Periorbital Paederus Dermatitis

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Periorbital Paederus Dermatosis A Missed Diagnosis Dr. Aiman A. Hashish (Presenting Author: Dr. Aiman A. Hashish)

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aederus alfieri Koch is an insect that has been incriminated in many occasions of contact dermatitis known as blistering beetle (Paederus) dermatosis.(1) The insect contains in its body fluid a vesic vesicant ant chemi chemical cal that could cause contac contactt (2) dermatitis. The insect does not bite or sting, but it releases its coelomic fluid during accidental brushing against or crushing of the insect over the skin.(1) Histopathological studies of Paederus dermatitis showed a spectrum of microscopic changes, in thee fo th form rm of ac acut utee ep epid ider erma mall ne necr cros osis is an and d blistering (in acute stage) and marked acanthosis with evident mitosis (in late stage). Additionally, foci of acantholysis attributed to the release of epidermal protease have been reported.(3) My aim of this work was to focus on opht op htha halm lmolo ologi gica call pr pres esen enta tati tion on in ca case sess of periorbital Paederus dermatosis during the last years in the area of Tanta, Gharbia Governorate, Egypt.

Materials and Methods In the last few years starting by 2001 till the beginning of 2009 cases of Paederus dermatosis in the area of Tanta, Gharbia Governorate, were recorded. I have studied studied the ophthalmological ophthalmological pres pr esen enta tati tion on of th thee ca case sess pr pres esen ente ted d wi with th periorbi peri orbital tal Paed Paederus erus derm dermatosi atosiss in that peri period. od. A fulll oph ful ophtha thalmol lmologi ogical cal exa examin minati ation on was don donee and photos pho tos wer weree tak taken en for all cas cases. es. Med Medial ial tre treatm atment ent in the form form of triderm triderm (Sche (Scheringring-Ploug Plough) h) skin cream was prescrib prescribed ed for skin lesion lesionss once at bed time and tobradex (Alcon) eye drops three times tim es a day if con conjun juncti ctivit vitis is was pre presen sent. t. In cas cases es of ke kera rati titi tiss be besi side de th thee pr prev evio ious us tr trea eatm tmen entt thilotears (Thilo) eye gel was given till the cure of conjunctivitis then covering of the eye till the cure of of the cornea. cornea. follo follow w up of the cases cases was was

done till their cure.

Results From 20 From 2001 01 ti till ll 20 2009 09 I re reco cord rded ed 14 1466 ca case sess of Paederus periorbital dermatosis in the area of Tanta, Gharbia Governorate. Season of affection bega be gan n in la late te Ap Apri rill ti till ll en end d of Oc Octo tobe berr an and d sporadic cases are recorded all over the year. Mostt of patie Mos patients nts were were male maless (75.3% (75.3%). ). Age Agess ranged between 9 and 52 years. The lesion was common com mon as uni unilat latera erall (93 (93.1% .1%). ). The eye was affe af fect cted ed in (5 (57. 7.5% 5%)) of ca case ses. s. Th Thee cl clin inic ical al presenta pres entations tions were toxic conju conjunctiv nctivitis itis in (57. (57.5%); 5%); supe su perf rfic icia iall pun punct ctat atee ke kera rati titi tiss (1 (12. 2.3% 3%)) an and d subconjunctival hemorrhage (1.4%). As regarding the clinical data, all the repor reported ted cases complained of sudden onset of itchy and burning burni ng of skin lesions usually in the morni morning ng without with out any histor history y of insect insect bite or sting. sting. On examination, the early lesions were erythema and an d ed edem emaa wh whic ich h wa wass hi high ghly ly bu burn rnin ing g an and d patien pat ients ts can can't 't sus sustai tain n loc local al tou touch, ch, whe when n eye les lesion ion was present present it was was from the first first day. On the second sec ond day les lesion ionss cha change nged d to ery erythe themat matoovesicular and sometimes sometimes erythemato-vesiculoerythemato-vesiculobull bu llous ous wi with th so some me of th them em ha havi ving ng a li line near ar configura confi guration tion that know known n as whipl whiplash ash derm dermatit atitis. is. Kissing lesions were seen when the eyelids were affected. The older lesions were scaly, crusted and sometime sometimess ichthyosifo ichthyosiform rm [Fig ]. Some cases exhibited post-inflammatory hyperpigmented patches.. The cycle of the disease patches disease takes takes from two to three weeks weeks before before complete complete healing. healing. This cycl cy clee wo woul uld d sto top p on once ce th thee pa pattie ient nt to took ok mediations. The eye was affected in 84 cases (57.5%). The clinical presentations were toxic conjunctivitis in 84 cases (57.5%); superficial punctate keratitis recorded in 18 cases (12.3%) and subconjunctival

EXTERNAL DISEASES SESSION

hemorrhage was present in 2 cases (1.4%). Conjunctivitis responded to treatment and cured within three days. Keratitis was very annoying to patients till its cure within two weeks. Subconjunctival hemorrhage disappeared after three weeks and the patient was investigated for any systemic cause of bleeding tendency and the conjunctiva was thoroughly examined for local cause of bleeding and no cause was detected. No residual visual affection was present in any case. Examination of posterior segment after patients cure (as examination was difficult during the disease) reveals no posterior segment complications.

Discussion Generally speaking, beetles are minute to large insets, with tough or hard exoskeleton, chewing mouth parts, variable antennae, large compound eyes, usually no ocelli and typically two pairs of wings, of which the fore wings are thickened and highly chitinized to form sheathed covers which come together in a median dorsal line overall of body. The abdomen is usually ten segments without cerci. The rove beetles (family: Staphylinidae) contain pedrine which on contact with the human body causes a necrotizing lesion which heals very slowly.(4) Tawfik et al (1974)(5) reported that this insect is common in Egypt and known as “El-Rawagha or the escaper”. It is present in the fields of maize, cotton and clover and has a great agricultural benefit as an eater of aphides. The cause of Paederus dermatosis may be due to the presence of large numbers of Paederus alfieri due to the less use of insecticides for cotton pests, ( Ibrahim; 1962)(6) and that this beetle flies to the residential buildings being attracted by bright lights. However, it can not fly for a long distance unless being disturbed by a provocative like smoke arising from the burning dry remains of rice in the intermediate area of cultivable land.(7) The clinical results are in agreement with the work of Ramadan et al (1999)(8) who studied similar cases in Tanta city and its surrounding area. And in agreement with the results of Hewedy et al (1999)(9) who in a study of 86 cases of Paederus dermatitis showed that the lesions were present mainly on the exposed areas particularly the face and neck (36.05% and 43.02% respectively). As Paederus alfieri

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couldn’t bite nor suck because its mouth parts are adapted only for its function as a predator, (1) this explain why the patients didn’t experience any bites or stings. As regards sex I found that the disease affected mainly males (75.3%) and this is in agreement with results of Ramadan et al (1999)(8) but against the results of Hewedy et al (1999)(9) who stated that most of the affected cases were females, this may be explained by the distribution of females buildings in their campus. Roberts and Tonking (1935)(10) drew attention not only to dermatitis but also to the conjunctivitis that was caused by Paederus crebipunctatus “Nairobi eye”. Although Paederus alfieri is another species of genus Paederus other than crebipunctatus species, Morsy et al (1996)(11) proved experimentally that an extract from Paederus alfieri causes conjuntival congestion in 75% of used mices. This goes with my results as 57.5 % of the cases showed toxic conjunctivitis with mucoid discharge. The contact of cornea with pedrine of the insect explains the superficial punctate keratitis and may explain subconjunctival hemorrhage or the hemorrhage may be attributed to excessive rubbing of the eye i.e. mechanical. As pedrine acts superficially, this explains the absence of posterior segment complications and no visual disturbance after the cure of patient. The given medical treatment in the form of triderm (Schering-Plough) skin cream; tobradex (Alcon) eye drops and thilotears (Thilo) eye gel shortened the period of disease and made it comfortable. Paederus dermatosis was recently reported in different areas of the world namely Sri Lanka,   (12) Turkey,   (13) Australia   (14) and Iran (15). Conclussion:   There is a newly recognized periorbital dermatosis in the surrounding area of Tanta, Gharbia Governorate, Egypt. An insect called Paederus alfieri is accused to be the cause. Smoke, resulting from burning of the dry remains of plants or refuse, could be the factor that provokes flying of the causative inset towards the nearby residential buildings. The eye was involved in most of cases of periorbital dermatosis. Although it is a treatable disease it is easily misdiagnosed.

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References 1. Gelmelti C & Grimalt R. Paederus dermatitis: An easy diagnosable but misdiagnosed eruption.  Eur J  Pediatr  1993;152(1):6-8. 2. Nicholls D; Christmas T & Greig D. Oedemerid blister beetle dermatosis: a review.   J Am Acad Dermatol 1990;22:815-9. 3. Borroni G; Brazzelli V & Rosso R. Paederus fuscipes dermatitis: A Histopathological study. Am J  Dermatopathol 1991;13(5):467-74. 4. Armstrong R & Winfield J. Paederus Fuscipes dermatitis. An epidemic in Okinawa. Am J Trop Med Hyg. 1969;18:147-50. 5. Tawfik M; Kira M & Metwally S. On the abundance of major pests and their associatedpredators in corn plantations. Bull Soc Entomol Egypt  1974;58:167-77. 6. Ibrahim M. An indication of effect of the widespread use of some predators in cotton fields. Bull Soc Entomol Egypt  1962;46:317-23. 7. Okiwelu S; Umeozor O & Akpan A. An outbreak of vesicating beetle Paederus sabeus Er. (Coleoptera: Staphylinidae) in Rivers State, Nigeria.  Ann Trop  Med Parasitol  1996;90(3):345-6. 8. Ramadan W; Abd Rabou F; Kolkaila A et al. Blistering beetles’ dermatosis in Tanta, Egypt. Egyptian J Dermatol & Venereol  1999;19(1):25-8.

9. Hewedy E; Atlam S; Ayad k et al. A study of an outbreak of itchy skin lesions in Tanta University campus in Kafr Al-Sheikh.  Tanta Med J   1999;27(1): 767-80. 10. Roberts J & Tonking H. Notes on an East African vesicant beetle. Paederus crebipunctatus sp.  Ann Trop Med Parasit 1935;29:415. 11. Morsy T; Arafa M; Younis T & Mahmoud I. Studies on Paederus alfieri Koch (Coleoptera: staphylinidae) with special references to the medical importance. J Egypt Soc Parasitol 1996;26(2): 337-5. 12. Kamaladasa SD, Perera WD, Weeratunge L: Kamaladasa SD, Perera WD, Weeratunge L. An outbreak of Paederus dermatitis in a suburban hospital in Sri Lanka.  Int J Dermatol  1997;36(1):34-6. 13. Sendur N, Savk E, Karaman G. Paederus dermatitis: a report of 46 cases in Aydin, Turkey. Dermatol 1999; 199(4):353-5. 14. Banney LA, Wood DJ, Francis GD. Whiplash rove beetle dermatitis in central Queensland.  Australas J  Dermatol 2000;41(3):162-7. 15. Zargari O, Kimyai-Asadi A, Fathalikhani F, Panahi M. Paederus dermatitis in northern Iran: a report of 156 cases.  Int J Dermatol  2003;42(8):608-12.