Letters Dermatosis Caused by Blood-Sucking Figure 1. Skin Lesions on the Left Arm and Shoulder Corythucha Ciliata Due to Lace Bug Bites Native to temperate regions of North America, Corythucha ciliata, or lace bug, is an invasive insect that is spreading from relatively cold regions to relatively hot regions and is now dis- tributed throughout the temperate and subtropical zones.1 Un- til recently, lace bugs were not reported in the scientific litera- ture as biting or stinging humans. Report of a Case | A healthy man in his 20s presented with pru- riginous skin lesions of several weeks’ duration suggestive of insect bites (Figure 1). Results of a search for Sarcoptes by skin scrapings and microscopy were negative, and the lesions were considered related to bedbug bites. Surprisingly, during the ex- amination, the patient felt a sting on the chest, where a small insect (2- to 3-mm long) was discovered (Figure 2), identified as an adult C ciliata. Subsequently, more adult lace bugs were provided by other patients presenting with similar symptoms, and these were evaluated under a binocular magnifier for entomological iden- tification. The probable presence of blood in the insects’ di- gestive apparatus was noticed for each insect. For insect iden- tification, a fragment of the mitochondrial cytochrome oxidase 1 gene was amplified, as previously described.2 To assess the Figure 2. External Ventral View of Adult Corythucha ciliata presence of a blood meal and evaluate its origin, a fragment of vertebrate cytochrome b gene was amplified for sequence analysis, and a fragment of human β-globin was amplified and directly sequenced with primers for the human β-globin Control Primer set of the Takara kit (Takara Bio). All insects were identified unambiguously as C ciliata by sequence alignment. The presence of human blood in each in- sect was confirmed by alignment of sequences of both stud- ied genes. Discussion | Blood-sucking lace bugs appear to be an emerging problem. In 2013, 3 cases of slight dermatosis in Italy were at- tributed to bites of the lace bug, but the causality was not demonstrated.3 Our case report and the molecular study of blood ingested indicate that C ciliata may bite humans. As with the bites of bedbugs, the bites of lace bugs generally go unnoticed; most people do not report a reaction to the bite, and cutane- ous lesions and systemic reactions develop in only a small pro- portion of those bitten.4,5 We did not observe bacterial or fun- gal infections among the reported cases, although this may occur with scratching. Corythucha ciliata was reported for the first time in Europe in Padua, Italy, in 1964,6 and for the first time in France, in Antibes in 1975.7 Its host (Platanus species), a native forest tree, is used as a common shade and ornamental tree in many urban and suburban areas. Corythucha ciliata can usually be found on trees growing in natural stands, but as a pest, it is abundant in urban and suburban forests. In summer, adult lace bugs can become abundant and often drop from leaves and land on people. Adult lace bugs can also invade houses. How this usually oligophagous and vegetarian insect be- came a human bloodsucker, and what proportion its numbers made the change, warrants dedicated studies. The possibility sidered, with implications for transmission of infectious agents. of C ciliata biting multiple people in sequence should be con- Whether the insect can bite other animals is unknown. jamadermatology.com (Reprinted) JAMA Dermatology August 2015 Volume 151, Number 8 909 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Letters Lace bug infestations may have health consequences, in- Figure 1. Primary Cutaneous Nodular Amyloidosis of the Distal Shaft cluding nuisance biting and cutaneous and systemic reac- and Glans Penis tions. Clinicians should be aware of the existence of this insect with its newly recognized bloodsucking ability as po- tentially responsible for skin lesions and pruritus that can cause real discomfort and anxiety. Bites from the lace bug may also be considered in the differential diagnosis of bedbug bites5 and scabies.8 Arezki Izri, MD, PhD Valérie Andriantsoanirina, PhD Olivier Chosidow, MD, PhD Rémy Durand, PharmD, PhD Author Affiliations: Université Paris 13, Bobigny, France (Izri, Andriantsoanirina, Durand); Laboratoire de Parasitologie-Mycologie, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris (AP-HP), Bobigny, France (Izri, Andriantsoanirina, Durand); UMR 190, Unité des virus émergents, Université Aix-Marseille, Marseille, France (Izri); Université Paris-Est Créteil Val de Marne, Créteil, France (Chosidow); Service de Dermatologie, AP-HP, Hôpital Henri-Mondor, et Centre d’Investigation Clinique (CIC) 006, Créteil, France (Chosidow); Institut de Recherche pour le Développement, UMR 216, Mère et enfant face aux infections tropicales, Paris, France (Durand); PRES Sorbonne Paris Cité, Université Paris Descartes, Faculté des Sciences Pharmaceutiques et Biologiques, Paris, France (Durand). Corresponding Author: Rémy Durand, PharmD, PhD, Laboratoire de Parasitologie-Mycologie, Hôpital Avicenne, AP-HP, 125 rue de Stalingrad, 93009 Bobigny CEDEX, France ([email protected]). This case shows raised, firm, and translucent-to-yellowish nodules on the glans Published Online: May 13, 2015. doi:10.1001/jamadermatol.2015.0577. penis and distal shaft. Conflict of Interest Disclosures: None reported. Funding/Support: This study was partially funded by a research grant from the French Society of Dermatology. Report of a Case | A man in his 50s presented with a 6-year his- Role of the Funder/Sponsor: The French Society of Dermatology had no role in tory of slowly expanding asymptomatic lesions on the penis the design and conduct of the study; collection, management, analysis, and that “bruised” after sexual activity and had eluded correct interpretation of the data; preparation, review, or approval of the manuscript; diagnosis for over 6 years. On examination, the patient had and the decision to submit the manuscript for publication. painless, raised, firm, translucent-to-yellowish nodules on Additional Contributions: We thank the staff at the dermatology department the glans penis and distal shaft, suggestive of nodular amy- at Avicenne Hospital, Bobigny, France. loidosis (Figure 1). The biopsy revealed a mixed cellular 1. Ju RT, Li YZ, Wang F, Du Y. Spread of and damage by an exotic lacebug, Corythucha ciliata (Say, 1832) (Hemiptera: Tingidae), in China. Entomol News. infiltrate of lymphocytes and plasma cells as well as a few 2009;120(4):409-414. globules of amorphous hyaline-like material in the reticular 2. Navajas M, Gutierrez J, Lagnel J. Mitochondrial cytochrome oxidase I in dermis (Figure 2A). Congo red staining was positive, with tetranychid mites: a comparison between molecular phylogeny and changes of birefringence (Figure 2B). Immunohistochemically, the morphological and life history traits. Bull Entomol Res. 1996;86:407-417. amyloid was positive for 34ßE12 (Figure 2C). No specific 3. Dutto M, Bertero M. Dermatosis caused by Corythuca ciliata (Say, 1932) staining for either κ or λ light chain was seen. Screen results (Heteroptera, Tingidae). diagnostic and clinical aspects of an unrecognized pseudoparasitosis. J Prev Med Hyg. 2013;54(1):57-59. for systemic amyloidosis with serum immunoglobulin light 4. Durand R, Cannet A, Berdjane Z, et al. Infestation by pyrethroids resistant chains and urinary Bence-Jones proteins were negative. The bed bugs in the suburb of Paris, France. Parasite. 2012;19(4):381-387. clinical appearance, the histologic findings, and the absence 5. Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O. Bed bug infestation. BMJ. of systemic involvement were consistent with the diagnosis 2013;346(7892):f138. of primary cutaneous nodular amyloidosis of the glans 6. Servadei A. Un tingide neartico comparso in Italia (Corythuca ciliata Say). Bull penis. Soc Ent It. 1966;96:94-96. 7. d’Aguilar RP, Rabasse JM, Mouton R. Introduction en France du tigre du Discussion | Primary cutaneous nodular amyloidosis is typi- platane: Corythucha ciliata (Say) (Hemiptera: Tingidae). Bull Soc Entomol Fr. 1977;82:1-6. cally characterized by single, tan or yellow, waxy nodules or 8. Chosidow O. Clinical practices: scabies. N Engl J Med. 2006;354(16): plaques that preferentially occur on acral areas such as the 1718-1727. lower extremities, head, trunk, scalp, and genitals.1 To our knowledge, 14 cases of primary cutaneous amyloidosis of Nodular Amyloidosis of the Penis: the penis have been reported, and all were the nodular A Case Demonstrating Keratinocyte Origin type.2,3 Herein we describe the first case to our knowledge of primary In contrast to keratin-derived deposits found in cutane- nodular amyloidosis of the glans penis, in which the amyloid ous macular amyloidosis and lichen amyloidosis, light originates from keratinocytes rather than immunoglobulins. chain–derived amyloid has historically been the histologic 910 JAMA Dermatology August 2015 Volume 151, Number 8 (Reprinted) jamadermatology.com Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021.