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Petechial cimicosis in a patient on aspirin 81 mg, clopidogrel and warfarin
  1. Michael Saul Lundin1,2 and
  2. Gregory G Messenger3
  1. 1 Internal Medicine, Michigan State University, East Lansing, Michigan, USA
  2. 2 Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
  3. 3 Messenger Dermatology, Lansing, Michigan, USA
  1. Correspondence to Dr Michael Saul Lundin, lundinmi{at}msu.edu

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Description

A 73-year-old man presented to the community dermatologist with a chief complaint of rash. The patient was covered in non-palpable, non-blanching petechiae, 1–6 mm in size, from neck to toe (figure 1 and 2). There was no lymphadenopathy. The patient denied bleeding from any site, dark urine, fever, aggravation with cold, upper respiratory symptoms or arthralgias. Medications were aspirin 81 mg, clopidogrel, warfarin, doxazosin, furosemide, sotalol, atorvastatin, isosorbide mononitrate, losartan, docusate sodium, vitamin D, fish oil and lutein. Peripheral smear, blood count and vasculitis workup from 1 month prior (when the patient saw his primary-care and advanced-care provider) were all negative except for equivocal hepatitis (IgM) and positive hepatitis (A IgG).

Figure 1

A photograph of one of the patient’s leg shows numerous, non-blanching petechiae.

Figure 2

A photograph of the patient’s back similarly shows numerous, non-blanching petechiae. The patient had petechiae all over his body except on his face.

As the patient encounter drew to a close, at first one and then numerous bedbugs were observed on the patient, with a few even crawling on the floor. This behaviour is unusual because bedbugs usually avoid the light, hide during the day and feed during the night.1 One of the bedbugs, on being grasped digitally, accidently ruptured and splattered blood all over the examiner’s finger. Four bedbugs were sent to an entomologist and confirmed to be Cimex lenticularis, the common bedbug, in various stages of development. The bedbugs may have acted this way because of their enormous numbers. On the other hand, the infestation probably grew out of hand because the patient did not react to them and he lived alone.

Bedbug bites (cimicosis) often present with 2 to 5 mm erythematous, pruritic papules or wheals with a central haemorrhagic punctum, which is a reaction to the bug. However, bedbug bites can have varying morphologies and most people do not react at all.2 3 Especially those of older age, such as this patient, are less likely to react and experience significant pruritus. This patient’s rash is most likely due to hundreds of bedbug bites exacerbated by the patient’s triple antiplatelet/anticoagulation therapy, which was initiated 1 month prior for a non-ST elevation myocardial infarction.

Learning points

  • Bedbug bites classically present with pruritic ‘breakfast, lunch and dinner’ papules. However, they can have varying morphologies, most people do not react at all and many do not experience pruritus.

  • In rare cases such as this (massive infestation, plus on aspirin/clopidogrel/warfarin), bedbugs may cause a petechial rash resembling other diseases.

Acknowledgments

The authors would like to acknowledge the entomologist Mr Tim Moore.

References

Footnotes

  • Contributors MSL as well as GGM saw the patient. MSL wrote the manuscript and GGM reviewed it.

  • 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 Obtained.

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