CASE REPORT * ETUDE DE CAS
Moth-associated dermatitis in Canadian travellers returning from Mexico Fran Jamieson, MD, FRCPC; Jay S. Keystone, MD, FRCPC; Lyn From, MD, FRCPC; Cheryl Rosen, MD, FRCPC were covered with them. He remembered touching one of the moths with his hands. The patient did not complain of fever, diarrhea, malaise or vomiting but did note slight arthralgia and fatigue. The use of a topical steroid cream and oral antihistamine treatment did not relieve his symptoms. The patient was seen in our unit 2 days after returning to Canada. An eruption consisting of erythematous papules and pustules was evident over his abdomen, groin and forearms. The intense pruritus persisted. The differential diagnosis included miliaria, insect bites and folliculitis. A biopsy specimen of one of the papules from the forearm showed a perivascular lymphohistiocytic infiltrate in the dermis (Fig. 1). A fragment of foreign material consistent with a moth hair was found in the stratum corneum. Beneath the fragment, within the stratum granulosum, could be seen necrotic epithelial cells and spongiosis with exocytosis of lymphocytes. The pruritus and the eruption lasted for approximately 2 weeks. The cause of the eruption was elucidated from Case report information obtained from the Mexican health auA previously healthy 38-year-old man and his thorities and confirmed when the biopsy specimen wife were on vacation in Cozumel from Jan. 2 to showed features of moth-associated dermatitis.4 Jan. 9, 1990. He noted the onset of a rash over his forearms, abdomen and inner thighs on Jan. 6. The Investigation of related cases rash was so severely pruritic that he was unable to The results obtained from the five patients seen sleep at night. Within 24 hours it had spread to his neck, inner arms, groin and legs. His wife had a and the six who filled out the questionnaire revealed similar eruption, although milder. The patient noted that they had all stayed in one of two hotels along that several other hotel guests had the same rash and the same beach area in Cozumel. All had noticed a complaints of pruritus. He had seen many red moths large number of moths along the hotel walls and in and around the hotel area; in particular, the walls around lights at night; most reported moths inside ermatitis may result from contact with body hairs of caterpillars, moths and butterflies and is usually limited to the geographic areas where specific genera are found. A pruritic, urticarial eruption caused by exposure to Hylesia moths has been termed "Caripito itch," because it has been reported previously in sailors who visited the port of Caripito, Venezuela.'-3 In early January 1990 the Tropical Disease Clinic at Toronto Hospital (General Division) received several telephone calls from people who had vacationed in Cozumel, Mexico, between Dec. 22, 1989, and Jan. 9, 1990. All patients described a maculopapular eruption of varying severity accompanied by marked pruritus that developed during their stay in Cozumel. We saw five of the patients in our clinic and interviewed six others by questionnaire. A typical case is described. The diagnosis of moth-associated dermatitis should be considered in the returning traveller who has an itchy, erythematous, papular eruption. D
From the departments of Medicine and Pathology, Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Ont.
Reprint requests to: Dr. Jay S. Keystone, Tropical Disease Unit, EN, G-214, The Toronto Hospital (General Division), 200 Elizabeth St., Toronto, ON MSG 2C4 NOVEMBER 1, 1991
CAN MED ASSOC J 1991; 145 (9)
1119
their hotel rooms. Each person had seen several other guests with a similar pruritic eruption. The mean age of the patients was 32.2 (limits 14 and 47) years. The average duration of the rash was 12 (limits 7 and 28) days. All of the patients described a similar distribution of the eruption principally along the inner arms, buttocks, backs of the knees and abdomen. They described the eruption as "raised red bumps" accompanied by moderate to severe pruritus. The pruritus was worst at night and resolved with the disappearance of the rash. Other symptoms noted were fatigue (six patients) and generalized arthralgia (two). Only two patients recalled having had direct contact with moths. In one instance a patient brushed a moth off his abdomen and several hours later noticed a very pruritic, red, macular lesion about 6 cm in diameter at the site. Over the next 24 hours a generalized papular eruption developed. All of the patients sought medical advice in Cozumel and were given varying diagnoses, including scabies, moth allergy, "Canadian virus" and chickenpox. The patients tried a number of medications, mostly antihistamines and topical antipruritics. Two patients experienced some relief from the nocturnal pruritus with hydroxyzine, and one noted improvement with crotamiton cream.
Comments Investigators from Mexico and the US Centers for Disease Control, Atlanta, concluded that the outbreak of moth-associated dermatitis that occurred in Cozumel from December 1988 to January 1989 was due to Hylesia alinda.5 A decrease in the natural predator of this moth had occurred as a
4t ?,
*
D'
Z
,.
Fig. 1: Biopsy specimen of papule, showing perivascular lymphohistiocytic infiltrate, exocytosis of lymphocytes, spongiosis, necrotic granular layer cells and parakeratotic material. Tiny spicule of foreign material in parakeratotic area is seen as clear space (arrow). (Original magnification x 250, reduced by about 50%.) 1120
CAN MED ASSOC J 199 1; 145
(9)
result of the ecologic disturbances created by the passage of Hurricane Gilbert through the area in September 1988.5 This was the first time that such an outbreak had occurred on the island. Local entomologists had predicted that the moth population would likely decrease to its usual size within a year. However, since the moth reproduces in 3-month cycles other travellers may experience moth-associated dermatitis. Many species of moth are known to cause dermatitis in people who come in contact with the caterpillars or the abdominal hairs of the adults.4 These irritant hairs are of obvious protective value to the moths. In most instances the hairs, or setae, originate from the caterpillar and are transferred to the abdominal surface of the moth as it exits the cocoon. H. alinda is exceptional in that only the adult setae are capable of causing dermatitis.6 Contact with dead moths or moth parts can cause the eruption.2 In addition, moth hairs may be airborne, so that direct contact with the moth is not necessary for symptoms to occur.' When the diagnosis of moth-associated dermatitis is being considered it may be helpful to apply a piece of clear tape to an affected area of the skin. The tape is then removed and examined under a microscope for adherent setae.7 As in our cases the typical clinical feature of moth-associated dermatitis is a pruritic papular eruption. Symptoms may begin within minutes to several hours after contact with the moth hairs. The eruption generally involves exposed areas, but the palms, soles, face and mucous membranes are spared. The eruption and pruritus usually resolve within 7 to 1 0 days if there is no further contact with the moth hairs.'2 The eruption is thought to be caused by histamine or proteases. These have been detected in extracts of the setae and are likely contained within the hollow core of the hair shaft.8'9 Direct mechanical irritation of the skin by the hairs may also occur.9 Various species of moth found in Central and South America as well as in Canada, the United States, Britain, Europe and Australia have been reported to cause dermatitis in humans.4'7'10 Since Hylesia moths generally inhabit tropical areas of Central and South America this diagnosis should be considered in travellers returning from those regions who present with a pruritic papular eruption.
References 1. Hill WR, Rubenstein AD, Kovacs J: Dermatitis resulting from contact with moths (genus Hylesia): report of cases. JAMA 1948; 138: 737-740 2. Dinehart SM, Archer ME, Wolf JE et al: Caripito itch: dermatitis from contact with Hylesia moths. J Am Acad LE 1 er NOVEMBRE 1991
Dermatol 1985; 13: 743-747 3. Zaias N, lonnides G, Taplin D: Dermatitis from contact with moths (genus Hylesia). JAMA 1969; 207: 525-527 4. Henwood BP, MacDonald DM: Caterpillar dermatitis. Clin Exp Dermatol 1983; 8: 77-93 5. Moth-associated dermatitis - Cozumel, Mexico. MMWR 1990; 39: 2 19-220 6. Southcott RV: Lepidoptera and skin infestations. In Nutting WB, Schwartzman RM (eds): Cutaneous Infestations of Man and Animal, Praeger, New York, 1983
Conferences
continuedfrom page 1103 May 10-15, 1992: 3rd International Symposium on Issues in Health, Safety and Agriculture Delta Bessborough Hotel, Saskatoon Abstract deadline is Dec. 1, 1991. M. Gillis-Cipywnyk, symposium coordinator, Centre for Agricultural Medicine, Royal University Hospital, Saskatoon, SK S7N OXO; (306) 966-8288, fax (306) 966-8799
May 12-16, 1992: 2nd World Conference of the Hellenic Bio-Medical Diaspora (organized by the Hellenic Medical Society of Great Britain and the Athens Medical Society as part of the 18th Panhellenic Medical Congress) Athens Abstract deadlines are Jan. 10 (symposia andfree communication abstracts) and Apr. 10 (poster abstracts), 1992. Conference Secretariat, Hellenic Medical Society of Great Britain, PO Box 955, London SEI 9RW, England; fax 01 1-44-1-071-955-4247 May 21-23, 1992: International Conference on Multiple Personality Disorder and Dissociative States Free University of Amsterdam, the Netherlands Bureau PAOG Amsterdam (Postgraduate Medical Education Amsterdam), Tafelbergweg 25, 1105 BC Amsterdam, the Netherlands; telephone 011-31-020566-4801, fax 011-31-020-696-3228 May 24-28, 1992: International Heart Health Conference: Bridging the Gap - Science and Policy in Action (sponsored in part by the Department of National Health and Welfare, the BC Ministry of Health and the Heart and Stroke Foundation of Canada) Victoria International Heart Health Conference Secretariat, c/o Venue West Ltd., 645-375 Water St., Vancouver, BC V6B 5C6; (604) 681-5226, fax (604) 681-2503
May 25-29, 1992: 12th International Congress of Hospital Engineering (in concurrence with the Hospital-Health Care International Exhibition) Congress Hall, Bologna, Italy Organizing Secretariat, SENAF, Via Michelino 69, 40127 Bologna, Italy; telephone 011-39-51-503318, fax 011-
39-51-505282
NOVEMBER 1,1991
7. Shama SK, Etkind PH, Odell TM et al: Gypsy-moth-caterpillar dermatitis. N Engl J Med 1982; 306: 1300-1301 8. Dinehart SM, Jorizzo JL, Soter NA et al: Evidence for histamine in the urticating hairs of Hylesia moth. J Invest Dermatol 1987; 88: 691-693 9. De Jong MCJM, Bleumink E, Nater JP: Investigative studies of the dermatitis cause by the larva of the brown-tailed moth. Arch Dermatol Res 1975; 253: 287-300 10. Beaucher WN, Farnham JE: Gypsy-moth-caterpillar dermatitis. NEnglJMed 1982; 306: 1301-1302
May 26-31, 1992: 5th International Conference on the Cell and Molecular Biology of Chlamydomonas Asilomar Conference Center, Pacific Grove, Calif. Dr. George Witman, organizer, Worcester Foundation for Experimental Biology, Shrewsbury, MA 01545, (508) 842-8921, fax (508) 842-3915; or Genetics Society of America, 9650 Rockville Pike, Bethesda, MD 20814, (301) 571-1825, fax (301) 530-7079
June 2-4, 1992: Bio-Recognition: an International Industrial Biotechnology Conference Montreal David Smith, Ottawa-Carleton Economic Development Corporation, 111 Lisgar St., Ottawa, ON K2P 2L7; (613) 236-3500 June 5-7, 1992: Ontario Fitness Council Conference Harmony in Motion Hamilton, Ont. Applications to present, letters of interest and resumes to: Judi Savage, Chair Program, 7 Alba St., Stoney Creek, ON L8G 1N9 June 8, 1992: 2nd International Symposium on Perinatal
Asphyxia Westin Bayshore, Vancouver Mrs. Joan Beards, Perinatal Asphyxia Conference, Education Department, Canadian Medical Protective Association, PO Box 8225, Ottawa, ON KIG 3H7;
(613) 236-2100, ext. 238, fax (613) 236-5588 June 17-20, 1992: Society for Scholarly Publishing Annual Meeting Chicago Society for Scholarly Publishing, 304-10200 W 44th Ave., Wheat Ridge, CO 80033; (303) 422-3914 Aug. 31-Sept. 2, 1992: IgA Nephropathy: the 25th YearInternational Symposium Nancy, France Meeting Secretariat, Laboratoire d'Immunologie, BP 184, Avenue de la Foret de Haye, 54500 Vandoeuvre-les-Nancy, France; telephone 011-33-8359-28-56, fax 011-33-83-44-60-22 Du 2 au 4 sept. 1992: Conference internationale sur l'entraide (parrainee par le Conseil canadien de developpement social) Centre des conferences du gouvernement, Ottawa Golden Planners, 404-126, rue York, Ottawa, ON
KIN 5T5
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Moth-associated dermatitis in Canadian travellers returning from Mexico Fran Jamieson, MD, FRCPC; Jay S. Keystone, MD, FRCPC; Lyn From, MD, FRCPC; Cheryl Rosen, MD, FRCPC were covered with them. He remembered touching one of the moths with his hands. The patient did not complain of fever, diarrhea, malaise or vomiting but did note slight arthralgia and fatigue. The use of a topical steroid cream and oral antihistamine treatment did not relieve his symptoms. The patient was seen in our unit 2 days after returning to Canada. An eruption consisting of erythematous papules and pustules was evident over his abdomen, groin and forearms. The intense pruritus persisted. The differential diagnosis included miliaria, insect bites and folliculitis. A biopsy specimen of one of the papules from the forearm showed a perivascular lymphohistiocytic infiltrate in the dermis (Fig. 1). A fragment of foreign material consistent with a moth hair was found in the stratum corneum. Beneath the fragment, within the stratum granulosum, could be seen necrotic epithelial cells and spongiosis with exocytosis of lymphocytes. The pruritus and the eruption lasted for approximately 2 weeks. The cause of the eruption was elucidated from Case report information obtained from the Mexican health auA previously healthy 38-year-old man and his thorities and confirmed when the biopsy specimen wife were on vacation in Cozumel from Jan. 2 to showed features of moth-associated dermatitis.4 Jan. 9, 1990. He noted the onset of a rash over his forearms, abdomen and inner thighs on Jan. 6. The Investigation of related cases rash was so severely pruritic that he was unable to The results obtained from the five patients seen sleep at night. Within 24 hours it had spread to his neck, inner arms, groin and legs. His wife had a and the six who filled out the questionnaire revealed similar eruption, although milder. The patient noted that they had all stayed in one of two hotels along that several other hotel guests had the same rash and the same beach area in Cozumel. All had noticed a complaints of pruritus. He had seen many red moths large number of moths along the hotel walls and in and around the hotel area; in particular, the walls around lights at night; most reported moths inside ermatitis may result from contact with body hairs of caterpillars, moths and butterflies and is usually limited to the geographic areas where specific genera are found. A pruritic, urticarial eruption caused by exposure to Hylesia moths has been termed "Caripito itch," because it has been reported previously in sailors who visited the port of Caripito, Venezuela.'-3 In early January 1990 the Tropical Disease Clinic at Toronto Hospital (General Division) received several telephone calls from people who had vacationed in Cozumel, Mexico, between Dec. 22, 1989, and Jan. 9, 1990. All patients described a maculopapular eruption of varying severity accompanied by marked pruritus that developed during their stay in Cozumel. We saw five of the patients in our clinic and interviewed six others by questionnaire. A typical case is described. The diagnosis of moth-associated dermatitis should be considered in the returning traveller who has an itchy, erythematous, papular eruption. D
From the departments of Medicine and Pathology, Women's College Hospital and Toronto General Hospital, University of Toronto, Toronto, Ont.
Reprint requests to: Dr. Jay S. Keystone, Tropical Disease Unit, EN, G-214, The Toronto Hospital (General Division), 200 Elizabeth St., Toronto, ON MSG 2C4 NOVEMBER 1, 1991
CAN MED ASSOC J 1991; 145 (9)
1119
their hotel rooms. Each person had seen several other guests with a similar pruritic eruption. The mean age of the patients was 32.2 (limits 14 and 47) years. The average duration of the rash was 12 (limits 7 and 28) days. All of the patients described a similar distribution of the eruption principally along the inner arms, buttocks, backs of the knees and abdomen. They described the eruption as "raised red bumps" accompanied by moderate to severe pruritus. The pruritus was worst at night and resolved with the disappearance of the rash. Other symptoms noted were fatigue (six patients) and generalized arthralgia (two). Only two patients recalled having had direct contact with moths. In one instance a patient brushed a moth off his abdomen and several hours later noticed a very pruritic, red, macular lesion about 6 cm in diameter at the site. Over the next 24 hours a generalized papular eruption developed. All of the patients sought medical advice in Cozumel and were given varying diagnoses, including scabies, moth allergy, "Canadian virus" and chickenpox. The patients tried a number of medications, mostly antihistamines and topical antipruritics. Two patients experienced some relief from the nocturnal pruritus with hydroxyzine, and one noted improvement with crotamiton cream.
Comments Investigators from Mexico and the US Centers for Disease Control, Atlanta, concluded that the outbreak of moth-associated dermatitis that occurred in Cozumel from December 1988 to January 1989 was due to Hylesia alinda.5 A decrease in the natural predator of this moth had occurred as a
4t ?,
*
D'
Z
,.
Fig. 1: Biopsy specimen of papule, showing perivascular lymphohistiocytic infiltrate, exocytosis of lymphocytes, spongiosis, necrotic granular layer cells and parakeratotic material. Tiny spicule of foreign material in parakeratotic area is seen as clear space (arrow). (Original magnification x 250, reduced by about 50%.) 1120
CAN MED ASSOC J 199 1; 145
(9)
result of the ecologic disturbances created by the passage of Hurricane Gilbert through the area in September 1988.5 This was the first time that such an outbreak had occurred on the island. Local entomologists had predicted that the moth population would likely decrease to its usual size within a year. However, since the moth reproduces in 3-month cycles other travellers may experience moth-associated dermatitis. Many species of moth are known to cause dermatitis in people who come in contact with the caterpillars or the abdominal hairs of the adults.4 These irritant hairs are of obvious protective value to the moths. In most instances the hairs, or setae, originate from the caterpillar and are transferred to the abdominal surface of the moth as it exits the cocoon. H. alinda is exceptional in that only the adult setae are capable of causing dermatitis.6 Contact with dead moths or moth parts can cause the eruption.2 In addition, moth hairs may be airborne, so that direct contact with the moth is not necessary for symptoms to occur.' When the diagnosis of moth-associated dermatitis is being considered it may be helpful to apply a piece of clear tape to an affected area of the skin. The tape is then removed and examined under a microscope for adherent setae.7 As in our cases the typical clinical feature of moth-associated dermatitis is a pruritic papular eruption. Symptoms may begin within minutes to several hours after contact with the moth hairs. The eruption generally involves exposed areas, but the palms, soles, face and mucous membranes are spared. The eruption and pruritus usually resolve within 7 to 1 0 days if there is no further contact with the moth hairs.'2 The eruption is thought to be caused by histamine or proteases. These have been detected in extracts of the setae and are likely contained within the hollow core of the hair shaft.8'9 Direct mechanical irritation of the skin by the hairs may also occur.9 Various species of moth found in Central and South America as well as in Canada, the United States, Britain, Europe and Australia have been reported to cause dermatitis in humans.4'7'10 Since Hylesia moths generally inhabit tropical areas of Central and South America this diagnosis should be considered in travellers returning from those regions who present with a pruritic papular eruption.
References 1. Hill WR, Rubenstein AD, Kovacs J: Dermatitis resulting from contact with moths (genus Hylesia): report of cases. JAMA 1948; 138: 737-740 2. Dinehart SM, Archer ME, Wolf JE et al: Caripito itch: dermatitis from contact with Hylesia moths. J Am Acad LE 1 er NOVEMBRE 1991
Dermatol 1985; 13: 743-747 3. Zaias N, lonnides G, Taplin D: Dermatitis from contact with moths (genus Hylesia). JAMA 1969; 207: 525-527 4. Henwood BP, MacDonald DM: Caterpillar dermatitis. Clin Exp Dermatol 1983; 8: 77-93 5. Moth-associated dermatitis - Cozumel, Mexico. MMWR 1990; 39: 2 19-220 6. Southcott RV: Lepidoptera and skin infestations. In Nutting WB, Schwartzman RM (eds): Cutaneous Infestations of Man and Animal, Praeger, New York, 1983
Conferences
continuedfrom page 1103 May 10-15, 1992: 3rd International Symposium on Issues in Health, Safety and Agriculture Delta Bessborough Hotel, Saskatoon Abstract deadline is Dec. 1, 1991. M. Gillis-Cipywnyk, symposium coordinator, Centre for Agricultural Medicine, Royal University Hospital, Saskatoon, SK S7N OXO; (306) 966-8288, fax (306) 966-8799
May 12-16, 1992: 2nd World Conference of the Hellenic Bio-Medical Diaspora (organized by the Hellenic Medical Society of Great Britain and the Athens Medical Society as part of the 18th Panhellenic Medical Congress) Athens Abstract deadlines are Jan. 10 (symposia andfree communication abstracts) and Apr. 10 (poster abstracts), 1992. Conference Secretariat, Hellenic Medical Society of Great Britain, PO Box 955, London SEI 9RW, England; fax 01 1-44-1-071-955-4247 May 21-23, 1992: International Conference on Multiple Personality Disorder and Dissociative States Free University of Amsterdam, the Netherlands Bureau PAOG Amsterdam (Postgraduate Medical Education Amsterdam), Tafelbergweg 25, 1105 BC Amsterdam, the Netherlands; telephone 011-31-020566-4801, fax 011-31-020-696-3228 May 24-28, 1992: International Heart Health Conference: Bridging the Gap - Science and Policy in Action (sponsored in part by the Department of National Health and Welfare, the BC Ministry of Health and the Heart and Stroke Foundation of Canada) Victoria International Heart Health Conference Secretariat, c/o Venue West Ltd., 645-375 Water St., Vancouver, BC V6B 5C6; (604) 681-5226, fax (604) 681-2503
May 25-29, 1992: 12th International Congress of Hospital Engineering (in concurrence with the Hospital-Health Care International Exhibition) Congress Hall, Bologna, Italy Organizing Secretariat, SENAF, Via Michelino 69, 40127 Bologna, Italy; telephone 011-39-51-503318, fax 011-
39-51-505282
NOVEMBER 1,1991
7. Shama SK, Etkind PH, Odell TM et al: Gypsy-moth-caterpillar dermatitis. N Engl J Med 1982; 306: 1300-1301 8. Dinehart SM, Jorizzo JL, Soter NA et al: Evidence for histamine in the urticating hairs of Hylesia moth. J Invest Dermatol 1987; 88: 691-693 9. De Jong MCJM, Bleumink E, Nater JP: Investigative studies of the dermatitis cause by the larva of the brown-tailed moth. Arch Dermatol Res 1975; 253: 287-300 10. Beaucher WN, Farnham JE: Gypsy-moth-caterpillar dermatitis. NEnglJMed 1982; 306: 1301-1302
May 26-31, 1992: 5th International Conference on the Cell and Molecular Biology of Chlamydomonas Asilomar Conference Center, Pacific Grove, Calif. Dr. George Witman, organizer, Worcester Foundation for Experimental Biology, Shrewsbury, MA 01545, (508) 842-8921, fax (508) 842-3915; or Genetics Society of America, 9650 Rockville Pike, Bethesda, MD 20814, (301) 571-1825, fax (301) 530-7079
June 2-4, 1992: Bio-Recognition: an International Industrial Biotechnology Conference Montreal David Smith, Ottawa-Carleton Economic Development Corporation, 111 Lisgar St., Ottawa, ON K2P 2L7; (613) 236-3500 June 5-7, 1992: Ontario Fitness Council Conference Harmony in Motion Hamilton, Ont. Applications to present, letters of interest and resumes to: Judi Savage, Chair Program, 7 Alba St., Stoney Creek, ON L8G 1N9 June 8, 1992: 2nd International Symposium on Perinatal
Asphyxia Westin Bayshore, Vancouver Mrs. Joan Beards, Perinatal Asphyxia Conference, Education Department, Canadian Medical Protective Association, PO Box 8225, Ottawa, ON KIG 3H7;
(613) 236-2100, ext. 238, fax (613) 236-5588 June 17-20, 1992: Society for Scholarly Publishing Annual Meeting Chicago Society for Scholarly Publishing, 304-10200 W 44th Ave., Wheat Ridge, CO 80033; (303) 422-3914 Aug. 31-Sept. 2, 1992: IgA Nephropathy: the 25th YearInternational Symposium Nancy, France Meeting Secretariat, Laboratoire d'Immunologie, BP 184, Avenue de la Foret de Haye, 54500 Vandoeuvre-les-Nancy, France; telephone 011-33-8359-28-56, fax 011-33-83-44-60-22 Du 2 au 4 sept. 1992: Conference internationale sur l'entraide (parrainee par le Conseil canadien de developpement social) Centre des conferences du gouvernement, Ottawa Golden Planners, 404-126, rue York, Ottawa, ON
KIN 5T5
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