1/17
“The skin truly can be a mirror of what’s going on inside the body “
During a #CPSbootcamp conversation we started discussing mosquito bites. How they can be a signal to internal disease ? Let& #39;s explore @deboracloureiro @KirtanPatolia @CPSolvers @seymss15
#MedTwitter
2/17
Mosquito saliva-induced type I hypersensitivity induces a strong itch sensation. This is a process of vasodilation + inflammation

First https://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pijl naar rechts" aria-label="Emoji: Pijl naar rechts"> immediate wheal and flare reaction develops within 15–30 minhttps://abs.twimg.com/emoji/v2/... draggable="false" alt="➡️" title="Pijl naar rechts" aria-label="Emoji: Pijl naar rechts"> delayed pruritic induration arises within a day or 2 which resolves
3/17
Hypersensitivity to mosquito bites (HMB):

HMB or severe mosquito bite allergy (SMBA) is a cutaneous form of chronic active Epstein–Barr virus disease (CAEBV).

HMB belongs to a category of Epstein–Barr virus (EBV)-associated NK cell lymphoproliferative disorders (LPD).
4/17
HMB may progress to systemic diseases, such as hemophagocytic lymphohistiocytosis, chronic active EBV disease, and EBV-associated malignancies.
@KirtanPatolia #bib11">https://www.sciencedirect.com/science/article/pii/S0006497120644652 #bib11">https://www.sciencedirect.com/science/a...
6/17
HMB skin signs- include erythema, bullae, ulcers, necrosis, and scarring following the mosquito bite + high fever and general malaise
HMB patients= high EBV DNA load + NK cell lymphocytosis.
Lymphadenopathy, HSM, hepatic dysfunction, hematuria, and proteinuria are noted
7/17
Skeeter syndrome:
Allergic reaction to mosquito bites, which can cause red, swollen lesions. They usally occur in children or immunocompromised adults.

The reaction is characterized by the signs of inflammation: swelling, heat, redness, and itching/pain. +/- fever
8/17
Skeeter syndrome is caused by allergenic polypeptides that spit off with mosquito saliva during siphoning human blood
Skeeter syndrome is often misdiagnosed as a bacterial skin infection called cellulitis
9/ 17
The reaction can evolve into:
-Facial edema
-eyelid edema
-limbs can turn red and swollen.
-can progresss to bruising and blistering, fever, vomiting or difficulty breathing
10/17
There also exists an exaggerated cutaneous response to bites in patients with hematological malignancies, especially CLL/CML

Skin lesions usually appear months to years after the dx of leukemia and are unrelated to lab findings, disease course, or therapy
11/ 17
As far back as 1911, this association was documented in the article Skin changes in the leukemias and altered conditions by J. Cutan in the journal- Disease.
#bib11">https://www.sciencedirect.com/science/article/pii/S0006497120644652 #bib11">https://www.sciencedirect.com/science/a...
12/17
The reaction to mosquito bites results in severe itchy papulovesicular lesions with induration edema, erythema, and intense pruritus; the reaction reaches its peak within 12-24 hours. Bullae up to 10 cm in diameter can develop in severe cases.
13/17
There have been many case reports of patients having these severe reactions and whilst seeking medical care they are found to have a diagnosis of CLL.
https://www.sciencerepository.org/insect-bite-like-reaction-showing-features-of-panniculitis-in-a-patient-with-chronic-lymphocytic-leukemia_COR-2019-1-101">https://www.sciencerepository.org/insect-bi...
14/17
- 21 y/o pt with an exaggerated hypersensitivity reaction to a mosquito bite noted to have splenomegaly. The blood tests that were performed were compatible with chronic myeloid leukemia (CML). Here the mosquito bite heralded the diagnosis of CML https://www.hindawi.com/journals/criem/2011/649548/">https://www.hindawi.com/journals/...
15/17
Lastly
An 11-year-old presents with swelling of his chin after being bitten by mosquitos. Maxillofacial computed tomography showed cellulitis of the chin without abscess. Lab workup was notable for a peripheral eosinophilia (1220/μL).
16/17
He was found to have : Wells syndrome, or eosinophilic cellulitis.- first described by Wells in 1971
Involves edema + induration & can appear very similar to bacterial cellulitis. It can be associated with red plaques and blisters/bullae. https://www.jaci-inpractice.org/article/S2213-2198(17)30162-9/fulltext">https://www.jaci-inpractice.org/article/S...
17/17
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