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Periorbital Paederus Dermatosis A Missed Diagnosis

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 vesicant chemical that could cause contact dermatitis.(2) 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)

(Presenting Author: Dr. Aiman A. Hashish)

Dr. Aiman A. Hashish

Histopathological studies of Paederus dermatitis showed a spectrum of microscopic changes, in the form of acute epidermal necrosis and 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 ophthalmological presentation in cases of periorbital Paederus dermatosis during the last years in the area of Tanta, Gharbia Governorate, Egypt.

From 2001 till 2009 I recorded 146 cases of Paederus periorbital dermatosis in the area of Tanta, Gharbia Governorate. Season of affection began in late April till end of October and sporadic cases are recorded all over the year. Most of patients were males (75.3%). Ages ranged between 9 and 52 years. The lesion was common as unilateral (93.1%). The eye was affected in (57.5%) of cases. The clinical presentations were toxic conjunctivitis in (57.5%); superficial punctate keratitis (12.3%) and subconjunctival hemorrhage (1.4%).

Results

done till their cure.

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 the ophthalmological presentation of the cases presented with periorbital Paederus dermatosis in that period. A full ophthalmological examination was done and photos were taken for all cases. Medial treatment in the form of triderm (Schering-Plough) skin cream was prescribed for skin lesions once at bed time and tobradex (Alcon) eye drops three times a day if conjunctivitis was present. In cases of keratitis beside the previous treatment thilotears (Thilo) eye gel was given till the cure of conjunctivitis then covering of the eye till the cure of the cornea. follow up of the cases was

Materials and Methods

As regarding the clinical data, all the reported cases complained of sudden onset of itchy and burning of skin lesions usually in the morning without any history of insect bite or sting. On examination, the early lesions were erythema and edema which was highly burning and patients can't sustain local touch, when eye lesion was present it was from the first day. On the second day lesions changed to erythematovesicular and sometimes erythemato-vesiculobullous with some of them having a linear configuration that known as whiplash dermatitis. Kissing lesions were seen when the eyelids were affected. The older lesions were scaly, crusted and sometimes ichthyosiform [Fig ]. Some cases exhibited post-inflammatory hyperpigmented patches. The cycle of the disease takes from two to three weeks before complete healing. This cycle would stop once the patient took 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

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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. 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)

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.

couldnt bite nor suck because its mouth parts are adapted only for its function as a predator, (1) this explain why the patients didnt experience any bites or stings.

Discussion

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

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)

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.

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.

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.

Paederus dermatosis was recently reported in different areas of the world namely Sri Lanka, (12) Turkey, (13) Australia (14) and Iran (15).

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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 associated predators 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.

References

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.