On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.4 Rio de Janeiro July/Aug. 2009
CLINICAL, EPIDEMIOLOGICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Vidal Haddad Junior
Ph.D., Professor, Faculdade de Medicina de Botucatu (Universidade Estadual Paulista) and collaborating physician of Hospital Vital Brazil, Instituto Butantan Sao Paulo (SP), Brazil
In recent years, there has been increasing contact between human beings that
live in urban regions and the wild environment due to a series of activities.
As a result, some poorly known dermatitis may present in private and dermatological
clinics, especially early in the week and at the end of vacation periods.
OBJECTIVES: To obtain and provide information for dermatologists on the problem.
PATIENTS AND METHODS: The author observed adult and pediatric patients with acute dermatitis associated with plants or animals in Ubatuba, coastal city of Sao Paulo for 2 months (June / July 2006) and Medical School of Botucatu (June / July 2007).
RESULTS: We observed 25 patients in the rural area and 43 in the coastal environment. In rural areas, the most common dermatitis were phytophotodermatitis and the stings of insects and in coastal areas, sea urchin injuries and phytophotodermatitis, but in both areas there were some other accidents that were difficult to identify by regular daily practice.
CONCLUSION: We should be alert to the fact that patients seek a dermatologist after the acute phase of injuries. Information on the most common diseases and their characteristics can be very useful to practice in ermatologic clinics. The author suggests an algorithm to support diagnosis.
Keywords: Animals, poisonous; Dermatology; Environmental exposure; Plant poisoning; Plant poisoning/etiology
Even though some dermatitis caused by plants and animals may occur in urban environments, most of the accidents take place within rural environments 1,2,3. We currently experience an important wave of sport and outdoor leisure activities, which take human beings to new sites. As a result, contact with many animals and plants may cause polymorphous dermatitis of variable severity and frequency. In most cases, they are caused by direct contact with agents and are associated with toxins or allergic phenomenon, differing from the diseases commonly observed in private offices. The most common accidents caused by poisonous animals are caused by arthropods such as beetles (especially genus Paederus and Epicauta), bees, spiders (genus Loxosceles and Phoneutria), and ants (especially genus Solenopsis). Anacardiaceous and photosensitizing plants are responsible for most of the episodes caused by plants. The knowledge of the most common insults and patient's report of having recently stayed in the wild are extremely useful. We should bear in mind that the patient will be examined by the dermatologist only when coming back to town, given that most of the time the first examination is performed by a local clinician that works in the local Emergency Department where the accident had happened.
To provide data for identification of causing agents and to warn dermatologist about the possibility of seeing patients with diseases caused by plants and animals from wild places.
MATERIAL AND METHODS
The author observed dermatitis caused by animals and plants in 68 adults and children during two months (July and August) based on the observation of care provided at Santa Casa de Ubatuba, in the coast of the State of São Paulo (June/ July 2006), and at the Screening Ambulatory, Medical School, Botucatu, Universidade Estadual Paulista (June/July 2007). Initial observations of patients were made by the clinical staff of the institution, as a routine. The author was invited to participate after pre-selection of patients by the teams. Patients whose etiology was doubtful after the dermatological examination or that could not provide clear information were excluded from the study. The patients were invited to complete a directed questionnaire and authorized the use of their data for a descriptive analysis of the condition by signing an informed protocol.
There were 25 patients observed in the rural area (Botucatu) and 43 in the coastal area (Ubatuba) within the conditions required by the study. Out of the total, approximately 50% (33) were children (below 12 years of age) and about 70% were patients who manifested their intention to go to a dermatologist once they returned home, because all patients had some extent of skin damage. The patients were classified by types of lesions that were presented and they were associated with the agents (Tables 1,. 2 and 3). Only about 10% (7 patients) brought with them the causing agent and none brought plants, despite later association between the lesion and contact with plants.
The city of Botucatu has nearby forest areas, rivers and mountains where it is possible to go fishing, hiking, cycling or practicing other sports. Phytophotodermatites were common owing to manipulation of citrus fruits 4 (Figure 1). Fly and mosquito bites were second, associated or not with allergic phenomenon 5 (Figure 2), as well as single bee stings 2. In rural areas, in some periods of the year, there is parasitism caused by ticks, especially those of genus Ixodes and Amblyomma which cause extremely pruriginous vesicle dermatitis. These arthropods are involved because they transmit diseases such as maculosa fever and Lyme's disease (Figure 2). Marked pain, papules and/or plaques are associated with accidents caused by poisonous animals such as caterpillars 2,6 (Megalopigidae family is the most common one), whereas sudden pustulosis in children, with history of outdoors staying, may be caused by Solenopsis invicta ants, even though right after the bite (within 24 hours), there are papule-erythematous-edematous lesions 2,7. Vesicles and blisters in exposed areas (especially in the neck region) may be caused by urticaria beetles (which belong to genus Paederus)2, common animals in the regions of North, Northeast and Center-West of Brazil, but still present all over the country (Figure 3). Cutaneous necrosis may be caused by poisonous fish (ray fish and river catfish, for example) or snakes genus Bothrops1,2, such as the species jararacas, urutus and jararacuçus in Brazil (Figure 4). Acute generalized eczematous conditions are suggestive of contact with disperse phenols in the plants of family Anacardiaceous (Figure 1).
In coastal areas, such as in Ubatuba, there is a risk of accidents similar to those of rural areas because of the increasing contact with forest areas and river courses in the region, but most accidents are still associated with the sea 1,8. We have identified large incidence of phytophotodermatitis because of tourism activities, but the most common accidents were with sea urchins. Stepped on by beachgoers, they cause initial inflammation followed by late nodular dermatitis, with presence of spicule, normally on the plantar region 1,2,9 (Figure 5). Accidents with jelly fish and cnidarians are also common and look like phytophotodermatitis, which may lead to diagnostic confusion, more probable in the non-inflammatory phase (about 24 hours after contact) 1,2,10,11 (Figure 6).
Management of these accidents varies depending on the etiology 1,2: accidents with inoculation of poison are primarily treated with anti-venom serum, but it is possible only in intoxication by snakes and spiders (all poison intoxication and some types of spiders2), given that anti-venom serum against most poisonous animals is not produced. Accidents with caterpillars, cnidarians and poisonous fish can only have symptoms relieved (caterpillars - by using analgesics and, sometimes, trunk anesthesia; cnidarians by using cool seawater and vinegar compresses; and poisonous fish using warm water immersion). Topical corticoids may be used in contact irritative dermatitis, such as in phytophotodermatitis, in dermatitis caused by beetles, in eczematous conditions of plants and in acute pruritus and tick stings. Myiasis should be extracted using pressure or instruments, which also applies to sea urchin spicules 1-7.
There are differences between the acute stages of accidents with animals and plants and the manifestations presented by patients after 24 48 hours. Initially, it is more likely that all cases of dermatitis reported here were observed by clinicians in the Emergency Department of local hospitals; however, within one or two days the likelihood of having a dermatological visit increased because all patients had cutaneous manifestations. Pain, a key element after contact with poisonous animals such as caterpillars, cnidarians, snakes and fish will not be there when the patient is seen in the private office. Therefore, cutaneous lesions may change their presentation, as we observed with ant bites, which formed pustules over the initial urticaria papules within about 24 hours. Phytophotodermatitis, which presents poor symptomatology, may become similar to contact lesions with jelly fish after 24 to 48 hours, because at that time, the latter no longer has the characteristic pain of such accidents. We should be on the watch for facts and information about the most common diseases and the knowledge about their characteristics may be useful in the clinical practice at the private office or outpatient clinic. To that end, we provide in Table 1. an algorithm table that shows the main signs and symptoms in patients who had suffered accidents with wild animals and plants (including poisonous animals) 24-48 hours after the accident, emphasizing the clinical examination and the affections that might had occurred since the initial contact at wild areas.
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Vidal Haddad Junior
Caixa Postal 557
CEP: 18618-000 - Botucatu - SP
Tel./Fax: (14) 3882-4922
Conflict of interest:
Financial funding: None
How to cite this article: Haddad Jr V. Identificação de enfermidades agudas causadas por animais e plantas em ambientes rurais e litorâneos: auxílio à prática dermatológica. An Bras Dermatol. 2009;84(4):343-8.