Insect bites continued

Hairbear posted a few weeks ago regarding insect bites and I know some others have had problems during the summer. I came across additional information and post it below. At the bottom are quite a few reference papers listed on this subject for anyone's further research.


A 61-Year-Old Caucasian Woman Presents With History of “Bizarre Insect Bites”

By Ted Rosen, MD | March 12, 2012 From Cancer Network. ‘ Oncology ‘ Journal.

Professor of Dermatology at Baylor College of Medicine; Chief of Dermatology at Michael E. DeBakey VA Medical Center.

A 61-year-old Caucasian woman presented in the month of August with an approximate 16-month history of "bizarre insect bites." As an avid gardener, she spent considerable time outdoors and had never before experienced a similar problem. However, during the prior two spring-summer seasons, almost every witnessed mosquito bite resulted in either a swollen, pruritic nodule or a substantial blister.

Discussion: The skin biopsy demonstrated a dense perivascular, perifollicular, and periadnexal infiltrate composed of mature lymphocytes admixed with abundant eosinophils. There was extreme papillary dermal edema, leading to subepidermal bulla formation. Direct and indirect immunofluorescence were both negative. The dermatopathologist commented that the histologic picture was most compatible with an arthropod assault and extreme hypersensitivity reaction. Basic screening laboratory studies disclosed the following abnormalities: elevated white blood cell count (60,000/mm3), white blood cell differential consisting of 75% lymphocytes and 20% neutrophils, and hemoglobin level of 8.3 gm/dL. The picture strongly suggested chronic lymphocytic leukemia (CLL), and the patient was promptly referred to a hematologist for further evaluation and appropriate treatment. A report received several weeks later indicated that additional testing revealed a CD20+/CD5+ clonal expansion of lymphocytes in both the peripheral blood and bone marrow, an absence of detectable adenopathy or organomegaly following multimodality imaging, and a final diagnosis of CLL, Rai stage III.

Exaggerated reactions to insect bites are characteristic of patients with hemoproliferative disorders. This association is particularly true of chronic lymphocytic leukemia (CLL).[1-10] Despite a fairly strong association, this phenomenon is rare. In a large retrospective study of over 1000 B-cell CLL patients, only 1% developed an eruption which suggested exaggerated response to insect bites.[9] Although the histology is nearly pathognomonic for an arthropod assault, patients may deny being bitten and, thus, the biopsy results can conflict with the patient's history.[2,7] On the other hand, some patients clearly associate the development of skin lesions with observed insect bites, usually due to mosquitoes.[1,3,5] In this particular case, the patient was well aware of being bitten by mosquitoes, something regularly endured in order to tend to her garden. At least one investigation demonstrated an objective hypersensitivity to pooled mosquito antigen in similar patients.[1]

Such skin lesions usually appear weeks to years after the diagnosis of CLL has already been established. However, the eruption may rarely precede or occur coincident with the diagnosis of CLL.[5,6] In this particular case, the cutaneous manifestations directly led to the laboratory testing which established the underlying diagnosis. Nonetheless, based on the patient's history, it is certainly possible that leukemia had been present for some time before being recognized. In virtually all reported cases, the appearance of this characteristic pruritic eruption seems unrelated to laboratory findings, disease severity or course, and mode of therapy. The eruption is likely to run a chronic course and represents a therapeutic challenge. Oral prednisone(Drug information on prednisone) appears to be the most effective therapy, although oral antihistaminics and potent topical corticosteroids may also be effective.[1,6,8,10]

Individual lesions may be intensely pruritic papules, nodules or plaques, all of which have a propensity for development of a vesiculobullous component. On the other hand, in some patients, the lesions initially present as tense blisters on an inflammatory base, which closely mimic autoimmune bullous disorders such as pemphigus and pemphigoid. In fact, despite uniformly negative immunofluorescence studies in most patients, controversy remains as to whether this phenomenon is actually a paraneoplastic form of pemphigoid. Using an immunoblotting technique, one study demonstrated serum autoantibodies directed against the 180-kDa minor pemphigoid antigen in half of such cases.[9] Nevertheless, most authorities still consider this finding an atypical response to insect bites, associated primarily with CLL, with an unknown precise pathogenesis.

Finally, it should be noted that this type of cutaneous reaction may also be associated with other hematologic and lymphoproliferative disorders, most notably mantle-cell lymphoma and natural killer cell leukemia and lymphoma.[11,12] The latter association has been described almost exclusively in Japan.


1. Weed RI. Exaggerated delayed hypersensitivity to mosquito bites in chronic lymphocytic leukemia. Blood 1965;26:257-268.

2. Rosen LB, Frank BL, Rywlin AM. A characteristic vesiculobulous eruption in patients with chronic lymphocytic leukemia. J Am Acad Dermatol 1986;15L943-950.

3. Kolbusz RV, Micetich K, Armin A, et al. Exaggerated response to insect botes. An unusual cutaneous manifestation of chronic lymphocytic leukemia. Int J Dermatol 1989;28:186-187.

4. Pederson J, Carganello J, Van-Der Weyden MB. Exaggerated reaction to insect bites in patients with chronic lymphocytic leukemia: Clinical and histologic findings. Pathology 1990;22:141-143.

5. Davis MDP, Perniciaro C, Dahl PR, et al. Exaggerated arthropod-bite lesions in patients with chronic lymphocytic leukemia: A clinical, histopathologic, and immunopathologic study of eight patients. J Am Acad Dermatol 1998;39:27-35.

6. Barzilai A, Shpiro D, Goldberg I, et al. Insect bite-like reaction in patients with hematologic malignant neoplasms. Arch Dermatol 1999;135:1503-1507.

7. Blum RR, Phelps RG, Wei H. Arthropod bites manifestingas recurrent bullae in a patient with cronic lymphocytic leukemia. J Cutan Med Surg 2001;5:312-314.

8. Cocuroccia B, Gisondi P, Gubinelli E, Girolomoni G. An itchy vesiculobullous eruption in a patient with chronic lymphocytic leukaemia. Int J Clin Pract 2004;58:1177-1179.

9. Bottoni U, Cozzani E, Innocenzi D, et al. Bullous lesions in chronic lymphocytic leukaemia: Pemphigoid or insect bites? Acta Dermato-Venereol 2006;86:74-76.

10. Walker P, Long D, James C, et al. Exaggerated insect bite reaction exacerbated by a pyogenic infection in a patient with chronic lymphocytic leukaemia. Australas J Dermatol 2007;48:165-169.

11. Dodiuk-Gad RP, Dann EJ, Bergman R. Insect bite-like reaction associated with mantle cell lymphoma: a report of two cases and review of the literature. Int J Dermatol 2004;43:754-758.

12. Adachi A, Horikawa T, Kunisada M, et al. Hypersensitivity to mosquito bites in association with chronic Epstein-Barr virus infection and natural killer (NK) leukaemia/lymphoma with expansion of NK cells expressing a low level of CD56. Br J Dermatol 2002;147:1036-1037.


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7 Replies

  • Interesting read and having returned from holiday in Bulgaria yesterday I'm relieved I didn't read it before going! I was in dread of the mozzies and possible adverse reactions but for some reason, they demonstrated not the slightest interest in me, preferring my husband for the full dining experience.

    He gallantly tells me that he's pleased they chose him as we were worried about a possible severe reaction in me and I was aware of people there who ended up on a drip after suffering 'exaggerated reactions'.

    Anyway I'm back from a wonderful holiday and apologise for my lack of response to any newcomers or regulars. Health wise I did well apart from the very painful joints which would have dogged me here just the same.

    Just hoping none of the 'mucous troppers' on the plane have infected me with anything that might manifest itself in the next few days.


  • Welcome home Newdawn,

    Looks like you have good reason to ensure your husband always accompany you on holidays- bait!

    May the next week pass without incident,


    Now on a short break

  • I actually believe that insect bites started my cll. I have always reacted badly to any bite from as early as my childhood years. In my 20's I was exposed to a period of many bites which would swell and weep and require me to dose up on so many anti-histamines I would get mood swings. I think this profusion of bites caused my DNA to mutate leaving me with P53 deletion. I like to believe that anyway as it massages my sci-fi affliction.

  • May not be a science fiction ish as you imagine Mark though it's obviously impossible to know if the insect bites caused your CLL. I think we all may have theories as to why our CLL developed. I certainly do. But the bites must be miserable for you to endure.

    It's interesting that scientists believe mosquitoes are very attracted to type O blood amongst others things.

    I found this article interesting (was researching mozzie bites and possible effects as I terrified myself in preparation for the holiday I've just had!)


  • Welcome home Newdawn, did you use any spray to keep the mozzies away ?

    I'm blood type 'A RH positive' but sadly not going anywhere to test the 'O' denoting good mozzie buffet.

    So pleased you enjoyed a lovely holiday, hope the plane bugs gave you a wide berth too.


  • Thanks Bubnjay,

    No I didn't use any sprays this time although I'd taken lots with me. Not entirely sure why I wasn't on the menu this time. I actually began to wonder if the mozzies could detect something wrong with my blood but that is a bit far fetched!

    I'm A + blood type too but it hasn't stopped them in the past. They were out in force this year as a guy we met up with was in quite a mess with them and needed to seek advice over possible cellulitis around the well bitten leg area.

    As for the plane bugs...mmm, not sure yet, sneezing a bit today and throat felt a bit scratchy but I'm hoping it's just a touch of paranoia! There did appear to be a coughing orchestra behind me! It's a hard balancing act to perfect this safety v living dilemma I find...(sigh)


  • Re mozzies and their apparent liking for O blood. I have just returned from a holiday in Italy and was definitely on the menu for the mozzie population. I am O rhesus negative and was bitten from big toe to eye lid and all places in between! Each bite resulted in a huge red lump and was itchy for around 3 days on average. My husband was bitten TWICE in two weeks... he is not O and his bites were little pimples.

    I had my 3 monthly W&W appointment this morning and was informed that my WBC had risen from 51 to 74.9, total lymphocytes from 48 to 70.5 and Platelets 161 to 186 since May. Wondering if there is any correlation between the attack of the mozzies and the increase in count. Interested in any similar stories.

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