Pediatric Dermatology Vol. 31 No. 3 353–355, 2014

The Eyelid Sign: A Clue to Bed Bug Bites Kim A. Quach, M.D., and Andrea L. Zaenglein, M.D. Department of Dermatology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania

Abstract: In pediatric patients, determining the culprit insect in arthropod assaults can be challenging. The patient’s history may be vague, the causative insect may not be readily associated with the bites, and the clinical appearance of bites can be variable. Six pediatric patients from the Penn State Milton S. Hershey Medical Center dermatology offices with bed bug bites were identified. All had bites involving the face, trunk, and extremities. Five patients demonstrated papules on one upper eyelid associated with erythema and edema. One patient had papules on both upper eyelids. When an arthropod assault is suspected, the “eyelid sign,” i.e., bites involving the upper eyelid associated with erythema and edema, may point to bed bugs.

Cimex lectularius, the common bed bug, is a nocturnal insect that feeds on birds and mammals, including humans (1). Bed bugs are reported in nearly every state of the United States and throughout Europe and Asia. Since 2001 there has been a steady increase in the number of news reports concerning bed bug infestations across all regions of the United States (2). Determining the source of multiple arthropod bites is often perplexing and distressing for patients and their families. Delayed identification of bed bug bites may allow the infestation to progress and potentially expose other household members (3). Because bed bugs range in size from 5 to 7 mm and tend to avoid light (1), they can escape notice unless the patient and family are alerted to a potential infestation.

METHODS The charts of children with suspected bed bug bites who presented to the Penn State Milton S. Hershey Medical Center dermatology offices from December 2009 to September 2012 were reviewed. If there was no clear documentation of bed bug infestation, a parent was contacted by telephone to confirm the diagnosis. RESULTS Six children were identified with similar clinical findings. Each had scattered, pruritic pink papules on the trunk and extremities and a crusted papule on one or both upper eyelids associated with mild erythema and ipsilateral eyelid edema (Fig. 1A, B). Patient characteristics including age, sex, and clinical presentation

Address correspondence to Andrea L. Zaenglein, M.D., Department of Dermatology, Penn State/Milton S. Hershey Medical Center, HU14, 500 University Drive, Hershey, PA 17033, or e-mail: [email protected]. DOI: 10.1111/pde.12332

© 2014 Wiley Periodicals, Inc.

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A

Figure 2. Bed bug bites. Patient 4 demonstrating a positive “eyelid sign” with the tell-tale insect bite involving the upper eyelid.

B

Figure 1. Bed bug bites. (A) Patient 3 with multiple pink papules on the face and trunk. (B) Close-up showing a characteristic inflammatory papule on the upper lid.

are presented in Table 1. In addition to crusted papules, patient 1 had vesicles on the face, trunk, and extremities, with papules on both upper eyelids and bilateral eyelid edema (Fig. 2). Other details of her clinical presentation were published previously (4).

Patient 3 also had a few pustules. In five patients (1, 3, 4, 5, and 6) the parents or exterminators observed bed bugs in the home. The parents of patients 1 and 4 brought bed bug specimens to the clinic for identification. Patient 2 had travelled out of the country before developing pruritic pink papules on the extremities and face, including the right upper eyelid. Exposure to bed bugs could not be confirmed, although his skin lesions were clinically consistent with multiple insect bites. The mother and older sister of patient 3 had a few scattered bites. No family members of the other five patients reported significant bites. DISCUSSION This series describes five confirmed cases and one suspected case of bed bug bites in children presenting to our institution. In addition to multiple insect bites

TABLE 1. Patient Characteristics Patient

Age

Sex

Morphology of skin lesions

Affected areas

1

10 mos

Female

2 3

10 mos 2 yrs

Male Male

Extremities, trunk, neck, face, both upper eyelids Extremities, face, right upper eyelid Extremities, trunk, face, left upper eyelid

4 5 6

3 yrs 3 yrs 5 yrs

Pink papules, crusted papules, vesicles Pink papules Pink papules, crusted papules, rare pustule Pink papules, crusted papules Pink papules, crusted papules Pink papules, crusted papules

Extremities, trunk, face, left upper eyelid Extremities, trunk, face, right upper eyelid Extremities, trunk, face, left upper eyelid

Female Male Male

*Patient had been bitten while traveling. Presentation was classic for bed bug bites.

Other family members affected

Bed bug identified

No

Yes

No Yes

No* Yes

No No No

Yes Yes Yes

Quach and Zaenglein: “Eyelid Sign”: A Clue to Bed Bug Bites

involving exposed areas such as the extremities and face, all six patients had characteristic reactions on one or both upper eyelids. We suggest the term “eyelid sign” to describe a bite on the upper eyelid with associated erythema and ipsilateral upper eyelid edema. This may be a subtle clue to bed bugs as the culprit insect in arthropod assaults in children. Bed bug bites are most often reported on the extremities, but any exposed area can be involved (5). A predilection for the eyelid has not been noted previously, although this area is exposed when bed bugs feed on a sleeping child. The eyelid edema is reminiscent of Roma~ na’s sign, the hallmark of Chagas disease, caused by conjunctival inoculation with Trypanosoma cruzi after the assassin bug bites the eyelid (6). Like the bed bug, the assassin bug (Reduviidae family) is a nocturnal feeder of human blood (7,8). Although other insects such as mosquitoes can bite the eyelid and cause swelling, sometimes mimicking acute orbital cellulitis, our patients presented with numerous, recurrent lesions and a chronic course of several months with no seasonal variation. Papular urticaria is considered a hypersensitivity reaction to various arthropod bites, including fleas, lice, and mosquitos (9,10). It can occur with bed bugs as well and may explain particularly severe or persistent lesions (9). In our cases, each child’s symptoms cleared quickly with bed bug extermination. Limitations of this study include the small number of cases available for review and that it was limited to children. The sensitivity or specificity of the “eyelid” cannot be determined given the limited number of patients and lack of a control group. Because bed bugs hide during the day and other household members may not experience bites, as in

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five of our cases, a high index of suspicion is needed to convince parents of the possibility of an infestation in the home. A delayed or missed diagnosis can allow the bed bugs to spread unchecked, leading to recurrent bites. When a child presents with insect bites involving the upper eyelid, the possibility of bed bug infestation should be discussed with the family. REFERENCES 1. Elston DM, Stockwell S. What’s eating you? Bedbugs. Cutis 2000;65:262–264. 2. 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. 3. Doggett SL, Dwyer DE, Pe~ nas PF et al. Bed bugs: clinical relevance and control options. Clin Microbiol Rev 2012;25:164–192. 4. Straub RD, Salvaggio HL, Adams DR et al. Diffuse clusters of vesicles on the face and extremities of a 10-month-old girl. Pediatr Dermatol 2009;26:747–748. 5. Potter MF, Haynes KF, Connelly K et al. The sensitivity spectrum: human reactions to bed bug bites. Pest Control Technol 2010;100:71–74. 6. Bern C, Kjos S, Yabsley MJ et al. Trypanosoma cruzi and Chagas’ disease in the United States. Clin Microbiol Rev 2011;24:655–681. 7. Hwang WS, Weirauch C. Evolutionary history of assassin bugs (Insecta: Hemiptera: Reduviidae): insights from divergence dating and ancestral state reconstruction. PLoS One 2012;7:e45523. 8. Rassi A Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet 2010;375:1388–1402. 9. Jordaan HF, Schneider JW. Papular urticaria: a histopathologic study of 30 patients. Am J Dermatopathol 1997;19:119–126. 10. Howard R, Frieden IJ. Papular urticaria in children. Pediatr Dermatol 1996;13:246–249.

The eyelid sign: a clue to bed bug bites.

In pediatric patients, determining the culprit insect in arthropod assaults can be challenging. The patient's history may be vague, the causative inse...
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