Letters period of time. Future studies will examine the efficacy of and usually considered harmless to humans, though there the ABC intervention on reducing the number of sunburns have been anecdotal reports of the development of inflam- experienced by patients. matory plaques with stink bugs (also in the Pentatomoidea superfamily). Kimberly A. Mallett, PhD Sarah Ackerman, MS Report of Cases |Case 1. In the monsoon season, a preschool child Rob Turrisi, PhD presented with asymptomatic brown macules that had ap- June K. Robinson, MD peared suddenly on the soles of both feet (Figure 1). The spots were noted after the child visited a Hindu temple where, as re- Author Affiliations: Prevention Research Center, Department of Biobehavioral quired by custom, he walked barefoot. His mother, who ac- Health, Pennsylvania State University, University Park (Mallett, Ackerman, companied him to the temple, had similar macules on her feet. Turrisi); Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Robinson); editor, JAMA Numerous small insects were found on the floor of the temple, Dermatology (Robinson). and the priest who lived in the temple premises had similar Corresponding Author: Kimberly A. Mallett, PhD, Prevention Research Center, lesions. Department of Biobehavioral Health, Pennsylvania State University, 320 Biobehavioral Health Building, University Park, PA 16802 ([email protected]). Case 2. An elementary school student developed asymptom- Published Online: October 29, 2014. doi:10.1001/jamadermatol.2014.3092. atic small brown macules on the neck and chest after visiting Accepted for Publication: August 14, 2014. a neighborhood grocery shop in the rainy season. Most of the Author Contributions: Drs Mallett and Turrisi had full access to all of the data in macules were round or oval, and some also showed a streaky the study and take responsibility for the integrity of the data and the accuracy of the data analysis. pattern. Many shop workers had similar spots on their skin. Study concept and design: Mallett, Turrisi. There were numerous winged, low-flying insects in the shop Acquisition, analysis, or interpretation of data: All authors. and the adjoining greenery. Drafting of the manuscript: Mallett, Ackerman. Critical revision of the manuscript for important intellectual content: Mallett, Turrisi, Robinson. Statistical analysis: Mallett, Ackerman. Figure 1. Burrowing Bug (Cydnidae) Pigmentation in a Child Obtained funding: Mallett. Administrative, technical, or material support: Ackerman. Study supervision: Mallett. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported in part by National Cancer Institute grant R03 CA144435 to Dr Mallett. Role of the Sponsor: The National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: Dr Robinson was not involved in the editorial review of or decision to publish this Research Letter. 1. Whiteman D, Green A. Melanoma and sunburn. Cancer Causes Control. 1994; 5(6):564-572. 2. Soto E, Lee H, Saladi RN, et al. Behavioral factors of patients before and after diagnosis with melanoma: a cohort study: are sun-protection measures being implemented? Melanoma Res. 2010;20(2):147-152. 3. Mallett KA, Turrisi R, Guttman K, Read A, Billingsley E, Robinson J. Assessing dermatologists’ ability to deliver a novel intervention to improve patients’ use of sun protection: the ABC method of physician-patient communication. Arch Dermatol. 2011;147(12):1451-1453. 4. Mallett KA, Turrisi R, Billingsley E, et al. Enhancing patients’ satisfaction and sun-protective behaviors using the ABC method of physician-patient communication. Arch Dermatol. 2012;148(9):1087-1089. 5. Saraiya M, Hall HI, Uhler RJ. Sunburn prevalence among adults in the United States, 1999. Am J Prev Med. 2002;23(2):91-97. OBSERVATION Cydnidae (Burrowing Bug) Pigmentation: A Novel Arthropod Dermatosis Insects can cause a variety of dermatologic problems usu- ally presenting with inflammatory skin lesions. Cydnidae insects (family, Cydnidae; order, Hemiptera; suborder, Het- eroptera; superfamily, Pentatomoidea), also known as bur- Brown macules of varying shapes and sizes on the soles. rowing (or burrower) bugs, are uncommon in urban areas 232 JAMA Dermatology February 2015 Volume 151, Number 2 (Reprinted) jamadermatology.com Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Letters Figure 2. The Cydnidae Insect Found to Cause the Reported Macules and Self-induced Lesions A B A, Chilocoris assmuthi Breddin, 1904. B, Lesions self-induced by pressing the subject insect between thumb and forefinger. Case 3. During the monsoon season, a man in his 20s pre- chus mixtus and Edessa maculata.6 To our knowledge, pig- sented with well-defined brown macules on both feet that had mentation as seen in our cases has not been previously appeared suddenly after he visited a neighborhood temple lo- described. cated in the middle of a park. At the temple were found in- The sudden development of small pigmented macules sects in large numbers. can be mystifying. In some cases, spots are mistaken for the petechiae of dengue, which also occurs during the rainy sea- Experimental Case. About 50 to 60 live insects were collected son. Older lesions may resemble lentigines. Clues to the from the grocery store and temples associated with the cases diagnosis include the suddenness with which the spots reported herein. One of us (A.K.M.) pressed an insect firmly appear, their occurrence in rainy weather, and the shape of between the thumb and index finger of the right hand for 60 some macules, which appear streaky or show tapering seconds. About 1 or 2 minutes after releasing the bug, red- edges. brown pigmented macules were observed at the site of con- tact. Similar lesions were reproduced by rubbing an insect on Amit K. Malhotra, MD the forearm. As lesions grew older, they turned a more uni- Jerzy A. Lis, PhD form dark brown. It was difficult to wash off the pigment with M. Ramam, MD soap and water. However, it could be rubbed off (with some effort) using acetone. Left alone, the pigment gradually and Author Affiliations: Department of Dermatology and Venereology, S. M. S. completely faded over 5 to 6 days. Medical College and Associated Hospitals, Jaipur, India (Malhotra); Department Insects preserved in 70% alcohol were identified by the one of Biosystematics, Opole University, Opole, Poland (Lis); Department of of us (J.A.L.) as Chilocoris assmuthi Breddin, 1904, represent- Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India (Ramam). ing the family Cydnidae (Figure 2). Corresponding Author: M. Ramam, MD, Department of Dermatology and Venereology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi Discussion | The causal association between the clinical lesion 110029, India ([email protected]). and the insect was established by self-induction of lesions on Published Online: October 29, 2014. doi:10.1001/jamadermatol.2014.2715. the thumb and forearm. These induced lesions had an appear- Conflict of Interest Disclosures: None reported. ance and evolution identical to that seen in patients present- Additional Contributions: We are indebted to N. P. Singh, PhD, of the ing with the condition, providing strong evidence for Cydni- Department of Zoology, University of Rajasthan, Jaipur, for help in preliminary dae being the cause. identification of the insect. Cydnidae generally live in soil or sand and feed on roots 1. Lis JA. Burrower bugs of the Old World: a catalogue (Hemiptera: or other underground parts of plants.1 They produce an odor- Heteroptera: Cydnidae). Genus (Wrocław). 1999;10:165-249. ous substance from special glands for self-defense, as do other 2. Lis JA, Hohol-Kilinkiewicz A. Adult dorso-abdominal scent glands in the burrower bugs (Hemiptera: Heteroptera: Cydnidae). Pol Pismo Entomol. 2002; true insects. These glands are found in the thorax in adult Pen- 71(4):359-395. tatomoidea insects and in the lateral part of the abdomen in 3. Hayashi N, Yamamura Y, Ôhama S, Yokohô K, Komae H, Kuwahara Y. 1,2 nymphs. Defensive substances from stink bugs of Cydnidae. Experientia. 1976;32(4):418- The secretion, which is expressed actively or can be 419. squeezed out by pressure on the insect, is a poorly studied mix- 4. Smith RM. The defensive secretion of the bugs Lampropharadifasciata, ture of hydrocarbonates and other derivatives that function Adrisanumeensis, and Tectocorisdiophthalmus from Fiji. NZ J Zool. 1978;5:821-822. as a repellent and can cause paralysis in prey, act as a danger 5. Krall BS, Zilkowski BW, Kight SL, Bartelt RJ, Whitman DW. Chemistry and defensive efficacy of secretion of burrowing bugs. J Chem Ecol. 1997;23(8):1951- signal, help in attracting mates, and have antimicrobial 1962. activity.3-5 6. Haddad V Jr, Cardoso J, Moraes R. Skin lesions caused by stink bugs (Insecta: Pentatomoidea are usually considered harmless, but Heteroptera: Pentatomidae): first report of dermatological injuries in humans. we found 2 reports of erythematous plaques due to Antiteu- Wilderness Environ Med. 2002;13(1):48-50. jamadermatology.com (Reprinted) JAMA Dermatology February 2015 Volume 151, Number 2 233 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021.