Blinking Bug Bite

Author Affiliation
Joseph Miller, MD Henry Ford Hospital, Department of Emergency Medicine, Detroit, Michigan
Mark Walsh, MD St. Joseph Regional Medical Center, Department of Emergency Medicine, Mishawaka, Indiana
Jessica Magyar, PA-C St. Joseph Regional Medical Center, Department of Emergency Medicine, Mishawaka, Indiana
Nuha Zackariya, Indiana University, Bloomington, Indiana
John Rice, MD South Bend Clinic, Michiana Pediatrics, South Bend, Indiana
Katherine Rice, St. Joseph Regional Medical Center, Department of Emergency Medicine, Mishawaka, Indiana
Dawn Ziegelmaier, RN Pulmonary and Critical Care Associates PC, South Bend, Indiana
Patrick Hanlon, MD Henry Ford Hospital, Department of Emergency Medicine, Detroit, Michigan
Joseph Dynako, BS Indiana University School of Medicine, South Bend, Indiana
David Zimmer, DVM Indiana University School of Medicine, South Bend, Indiana
Faadil Shariff, Indiana University, Bloomington, Indiana
Michael T. McCurdy, MD University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
Shane Kappler, MD Cambridge Health Alliance, Cambridge, Massachusetts
Paul Guentert, MD Pulmonary and Critical Care Associates PC, South Bend, Indiana

Case presentation
Diagnosis
Supplementary information

CASE PRESENTATION

A three-year-old female presented to a community emergency department with a one-day pruritic rash on her knee. The patient and the parents noted that the rash blanched intermittently and that this blanching appeared to be what they called a “blinking” bug bite. Physical examination revealed a normal child with no heart murmur and two bullous lesions around the left knee that blanched in a pulsatile fashion, corresponding to the femoral pulse (Images 1 and 2, Video).

 

Image 1
The insect bite skin lesions on the knee varying in size (arrows).

 

Image 2
Close-up of skin lesion (arrow).

DIAGNOSIS

A review of the medical literature revealed a single “Images in Clinical Medicine” from the New England Journal of Medicine, which revealed a severe dermatitis of the lower extremities that had similar presentation.1 No other cases were noted in the literature. The wounds were anesthetized and debrided for concern of a staph infection. The patient was placed on antibiotics and healed uneventfully. The case presented here represents an example of a physical manifestation of Quincke’s sign, not related to aortic insufficiency but to the rarely-noted effect of intense arterial dilatation in the bullous inflammation of the affected subcutaneous area. Quincke’s pulse is a physical finding of aortic insufficiency and, as in this case, focal arterial dilatation. Here, the arterial dilatation in the area of the bite led to an inability of arterioles to maintain sufficient pressure during diastole, resulting in the pulsating blanching and flushing that produced a “blinking” bug bite.

 

CPC-EM Capsule

What do we already know about this clinical entity?

Google Scholar and PubMed reveal only one case report of a “blinking” bug bite. However, searchable online blog posts reveal similar descriptions of these bites.

What is the major impact of the image(s)?

The images here demonstrate a classic example of the “blinking” bug bite, which has not been well described in the medical literature.

How might this improve emergency medicine practice?

These images and video may act as a reference for emergency physicians to more easily diagnose this benign condition.

 

Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.

Supplementary Information

This recording demonstrates the blinking bug bite, a manifestation of Quincke’s pulse.

 

Footnotes

Section Editor: Rick A. McPheeters, DO

Full text available through open access at http://escholarship.org/uc/uciem_cpcem

Address for Correspondence: Joseph Miller, MD, MS, Henry Ford Hospital, Department of Emergency Medicine, 2799 W Grand Blvd, Detroit, Michigan 48202. E-mail: jmiller6@hfhs.org. 2:382 – 383

Submission history: Revision received June 24, 2018; Submitted August 27, 2018; Accepted September 6, 2018

Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

REFERENCES

1. Lazar JD, Willis LK. A blinking knee. N Engl J Med. 2014;370(24):e36.