Ann Dermatol.  2018 Aug;30(4):468-472. 10.5021/ad.2018.30.4.468.

Insect Bite-Like Reaction with Bullous Lesions Mimicking Bullous Pemphigoid in a Patient with Chronic Lymphocytic Leukemia

• Kim JE
• Kim SC

• KMID: 2457527
• DOI: http://doi.org/10.5021/ad.2018.30.4.468

Abstract

Patients with chronic lymphocytic leukemia (CLL) rarely exhibit an exaggerated insect bite-like reaction without a history of an arthropod bite. We report a case of an insect bite-like reaction in a 74-year old man with CLL. The patient presented with a 2-year history of recurrent itchy erythematous patches and blisters on the whole body. He had been diagnosed with CLL 2 years ago, and the skin lesions developed 1 month after remission. The result of a skin biopsy was consistent with insect bite. Immunohistochemical staining of the infiltrated cells showed positive reactions for CD3, CD5 and negative for CD20, CD23. Direct and indirect immunofluorescence revealed negative results. The patient was treated with oral prednisolone and dapsone, under the diagnosis of CLL-associated insect bite-like reaction, and showed marked improvement. Dermatologist should be aware of insect bite-like reaction associated with CLL as a distinct disease entity that is similar to insect bite or bullous pemphigoid.

Keyword

B-cell chronic lymphocytic leukemia; Bullous pemphigoid; Insect bite-like reaction

MeSH Terms

Arthropods
Biopsy
Blister*
Dapsone
Diagnosis
Fluorescent Antibody Technique, Indirect
Humans
Insect Bites and Stings
Insects*
Leukemia, Lymphocytic, Chronic, B-Cell*
Pemphigoid, Bullous*
Prednisolone
Skin
Dapsone
Prednisolone

Figure

• 

  Fig. 1 Clinical features of the patient. (A, C, D) Erythematous excoriated papules, patches and vesicles on the face and extremities. (B) Flaccid bulla on the left leg.

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  Fig. 2 Histologic features of the skin biopsy. (A) Subepidermal bulla and inflammatory cell infiltration on the dermis and subcutaneous layer (H&E, ×40). (B, D) Inflammatory cell infiltration of lymphocytes and eosinophils on the deep dermis and subcutaneous layer (B: H&E, ×100, D: H&E, ×400). (C) Subepidermal separation and inflammatory cell infiltration of lymphocytes and eosinophils in the bulla (H&E, ×400).

• 

  Fig. 3 The immunohistochemical stains were positive for (A) CD3 (×100) and (B) CD5 (×100), while the immunohistochemical stains were negative for (C) CD20 (×100) and (D) CD23 (×100).

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