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New pandemic, old bugs: A case of cimicosis (Bed Bug) in a neglected elderly patient during the coronavirus disease quarantine

Abstract

Bed bugs are hematophagous arthropods that can parasitize humans. During the coronavirus disease pandemic, there has been an increase in elderly neglect. A man in his 90s came to the hospital complaining of generalized pruritus. Despite being a dependent patient, he was left alone in a home by his relatives during the pandemic. Examination revealed inflammatory nodules in addition to a live bed bug crawling over his trunk. Identifying a bed bug during consultation is an uncommon feature that can help determine a particular diagnosis. As this case shows, the need for social isolation during pandemics can contribute to elder abuse and neglect.

Keywords:
bed bug; Cimex lectularius; COVID-19

INTRODUCTION

Bed bugs are reddish-brown hematophagous arthropods that parasitize humans as well as other warm-blooded mammals and birds11. Peres G, Yugar LBT, Haddad Junior V. Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018;93(5):759-60. (Figure 1). They commonly inhabit carpets, cracked floor tiles, bedroom furniture, mattresses, and wall cracks11. Peres G, Yugar LBT, Haddad Junior V. Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018;93(5):759-60.,22. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3.. Approximately seven different species can parasitize humans, including the most common human bed bug Cimex lectularius, distributed worldwide11. Peres G, Yugar LBT, Haddad Junior V. Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018;93(5):759-60.,22. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3.. During the coronavirus disease (COVID-19) pandemic, there has been a marked increase in reports of elder abuse, including those related to poor hygiene conditions33. Criado PR, Belda Junior W, Criado RF, Vasconcelos e Silva R, Vasconcellos C. Bedbugs (Cimicidae infestation): the worldwide renaissance of an old partner of human kind. Braz J Infect Dis. 2011;15(1):74-80.. Herein, we present the case of an older adult (a victim of abuse) with a bed bug infestation during the quarantine period of the pandemic.

FIGURE 1:
A Cimex spp. specimen.

CASE REPORT

A man in his 90s came to the hospital for evaluation of diffuse pruritus that had been present for the past two weeks. Despite being a dependent patient, he was left alone in a home by his relatives; they did not visit him, nor was regular home cleaning undertaken. Food was also mainly by food delivery to ensure social isolation.

Physical examination revealed erythematous nodules and excoriations, predominantly on his trunk and arms. Some of the nodules were arranged in a group of three lesions, featuring the “breakfast, lunch, and dinner” sign which identifies flea and bed bug bites (Figure 2A)22. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3.. A live bed bug, not previously perceived by the patient, was also spotted on his trunk (Figure 2B).

FIGURE 2:
A: Erythematous nodules on the patient’s trunk. Note the arrangement where some lesions form a group of three, a few centimeters apart from each other; this is a pattern known as the “breakfast, lunch and dinner” sign (arrows); B: A live human bed bug (Cimex spp.) crawling over the patient’s trunk (polarized light, 4x magnification).

Diagnosis of cimicosis was made; topical corticosteroids and systemic non-sedating antihistamines were administered. All close relatives were informed to help the patient with his basic needs and to arrange for professional home disinfestation.

DISCUSSION

Accurate diagnoses of skin reactions to insect bites are challenging due to their non-specific clinical manifestations. The “breakfast, lunch, and dinner” pattern of these lesions is characteristic, not just for infestation by bed bugs of Cimex genus but also fleas22. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3. (Figure 1). Since bed bugs usually seek shelter during the day and become inactive while digesting their blood meal, direct observation of a live bedbug during a consultation (as shown in the image sequence) is an uncommon feature11. Peres G, Yugar LBT, Haddad Junior V. Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018;93(5):759-60..

Although topical corticosteroids, oral antihistamines, and good personal hygiene are usually enough to control cutaneous symptoms, bed bugs are very resourceful insects. Adults may live up to a year without feeding, making them difficult to eliminate; they usually require a professional pest control service22. Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3.. In Brazil, there are few reports about bed bug infestations the literature. Nowadays, bed bugs are considered uncommon in the industrialized world; furthermore, anecdotal reports suggest that bed bugs are increasingly common in the Western world33. Criado PR, Belda Junior W, Criado RF, Vasconcelos e Silva R, Vasconcellos C. Bedbugs (Cimicidae infestation): the worldwide renaissance of an old partner of human kind. Braz J Infect Dis. 2011;15(1):74-80..

Elder abuse can be physical, emotional, financial, or any combination of these44. Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc. 2020;68(7):1386-7.. As shown in this case, the need for social isolation can contribute to elder abuse in the form of neglect by family members. The rights of the elderly are secured by laws in many countries. In cases of severe or persistent neglect, healthcare professionals must also inform local authorities, to protect the patient.

REFERENCES

  • 1
    Peres G, Yugar LBT, Haddad Junior V. Breakfast, lunch, and dinner sign: a hallmark of flea and bedbug bites. An Bras Dermatol. 2018;93(5):759-60.
  • 2
    Thomas I, Kihiczak GG, Schwartz RA. Bedbug bites: a review. Int J Dermatol. 2004;43(6):430-3.
  • 3
    Criado PR, Belda Junior W, Criado RF, Vasconcelos e Silva R, Vasconcellos C. Bedbugs (Cimicidae infestation): the worldwide renaissance of an old partner of human kind. Braz J Infect Dis. 2011;15(1):74-80.
  • 4
    Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc. 2020;68(7):1386-7.

Publication Dates

  • Publication in this collection
    29 Jan 2021
  • Date of issue
    2021

History

  • Received
    07 Nov 2020
  • Accepted
    15 Dec 2020
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