol 2013; 69: 127–134. 9 Bondeson ML, Nystrom AM, Gunnarsson U, Vahlquist A. Connexin 26 (GJB2) mutations in two Swedish patients with atypical Vohwinkel (mutilating keratoderma plus deafness) and KID syndrome both extensively treated with acitretin. Acta Derm Venereol 2006; 86: 503–508. 10 Sahoo B, Handa S, Kaur I, Radotra BD, Kumar B. KID syndrome: response to acitretin. J Dermatol 2002; 29: 499–502. DOI: 10.1111/jdv.12936
Dermoscopy is useful for bed bug (Cimex lectularius) bites Editor Bed bugs (Cimex lectularius) are blood-feeding insects that are uncommon in developed countries. However, outbreaks of bed bugs have recently been reported in developed countries.1,2
Nowadays, many travellers from outbreak-countries visit whole over the world every year, and the risk of bed bug bites is increasing in developed countries. Indeed, reports to the health centres are increasing in Japan. However, there are no case reports of bed bug bites from Japan. Here, we report a case of bed bug bites in a Japanese female. In our case, dermoscopic findings clearly showed the bite spots, which were also histologically identified as haemorrhage. A 66-year-old woman was referred with red papules on the whole body that had been seen for 6 months. Physical examination revealed exudative erythema (Fig. 1a), maculopapules associated with slight induration (Fig. 1b) distributed on the trunk and extremities. The eruptions were seen on the back usually covered with clothes (Fig. 1c). She reported severe itchiness during sleeping in bed sometimes. Dermoscopic findings showed telangiectasia (Fig. 2a) and haemorrhage (Fig. 2b), which were regarded as bite spot. Antinuclear antibody and anti-CCP antibody were positive. Total IgE level was elevated, at 3974.4 IU/mL. The skin biopsy revealed vacuolar degeneration at the dermal–epidermal junction and perivascular infiltration with lymphocytes and some eosinophils in the dermis (Fig. 2c, d). The extravasation of erythrocytes was also seen, but neither vasculitis nor thrombosis was observed. On further questioning, she remembered her symptoms as having started after stays at several hotels around Japan. She carefully cleaned her house and found lots of bed bugs and faecal spots behind the bed, the sofa and other furniture (Fig. 1d). She was diagnosed with bed bug bites and was cured after intensive cleaning of her house. Bed bugs are insects of approximately 5 mm in length in the order Hemiptera. They feed on mammal hosts, including humans. Bed bugs hide in dark spaces during the daytime and are active at night, when they feed. Although they are big enough to be visible to the human eye, previous reports have noted that
(a)
(c)
(b)
(d)
Figure 1 (a) Targeted exudative erythema are seen on her thigh. (b) Maculopapules and pigmentation are distributed on the upper extremities. (c) Eruptions are seen on the back, which is usually covered by clothes. (d) Bed bugs and their faecal spots are seen behind the sofa.
JEADV 2016, 30, 446–556
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
540
(a)
(b)
(c)
(d)
most patients do not see them.3 This is because bed bugs have a strong aversion to light. At night, they are attracted by CO2 exhalations.4 The clinical manifestations of bed bug bite vary, typically showing maculopapules with central haemorrhagic punctum corresponding to the bite site, associated with severe itchiness.2 In some cases, targetoid lesions are seen.5 Although there are no reports, dermoscopy is valuable tool to observe the bite spots. The tiny haemorrhage spots are clearly observed by dermoscopy. Histological features of bed bug bites are little known,5,6 because skin biopsy is not often performed in case of bed bug bites. Bullous lesions associated with erythema are also seen, due to hypersensitivity to bed bugs mediated by IgE against salivary nitrophorin.6,7 The present patient demonstrated high level of total IgE, which might be associated with hypersensitivity reaction. When seeing a patient suspected of having bed bug bites, dermoscopy is easy and convenient examination to observe haemorrhagic bite spots. T. Shirato, H. Iwata,* N. Yoshimoto, Y. Nomura, N. Yamane, H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-ku, Sapporo 060-8638, Japan *Correspondence: H. Iwata. E-mail: [email protected]
References 1 Anderson AL, Leffler K. Bedbug infestations in the news: a picture of an emerging public health problem in the United States. J Environ Health 2008; 70: 24–27, 52–53. 2 Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O. Bed bug infestation. BMJ 2013; 346: f138.
JEADV 2016, 30, 446–556
Figure 2 (a) Dermoscopy shows diffuse telangiectasia (in the red line). (b) Haemorrhage, which is regarded as a bite site, is also clearly observed (black arrow). (c) Histologically, vacuolar degeneration at the dermal–epidermal junction and perivascular infiltration are seen. (d) In the dermis, lymphocytes and some eosinophils infiltrates associated with erythrocyte extravasation are observed.
3 Reinhardt K, Harder A, Holland S et al. Who knows the bed bug? Knowledge of adult bed bug appearance increases with people’s age in three counties of Great Britain. J Med Entomol 2008; 45: 956–958. 4 Anderson JF, Ferrandino FJ, McKnight S et al. A carbon dioxide, heat and chemical lure trap for the bedbug, Cimex lectularius. Med Vet Entomol 2009; 23: 99–105. 5 Melnick L, Samimi S, Elder D et al. Targetoid lesions in the emergency department. Bed bug bites (Cimex lectularius) with targetoid lesions on initial presentation. JAMA Dermatol 2013; 149: 751–756. 6 de Shazo RD, Feldlaufer MF, Mihm MC, Goddard J. Bullous reactions to bedbug bites reflect cutaneous vasculitis. Am J Med 2012; 125: 688–694. 7 Leverkus M, Jochim RC, Sch€ad S et al. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. J Invest Dermatol 2006; 126: 91–96. DOI: 10.1111/jdv.12938
Pemphigus herpetiformis: six additional cases with an emphasis on eczema-like features and the diagnostic utility of Tzanck smears Editor Pemphigus herpetiformis (PH) is a rare variant of pemphigus that is clinically characterized by pruritic herpetiform vesicles, bullae and papules, which often appear in a grouped pattern.1 Given that only approximately 100 cases have been reported in
© 2014 European Academy of Dermatology and Venereology
