HEALTH: NOCTURNAL CREATURES

HEALTH: NOCTURNAL CREATURESPeople are not the only creatures who love the nightlife.
“We’re sitting on the scene of the crime. I like to sleep on my couch,” says Sarah Clark, a soft-spoken thirty-something-year-old executive assistant.

Patients usually give me permission to use their real names, but not Clark. Sarah Clark is the alias chosen because she doesn’t want the world to know that for several months she housed a bedbug infestation in a trendy area of Uptown New Orleans.

Clark came to my office last May as a new patient, requesting a thyroid test. She also told me about an itchy skin eruption that had been going on for a month. She was having recurrent whelps on her legs and arms that sounded like hives.

I completely botched her diagnosis. After extensive laboratory testing, my diagnosis was idiopathic urticaria caused by one of her medications that she was taking for another problem. Idiopathic is a medical term that simply means of unknown cause. Urticaria is a $20 word for hives.
“Ms. Clark has a urticaria of one month’s duration. It’s probably an adverse drug reaction, but I’m unsure which drug is causing it. Otherwise, all we can do is call it idiopathic,” I wrote to her referring physician in late May.

In June, Clark returned. Her “urticaria” was worse. In addition, something about her history and physical findings didn’t really fit. I wondered about another itchy skin disease called pityriasis rosea, which sometimes can linger for weeks to months. Alternatively, were stress and tension causing her to scratch herself, causing these bumps? Dermatologists label a variety of self-induced rashes as neurodermatitis.

I referred her to a dermatologist for help. The dermatologist punched out a very small area of the border of one of her whelps from her right arm. Less than a week later, a pathologist who specializes in skin biopsies submitted a report: “Superficial and deep mixed perivascular dermatis consistent with arthropod assault.”

She returned in July and was no better. No, she was not around any mosquitoes. She was not a gardener, so there was no exposure to poison ivy or ants. She had some indoor cats but they had no fleas. She was still itching and I was frustrated. I didn’t believe the pathology report.

“The persistent nature of her dermatitis, its now widespread distribution and the reoccurrence of lesions must be more compatible with something else. Besides, no one including the patient has ever seen any crawling, living creature on her … I know bug bites, and as you know bugs – and especially spiders – get blamed for far more than they deserve,” I dashed off in a faxed note to the dermatologist asking her to give me a call.

In August, Clark called my office and left this message: “My problem was not hives. I was the victim of a bedbug epidemic.”

Maybe there was some psychological problem and her mind was playing tricks with her. I’ve practiced in New Orleans since 1978 and I had never even heard of bedbugs in New Orleans.

“Well, bedbugs are not a reportable condition, but no, we haven’t had any reports of them,” asserts the epidemiology section of the Louisiana Department of Health and Hospitals.

It was time for a house call. Clark agreed to let me come see for myself and said she had saved one for me to look at. One Saturday in early September, I knocked on the door of a two-story double.

Clark greeted me. Her medium-sized living room contained a sofa bed, a large upholstered chair, a TV and several bookcases packed with CDs and old records. There was a ball of yarn on a table beside the sofa. A friendly black and white cat came over for introductions. I scanned the cat’s fur – no fleas. The sofa, though, looked a bit worn and the fabric was circled with clear looking duct tape.

“How in the world did you figure out it was bedbugs?” I queried.
“I tend to keep a lamp on when I sleep on the sofa. One night I noticed something tiny that was crawling on my pillow. It was moving. Well, they were in my bed and they were bugs. I Googled ‘bed’ and ‘bug’ and saw the pictures,” she said.

The crawling speck that Clark found sounded like it could have been an immature bedbug or nymph. She watched more intently and soon saw a larger reddish bug. Over the next few days, she found about seven adults and four or five of the smaller nymphs.

“Were you able to save one for me?” I asked, no longer able to contain my excitement – and still wondering if they were real.

“Yes, they’re here,” Clark said, gesturing to the back of her sofa. “I surrounded the base of my sofa with this double-stick tape. The adults get stuck and I squash them. The smaller nymphs die on their own.”

There, embedded in the tape, were a squashed adult bedbug and two nymphs. She gave me a long strip of the tape embedded with three dead insects. Later in my office, I checked them under a microscope. It was the first bedbug I’d seen since I was a sophomore in a parasitology class.
“There’s a worldwide epidemic of bedbugs going on,” Clark continued.

She was referring to several articles that have appeared in the popular press over the past few years. A New York Times article from November 2005, described infestations in a duplex apartment on Park Avenue, a co-op on Riverside Drive and also mentioned a lawsuit by a guest who stayed in the Helmsley Park Lane Hotel on Central Park South.

Nevertheless, how did bedbugs end up in Clark’s clean but somewhat cluttered Uptown apartment?

“After Katrina I returned November 1st. I volunteered with an animal rescue group. We had volunteers come in from all over the country, and several slept on my sofa. They were from the East coast and California. One was from a New York suburb. She might have brought them, as I know there has been a bedbug epidemic in New York, but I really don’t want to blame anyone.

“They were all nice women in their 30s-50s, and they didn’t seem to have any hygiene problems. They were always anxious to shower after returning dirty from feeding and working with all the animals. They were manning feeding stations in flooded areas, trapping cats and all sorts of stuff,” concluded Clark.

It was all I could do not to repeat a rhyme I heard as a child from my father, who quoted his father – the first curator of insects of the American Museum of Natural History in New York:
Butterflies have wings of gold,
Humming birds wings of flame,
Bedbugs have no wings at all
But they get there just the same.

Bedbug Primer
• Bedbugs are small crawling insects that seek out people at night to painlessly sip a few drops of blood.

• Hatchling bedbugs are about the size of a poppy seed and adults are about 1/4 inch in length. They are oval but flattened in shape.

• While feeding, they inject a tiny amount of their saliva into the skin that can cause a mild to intense allergic response. The bite of a bedbug resembles those caused by other blood feeding insects such as mosquitoes and fleas.

• Because bedbugs readily hide in small crevices, they can be stowaways in luggage, furniture, clothing, pillows, boxes and other such objects, when these are moved between apartments, homes and hotels. They no doubt came to America with our best families in the Mayflower.

• Bedbugs became relatively scarce during the latter part of the 20th century, but their populations have resurged in recent years, particularly throughout parts of North America, Europe and Australia.

• They generally hide nearest the bed or other furniture used for sleeping. Their flattened bodies allow them to conceal themselves in cracks and crevices around the room and within furniture. Favored hiding sites include the bed frame, mattress and box spring.

• Under ideal conditions, adult bed bugs can survive for more than one year between meals.

• Fortunately, bedbugs do not transmit any infectious agents. They have only one or two generations a year, and it’s not true that “they become grandfathers in a night.”

• If you suspect that you have bedbugs, don’t panic and throw out all your furniture and linens. Checkout the website below for more information.

Sources: http://www.hsph.harvard.edu/bedbugs and Frank E. Lutz, Field Book of Insects, Putman, in editions from 1918-‘54.

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