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Mantle cell lymphoma presenting with exaggerated skin reaction to insect bites
  1. Kavita Darji1,
  2. Emily Bahram-ahi2,
  3. Maulik Dhandha3 and
  4. Mary Guo1
  1. 1 Department of Dermatology, Saint Louis University Hospital, Saint Louis, Missouri, USA
  2. 2 Department of Internal Medicine, Saint Louis University Hospital, Saint Louis, Missouri, USA
  3. 3 Department of Dermatology, MDFMR Dermatology Services, Augusta, Maine, USA
  1. Correspondence to Dr Mary Guo, amary.guo{at}


We present the case of a 62-year-old African-American woman with medical history of hypertension and hyperlipidaemia who presented to dermatology clinic for ‘bug bites’. Skin examination showed resolving bullae on the shins and postinflammatory pigment changes. Histopathology showed eosinophilic spongiosis and direct immunofluorescence (DIF) was negative for IgG, IgM, IgA and C3. After returning to clinic with recurrent severe bullous eruptions, the patient presented with anaemia, lymphocytosis, posterior cervical lymphadenopathy and weight loss. An exuberant bite reaction in the setting of lymphoma was suspected. Further workup with haematology revealed elevated IgG level and total protein levels. Flow cytometry showed a B cell lymphoma subtype. Extensive imaging was positive for diffuse lymphadenopathy, with accompanying evidence of Ebstein-Barr virus infection. Our case highlights the importance of considering exuberant arthropod bite reaction in the setting of undiagnosed lymphoma in a patient with bullous eruption and negative DIF.

  • dermatology
  • haematology (drugs and medicines)
  • skin
  • haematology (incl blood transfusion)

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  • Contributors KD and EB-a are joint first authors of this case report. KD contributed to chart review, data collection, manuscript writing and editing, manuscript formatting and submission, patient consent, inclusion of patient photographs and follow-up data, and manuscript revisions. EB-a contributed to chart review, data collection, and manuscript writing, editing, and revisions. MD contributed to chart review; data collection; manuscript writing, editing, revisions, and review; and mentorship. MG contributed to manuscript editing, revisions, and comprehensive review, overall mentorship, and is the corresponding author. All authors agreed on the final version of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.