Sleep Tight!Sleep Tight!

By Roslyn Joinvil & Kedarry RansomeBy Roslyn Joinvil & Kedarry RansomeMentor: Mary-Lee Wong, MDMentor: Mary-Lee Wong, MD

Tania Rivera, MDTania Rivera, MDCo-Mentor: Shirley GomezCo-Mentor: Shirley Gomez

Department of Internal MedicineDepartment of Internal MedicineAllergy & ImmunologyAllergy & Immunology

Beth Israel Medical CenterBeth Israel Medical Center

EpidemiologyEpidemiology Bed bugs = Cimex lectularius

Cimex Roman for bug lectularius Latin for couch or bed

They are part of an insect family called Cimicidae (bed bugs, bat bugs, and swallow bugs)

The 91 species in this family are wingless, obligate hematophagous ectoparasites that feed on bats, birds, and mammals

Attracted to human's high body temperature and carbon dioxide production

EpidemiologyEpidemiology They generally avoid light, hide

during the day, and feed at night. Hiding places are usually within 1 to 2 meters of suitable hosts: seams in mattresses crevices in box springs backsides of headboards spaces under baseboards

or loose wallpaper behind hanging pictures

will feed during the day if will feed during the day if hungry and the light is dim.hungry and the light is dim.

Outbreak – WHY NOW??Outbreak – WHY NOW?? Bed bug infestations are rapidly increasing worldwide Bed bug infestations are rapidly increasing worldwide

(developed countries):(developed countries): Increased international travel and immigrationIncreased international travel and immigration Increased temperaturesIncreased temperatures Allowing used furniture & bedding w/o inspectionAllowing used furniture & bedding w/o inspection Changes in pest control practices and increased Changes in pest control practices and increased

insecticide resistanceinsecticide resistance Ex: DDT used after World War IIEx: DDT used after World War II

Reports of bed bug infestations in San Francisco doubled Reports of bed bug infestations in San Francisco doubled between 2004 and 2006between 2004 and 2006

Goddard et al 2008Romero et al 2007Doggett et al 2004

Life CycleLife CycleEgg – The female lays her eggs, usually in clusters of 50 per day. Eggs hatch in 1-2 weeks.

Nymph – The nymph must consume a blood meal before it can molt. It molts 5 times to reach adulthood. The nymph stage lasts 3 weeks in warm temperatures and months in cold temperatures.

Adult – Adult bed bugs live about 10 months, and can survive up to 1 year without feeding

How to Recognized How to Recognized Them?Them?

Adult bed bugs are oval shaped, flat, and approximately 5 mm longThey resemble unfed ticks or small cockroaches and are easily visible, even to the untrained eye. Adults are reddish brown (chestnut) in color. *immatures are smaller and light yellow. They have a pyramid-shaped head with prominent eyes, and slender antennae

After a blood meal, the bugs may increase in length by 30% to 50% and in weight by 150% to 200%.

Clinical PresentationsClinical Presentations

Cutaneous manifestationsCutaneous manifestations Systemic reactionsSystemic reactions

Clinical Presentation:Clinical Presentation:Cutaneous ManifestationsCutaneous Manifestations

Stucki. Nejm Sept 2008.

Most common: 2-5 mm pruritic maculopapular erythematous lesions at bed bug feeding sites. Resolve within 1 week

Complex cutaneous reactions: pruritic wheals (local urticaria) around a central punctum, papular urticaria, and diffuse urticaria at bite sites

Definitive diagnosis depends on identification of the bedbug or positive skin test

Clinical Presentation:Clinical Presentation:Cutaneous ManifestationsCutaneous Manifestations

The timing of cutaneous reactions to bed bugs may change with multiple exposures.

This appears to reflect host immunological responses to salivary proteins.

Three salivary proteins have been identified (play a role in host immunological responses) a nitric oxide–liberating heme protein [nitrophorin] 17-kDa anticoagulant [Factor X] 40-kDa apyrase-like nucleotidebinding enzyme

Clinical Presentation:Clinical Presentation:Cutaneous ManifestationsCutaneous Manifestations

Bullous Allergic Hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin

Bullous rashes may occur subsequent to biting events days later

Clinical Presentation:Clinical Presentation:Systemic ReactionsSystemic Reactions

Asthma Generalized urticaria

(hives) Hives presents with Hives presents with

spontaneous weals spontaneous weals anywhere on the bodyanywhere on the body

release of chemicals in release of chemicals in the skin causes small the skin causes small blood vessels to leak blood vessels to leak and results in tissue and results in tissue swellingswelling

Anaphylaxis

Diseases Transmitted Diseases Transmitted The role of bedbugs as a vector for disease transmission

remains unclear. Transmission of more than 40 human diseases has been

attributed to bed bugs, but there is little evidence that such transmission has ever occurred.

How to Eradicate?How to Eradicate?

1. proper identification of the bed bug species present, because some bat-infesting species may be found inside homes.

2. education of people involved

3. thorough inspection of infested and adjacent areas

4. implementation of chemical and nonchemical control measures

5. follow-up to evaluate the success of eradication

Measurement to prevent??Avoidance, because no repellents for the

insects have been demonstrated conclusively

Don’tsDon’ts DO NOTDO NOT panic and move. This will only prolong your suffering. panic and move. This will only prolong your suffering. DO NOTDO NOT move your bedroom set or throw away. move your bedroom set or throw away.

Wherever you go, the bedbugs will follow.Wherever you go, the bedbugs will follow.

DO NOTDO NOT bomb or fog your apartment. bomb or fog your apartment. will send the bedbugs further into their hiding places, making them much harder will send the bedbugs further into their hiding places, making them much harder

to kill.to kill.

DO NOTDO NOT attempt to treat bed bugs yourself. attempt to treat bed bugs yourself. if bed bugs are not thoroughly treated, the situation will not improve and you end if bed bugs are not thoroughly treated, the situation will not improve and you end

up wasting your time and money. up wasting your time and money. Professional exterminators have certified knowledge, D.E.C approved chemicals Professional exterminators have certified knowledge, D.E.C approved chemicals

that are restricted from public use, and the right mechanical tools to treat your that are restricted from public use, and the right mechanical tools to treat your infested property.infested property.

Do’sDo’s DODO take notice of yourself and other people in your household who take notice of yourself and other people in your household who

have mysterious bites, welts or unexplained itching.have mysterious bites, welts or unexplained itching. DODO remove clutter remove clutter

i.e. throw away unwanted materials. Bedbugs like wood and like to hide in clutter i.e. throw away unwanted materials. Bedbugs like wood and like to hide in clutter - clothes on floor, around bed, etc.- clothes on floor, around bed, etc.

DODO give a thorough inspection to your bedding area: give a thorough inspection to your bedding area: i.e., night table, bed, dresser and box spring. Look for white to light brown i.e., night table, bed, dresser and box spring. Look for white to light brown

castings (skins) of the bedbugs. castings (skins) of the bedbugs. look for tiny blood droppings on mattress tufts, behind picture frames, and all look for tiny blood droppings on mattress tufts, behind picture frames, and all

wooden objects in the bedroom.wooden objects in the bedroom. put bedding, clothing, etc. in a plastic bag to transport to the laundry room, and put bedding, clothing, etc. in a plastic bag to transport to the laundry room, and

wash in hot water right away and in a hot dryer.wash in hot water right away and in a hot dryer.

DODO put isopropyl alcohol in a spray bottle put isopropyl alcohol in a spray bottle spray the braiding of the mattress, the headboard, and the box springs. Test on a spray the braiding of the mattress, the headboard, and the box springs. Test on a

small section of furniture to see if it stains. Alcohol kills on contact, but it does not small section of furniture to see if it stains. Alcohol kills on contact, but it does not remain on the surfaces to continue killing bedbugs. Remember that the alcohol is remain on the surfaces to continue killing bedbugs. Remember that the alcohol is a temporary fix.a temporary fix.

ReferencesReferences1. Who knows the bed bug? Knowledge of adult bed bug appearance increases with

people's age in three counties of Great Britain. Reinhardt K, Harder A, Holland S, Hooper J, Leake-Lyall C. J Med Entomol. 2008 Sep;45(5):956-8.

2. Images in clinical medicine. Bedbug bites. Stucki A, Ludwig R. N Engl J Med. 2008 Sep 4;359(10):1047.

3. Romero, A., M. F. Potter, D. A. Potter, and K. F. Haynes. 2007. Insecticide resistance in the bed bug: a factor in the pest’s sudden resurgence? J. Med. Entomol. 44: 175-178.

4. Doggett, S. L., M. J. Geary, and R. C. Russell. 2004. The resurgence of bed bugs in Australia: with notes on their ecology and control. Environ. Health 4: 30-38.

5. Reinhardt, K., and M. T. Siva-Jothy. 2007. Biology of bed bugs (Cimicidae). Annu. Rev. Entomol. 52: 352-374.

6. Goddard J, deShazo RD. Rapid rise in bed bug populations: the need to include them in the differential diagnosis of mysterious skin rashes. South Med J. 2008;101:854-855.

7. Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin. Leverkus M, Jochim RC, Schäd S, Bröcker EB, Andersen JF, Valenzuela JG, Trautmann A. J Invest Dermatol. 2006 Jan;126(1):91-6.

8. http://www.pestcentral.com/bedbugs/bedbug-dos-and-donts.html

AcknowledgementsAcknowledgements

Harlem Children SocietyHarlem Children Society Dr. SatDr. Sat Dr. Mary Lee-WongDr. Mary Lee-Wong Shirley GomezShirley Gomez AudienceAudience