The Flip Side of Warm Weather

bugWarm weather is here and among the less charming aspects of summer are insects. Over the top reaction to insect bites (as well as poison ivy etc) is sometimes seen in CLL patients. I know dozens of patients with this problem. Unfortunately, there is no quick fix if you are among the patients that have this problem – other than lathering on bug repellents before going out, wearing long sleeved shirts, long pants, socks etc.

Here are some commonsense things you should be aware of:

  • Prevent infection. Immediately wash the area of the bug bite with warm water. Using an antibacterial soap or thin layer of antibiotic cream may help.
  • Some patients find a cold (or hot) compress helps – which ever works for you to reduce the itching.
  • Cover the bug bite with a bandage to keep from scratching. Over the counter anti-itch spray or ointment may help. The idea is to prevent making things worse and get a bad case of bacterial infection.
  • Know how to recognize skin infection. Look for redness and swelling that has enlarged beyond the original area of the bug bite. Check to see if the area is warm and tender to the touch. Watch for pus or drainage in the area of the bite. All of these are signs of secondary infection.
  • If in spite of your best efforts the bug bite becomes infected, see your doctor. It is not a good idea to self-medicate or be macho and neglect the issue if there are any signs of the bite getting infected.
  • Some doctors recommend antibiotic treatment to deal with the infection. You may also be told to use a topical corticosteroid cream to pacify the aggressive and inappropriate immune reaction of your body.
  • Here is the link to a site that seems to have reasonable guidance on what to do.

There have been a number of recent articles on the subject – I have attached a few of the abstracts below for your information.  The consensus seems to be that the problem is due to inappropriate and over aggressive immune response because of the underlying CLL. What else is new.

J Cutan Med Surg. 2001 Jul-Aug;5(4):312-4. Epub 2001 Jul 18.

Arthropod bites manifesting as recurrent bullae in a patient with chronic lymphocytic leukemia.

Blum RR, Phelps RG, Wei H.

Department of Dermatology, Mount Sinai School of Medicine, New York, NY 10029, USA.

BACKGROUND: We report a patient with chronic lymphocytic leukemia (CLL) that developed recurrent vesicobullous lesions that histologically demonstrated features of an exaggerated response to an arthropod bite. OBJECTIVE: Patients with CLL can present with many cutaneous manifestations, including specific and nonspecific lesions. Although rare, patients with CLL can develop an exaggerated response to an arthropod bite. CONCLUSION: Emphasis needs to be placed on the clinical recognition of arthropod bites as an unusual cutaneous manifestation of CLL, as they provide the physician with both a diagnostic and a therapeutic challenge. Patients often deny being bitten and, thus, the biopsy results conflict with the patient’s history. Additionally, as there is no specific treatment, both the patient and physician are faced with a similar dilemma. Although our patient initially responded well to corticosteroids, his lesions significantly improved while being treated with dapsone.

PMID: 11907842

J Am Acad Dermatol. 1998 Jul;39(1):27-35.

Exaggerated arthropod-bite lesions in patients with chronic lymphocytic leukemia: a clinical, histopathologic, and immunopathologic study of eight patients.

Davis MD, Perniciaro C, Dahl PR, Randle HW, McEvoy MT, Leiferman KM.

Department of Dermatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.

BACKGROUND: Unusual papulovesicular lesions resembling arthropod bites have been described in patients with chronic lymphocytic leukemia (CLL). OBJECTIVE: Our purpose was to describe and characterize further the clinical, histopathologic, and immunopathologic features of these lesions. METHODS: Eight patients were identified retrospectively who had CLL and characteristic skin lesions. Clinical and histologic features were recorded. Skin biopsy specimens were analyzed immunohistochemically for eosinophil granule major basic protein, eosinophil-derived neurotoxin, neutrophil elastase, and mast cell tryptase. RESULTS: The clinical features, including the lesional distribution, suggested arthropod bites, although most patients could not recall having been bitten. Mixed T- and B-cell lymphoid cell infiltrates were present within lesions, along with prominent eosinophil infiltration and eosinophil granule protein deposition. CONCLUSION: Exuberant papulovesicular lesions develop in patients with CLL apparently as an exaggerated response to arthropod bites. Prominent eosinophil infiltration and degranulation within these lesions likely contribute to the severity of symptoms.

PMID: 9674394

Am J Dermatopathol. 2005 Aug;27(4):290-5.

Insect bite-like reaction associated with mantle cell lymphoma: clinicopathological, immunopathological, and molecular studies.

Khamaysi Z, Dodiuk-Gad RP, Weltfriend S, Ben-Arieh Y, Dann EJ, Sahar D, Bergman R.

Department of Dermatology, Rambam Medical Center, Haifa, Israel.

A cutaneous eruption simulating insect bites has been repeatedly described in association with chronic lymphocytic leukemia (CLL). It was only rarely described with mantle cell lymphoma (MCL). Our study was performed to elucidate the clinical, histologic, immunopathological, and molecular characteristics of insect bite like reaction (IBLR) associated with MCL. The clinical presentation and histologic findings in 3 IBLR cases associated with MCL were found to be similar to 3 IBLR cases associated with CLL. The eruptions consisted of itchy erythematous papules, nodules, plaques, and vesicles. Non-vesicular lesions were characterized histologically by normal or mildly spongiotic epidermis. Vesicular lesions were characterized by marked spongiosis and intraepidermal spongiotic vesicles containing eosinophils, or marked subepidermal edema occasionally leading to a dermoepidermal separation. Most of the lesions were characterized by superficial and mid dermal to deep perivascular and interstitial, and occasionally periadnexal, inflammatory-cell infiltrate consisting of mononuclear cells and eosinophils. The densities of the infiltrates varied and the inflammatory-cell infiltrate extended often into the fat lobules. Neutrophils and nuclear dust were found more frequently and abundantly in the IBLR lesions associated with MCL. Immunophenotyping, direct immunofluorescence (DIF) tests, and IgH gene rearrangement studies were performed in the lesions associated with MCL only. The majority of the infiltrating lymphocytes were CD3+, CD5+ and CD43+, more CD4+ than CD8+, and only a small minority was CD20+. The cells did not stain for bcl-1 protein and CD30, and with no evidence of clonality. The DIF test result was negative. The IBLR eruption associated with MCL resembles clinically and histologically IBLR associated with CLL. The eruption seems to be reactive rather than neoplastic, because there is no evidence of MCL involvement in the skin lesions.

PMID: 16121047

Insect bite