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A MINI-REVIEW on SKEETER SYNDROME OR LARGE LOCAL ALLERGY to MOSQUITO BITES by AMR M

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A MINI-REVIEW on SKEETER SYNDROME OR LARGE LOCAL ALLERGY to MOSQUITO BITES by AMR M Journal of the Egyptian Society of Parasitology, Vol. 47, No. 2, August 2017 J. Egypt. Soc. Parasitol. (JESP), 47(2), 2017: 415 – 424 A MINI-REVIEW ON SKEETER SYNDROME OR LARGE LOCAL ALLERGY TO MOSQUITO BITES By AMR M. EL-SAYED ABDEL-MOTAGALY1, HANAA MAHMOUD MOHAMAD1 and TOSSON A. MORSY2 Military Medical Academy1, Cairo 11291 and Department of Parasitology, Faculty of Medicine, Ain Shams University2, Cairo 11566, Egypt Abstract Skeeter Syndrome is an allergy to mosquito saliva secreted while taken a human blood meal. It is present with extreme swelling, itching, blistering, infection, fever and general malaise, some cases develop asthma and cellulitis and even threatening anaphylactic shock. Most people of all ages particularly small children, toddlers and seniors who suffer from skeeter syndrome experi- ence a very extreme reaction showed some allergic reaction level, with itching and redness. Sometimes, the swelling is painful and so extreme that the affected limb doubles in size, eyes swell shut, and the area feels hot and hard to the touch or the bite will blister and ooze. Key words: Mosquito bite, Skeeter syndrome, Differential diagnosis, Treatment, Prevention. Introduction hough the immediate reactions persist. Peo- The reactions to mosquito bites are ple who are repeatedly exposed to bites from caused by an immunologic response to pro- the same species of mosquito eventually also teins (polypeptides) in mosquito saliva. lose their immediate reactions. The duration Many people who are bitten by mosquitoes of each of these five different stages differs, develop an immune response to these pro- depending on the intensity and timing of teins; however, only a small proportion of mosquito exposure (Reunala et al, 1994). them develop clinically relevant allergic re- These typical reactions are annoying, but actions, most commonly large local reac- should not cause undue alarm. The immuno- tions (Peng and Simons, 2007). logical basis of sensitization and natural de- Types of reactions due to mosquito bites: sensitization to mosquito bites was described There are two main types of mosquito bites in the 1990s (Peng et al, 1966). 1- Typical (normal) reactions: Typical local 2- Large local reactions to mosquito bites cutaneous reactions to mosquito bites consist (Skeeter Syndrome): Large local reactions of immediate wheals (swelling) with sur- are by far the most common type of allergic rounding flares (redness) peaking at 20 reactions to mosquito bites: 1- Large local minutes, and delayed itchy, indurated (firm) reactions (termed Skeeter Syndrome) typi- papules peaking at 24 to 36 hours, which cally consist of an itchy or even painful area diminish over 7 to 10 days. of redness, warmth, swelling and/or indura- The typical clinical course of sensitization tion that ranges from a few cm to more than and natural desensitization to the salivary 10cm in diameter. Large local reactions de- proteins injected when mosquitoes bite was velop within hours of the bite, progress over described initially in the 1940s. It evolves 8 to 12 hours or more, and resolve within 3 over months or years. People who have nev- to 10 days, 2- Large local reactions can in- er been exposed to a particular species of volve the entire periorbital region and much mosquito do not develop reactions to the ini- of the face, or an entire extremity, especially tial bites from such mosquitoes. Subsequent in an infant or child. They can interfere with bites result in the appearance of delayed lo- seeing, eating, drinking, or normal use of cal skin reactions. After repeated bites, im- extremities. Severe large local reactions can mediate wheals develop (Mellanby, 1946). be accompanied by low grade fever and ma- With further exposure, the delayed local re- laise, 3- By inspection and palpation, it can actions wane and eventually disappear, alt- be difficult to differentiate between allergic 415 inflammation caused by mosquito bites and were reported as negative. In two of the inflammation caused by secondary bacterial children, radiographs were obtained to rule infection after scratching the bites. It is im- out osteomyelitis underlying the extensive portant to obtain a meticulous history of the soft tissue swelling at the site of a witnessed time of onset of the red, warm swollen area bite on an extremity (Naidu et al, 2008). at the site of a witnessed or likely mosquito An ELISA was used to measure IgE & bite in relationship to the time of the bite. IgG4 subclasses recognizing salivary gland Large local reactions typically begin within allergens of the predominant indigenous hours. Secondary bacterial infections typi- mosquito Aedes vexans. The salivary aller- cally begin within days and sometimes, de- gens used in the ELISA were obtained by velop an ecchymotic appearance or are asso- dissecting the salivary glands from the heads ciated with blisters, vesicles or bullae (Si- and thoraces of 370 laboratory-reared female mons and Peng, 1999). A. vexans mosquitoes and dispersing them Systemic allergic reactions: Systemic al- in 1 mL of diluent. In the children with lergic reactions to mosquito bites include Skeeter Syndrome, serum levels of IgE, papular or acute generalized urticaria, and IgG1, IgG3, & IgG4 to A. vexans salivary rarely, asthma symptoms, anaphylaxis, se- gland allergens were significantly elevated rum sickness, or lymphadenopathy, hepato- as compared with the levels in control chil- splenomegaly, fever, and necrotic skin reac- dren. In Western blotting, sera from children tions at mosquito bite sites (Engler, 2001). with Skeeter Syndrome (but not from con- Epidemiology: People at increased risk of trol children) reacted with 8 to 10 A. vexans allergic reactions to mosquito bites include: salivary gland allergens (Peng et al, 2004b). 1- Those with a high level of exposure (e.g., The IgE and IgG, especially IgG4 and IgG1, civilian or military outdoor workers), 2- In- are involved in the development of Skeeter fants and young children with low or absent Syndrome. Serum mosquito salivary gland– natural immunity, 3- Immigrants or visitors specific IgG levels correlated significantly to a geographic area where there are indige- with the size of the immediate skin reaction nous mosquitoes that they had not previous- to mosquito bites and with salivary gland– ly encountered and to which they have no specific IgE levels. Specific IgE and IgG natural immunity, and 4-Patients with pri- concentrations were significantly higher at mary or secondary immunodeficiency dis- the end of summer, as compared with levels eases (Peng et al, 2004a). at the end of the following winter after no Clinical features and pathogenesis of large exposure to mosquitoes had occurred for six local reactions: The pathogenesis of Skeeter months (Pauthner et al, 2016). Syndrome was investigated in a study of five Natural history of large local reactions: In otherwise healthy young children age two to the absence of immune deficiency, the prog- four years who developed large local reac- nosis of Skeeter Syndrome appears to be fa- tions within hours of witnessed mosquito vorable. As an example, children often con- bites, and five age-matched control children tinue to develop recurrent large local reac- who developed smaller typical reactions tions to mosquito bites for several more within hours of mosquito bites. All the chil- summers, after which the reactions cease to dren with the large local reactions had been occur. The time to resolution varies, howev- diagnosed initially with bacterial cellulitis er (Palosuo et al, 1997) and in some patients by primary care clinicians. All received sys- in northern latitudes (eg, Alaska, Canada, temic antibiotic treatment which was discon- and the Nordic countries) this natural desen- tinued after a few days when the swelling sitization may take longer to develop be- was subsiding and the blood cultures per- cause it depends on the frequency and inten- formed at the time of initial presentation sity of the patient's exposure to mosquitoes, 416 which is intermittent and limited in most Bacterial cellulitis: The key information cases by the short summer season. Addition- needed to facilitate the diagnosis of Skeeter ally, it is reduced by efforts to avoid mosqui- Syndrome is the time elapsed (hours) be- toes and prevent mosquito bites (Cohen and tween a witnessed mosquito bite, or expo- George, 2013). sure to mosquitoes and a likely mosquito In a subsequent study of sera from 402 chil- bite, and the appearance of an itchy, red, dren living in the same region of Canada warm, swollen, area at the bite site. A typi- where Skeeter Syndrome was originally de- cal presentation of Skeeter Syndrome might scribed, levels of mosquito saliva-specific involve a two-year-old child who presents IgE and IgG correlated inversely with age, with a history of playing in a park and being peaked at one to six months of age, and de- exposed to mosquitoes the previous evening, creased after age five years (Peng et al, and then wakes up the next morning with an 2002). In this geographic region, only 18% itchy, red, warm swelling of the entire peri- of 1059 adult blood donors had demonstra- orbital region at the site of a mosquito bite. ble antibodies to mosquito salivary aller- In contrast, bacterial cellulitis does not typi- gens, suggesting that in most adults, sensiti- cally develop within hours of a mosquito zation had been lost and natural desensitiza- bite. Instead, it appears several days later, tion had occurred. after scratching and excoriation of the itchy Diagnosis: Skeeter Syndrome develops area at the bite site and development of a within hours of mosquito bites. Diagnosis is secondary infection (Tay et al, 2014). On the based on the time of onset of the reaction in other hand, Cellulitis is a common problem, relationship to a witnessed or likely mosqui- caused by spreading bacterial inflammation to bite, and on the physical finding of an of the skin, with redness, pain, and lym- itchy, red, warm swollen area at the site of phangitis.
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