Picture Blog: Case 1 Answer (Sleep Tight)

Bedbugs.

Typical lesions from bed bugs are erythematous macules with central vesicles. These lesions tend to be very pruritic though they can be asymptomatic. They often are located on unclothed areas, such as the extremities, as seen above. Bedbug bites can also form wheals, vesicles, bullae, or nodules. Classically they occur in clusters.

Key historical points might be blood spots on sheets and bites in the distribution of areas not covered by  sleepwear.

Bedbugs have oval-shaped bodies that are flat and dark colored. They need to feed on blood, as this is their regular source of nutrition. They do not only feed on humans, but they are attracted to the warmth of the human body. Before the bugs feed, they are brown. After feeding, once engorged with blood, the bugs become larger and redder. Often, bedbug carcasses or linear streaks of blood and droppings can be seen in the bedding. Occasionally, the offending bugs can be seen as well.

You can assume this diagnosis based on the presence of the typical rash, but your diagnosis is verified by finding an actual bedbug. You should tell the patient to use topical corticosteroids for symptomatic relief.

In New York City the landlord is required to handle eradication and there is a 3-1-1 bedbug hotline. Extermination of the bugs requires insecticide and heat treatments, sometimes in multiple rounds. All of the patient’s clothes need to be dried with high heat. If they do not want to throw away other items, they can be placed in a freezer for around 4 days to kill the bugs.

Patients can develop local skin reactions including cellulitis and should be instructed to return for worsening cutaneous symptoms.

Eradication measures are not always successful. Patients should be on the lookout for continuing skin lesions and be vigilant about looking for insects in their homes.