Outbreak of dermatitis linearis caused by Paederus ilsae and Paederus iliensis (coleoptera: staphylinidae) at a military base in Iraq.Introduction
Several families of beetles have the ability to secrete vesicating chemicals. The presumed significance of these chemicals is that they deter predators, and, when passed along to the eggs, improve the likelihood of successful reproduction. (1,2) From a medical standpoint, the vesicating chemicals can injure human skin. From a public health standpoint, some of the beetles swarm during certain seasons and the large numbers of beetles pose a considerable public health threat.
The beetle families with the greatest impact on humans are Meloidae (blister beetles), Oedemeridae (false blister beetles), and Staphylinidae (rove beetles). Although many people use the term "blister beetle" to describe any beetle with vesicating properties, in this article that term will be applied strictly to Meloid beetles. Blister beetles and false blister beetles are medically important because they produce the chemical cantharidin that causes skin blistering. There are approximately 2,500 species within the family Meloidae worldwide, and all produce cantharidin. (3) There are approximately 1,000 species within the family Oedemeridae, but only a few species in the Pacific basin and Caribbean are known to produce cantharidin. (4,5) Cantharidin is synthesized by male beetles and passed to females during mating. (2) It is contained in the hemolymph and is exuded by reflexive bleeding from leg joints of adult beetles as a defensive mechanism or in response to external pressure, such as a person rubbing a beetle against the skin. It is a potent vesicant and causes blisters within 24 hours of skin contact. If a blister beetle is ingested, the consumed cantharidin causes severe irritation of the gastrointestinal tract and inflammation of the kidneys. (6) Cantharidin poses a special hazard for horses which can die after eating Meloid contaminated hay. (7,8) Soldiers may encounter these beetles when working outdoors. Indeed, there are numerous examples of cantharidin affecting military operations. A large number of French Legionnaires were hospitalized in Algeria for cantharidin poisoning after eating frogs that had ingested Meloids, (9) and Oedemerids have caused blistering among troops in New Zealand. (10)
The genus Paederus (Staphylinidae) contains more than 600 members with species occurring in all temperate and tropical continents, north and south of the equator. (11) Most species are slender, about 7 mm to 13 mm long, and are distinctly colored with black heads, orange bodies, black abdominal tips, and metallic blue or green elytra (Figure 1). One or a combination of the vesicating chemicals pederin, pseudopederin, and pederone have been found in 20 species of Paederus (12) Pederin is the most common chemical of the three and is one of the most complex nonproteinaceous insect secretions known. (12) It acts at the cellular level by blocking mitosis and is produced by endosymbiotic bacteria within beetles. (13) Females that are "infected" with these symbiotic bacteria produce eggs that contain the bacteria in the outer shell walls. Subsequent generations of beetles acquire the symbiotes necessary to produce pederin by ingesting eggs shells "infected" by the symbiotic bacteria or by cannibalizing larvae containing the bacteria. (14) Not all Paederus contain endosymbiotic bacteria and uninfected beetles do not produce pederin. Outbreaks often contain mixed populations of infected and noninfected Paederus. (15)
Paederus beetles do not release pederin as a defensive secretion and people are exposed to the chemical only when a beetle is accidentally crushed on the skin. (12) Therefore, skin blistering most often occurs on exposed skin of body parts such as the neck, head, arms, and legs where a beetle is felt crawling on the skin and subsequently crushed (Figure 2). Mirror-image lesions, commonly called "kissing" lesions, may form when uncontaminated skin is pressed against an opposite area of pederin contaminated skin. Pederin is sometimes transferred to other sensitive areas of the body such as the eyes or genitals by pederin-contaminated hands. Ocular and periocular lesions caused by accidentally rubbing pederin into the conjunctivae and eyelids are commonly known as "Nairobi eye" in east Africa. (16)
[FIGURE 2 OMITTED]
The skin condition in humans that is caused by vesicating chemicals from Paederus is called dermatitis linearis. (17) This eruption usually begins 24 to 72 hours after pederin contacts exposed human skin. Initially, affected areas turn red and then vesicles form a few days later. These vesicles typically coalesce into bullae that last for one or 2 weeks and eventually crust over, dry, and peel off, leaving red marks that can last for months. (6) The lesions are often very uncomfortable and may itch or burn severely. (18) In rare cases, contact with pederin can cause fever, headache, joint pain, and vomiting. (17)
[FIGURE 1 OMITTED]
Dermatitis caused by cantharidin is generally less symptomatic than that caused by pederin because cantharidin blisters do not cause as intense burning or itching. Cantharidin signs and symptoms usually begin within 12 to 24 hours, which is sooner than pederin's effects. (18) Another difference is that victims usually remember coming into contact with Meloid or Oedemerid beetles because of their large size (Figure 3). Many victims are not aware that Paederus were ever crushed on their skin because of their small size and the delayed onset of blistering.
An additional militarily-relevant concern with Paederus is that blisters can easily be mistaken for the effects of chemical weapons. Some authors regard pederin as a natural mimic of vesicating warfare agents such as mustard and Lewisite. (19) When adult beetles are active, a large number of individuals may be affected, which could lead to the false assumption that a chemical agent was used. In 1997, during a training exercise in Arizona, several Marines developed blisters, probably caused by Paederus, but believed they had been exposed to chemical weapons. (20)
In the tropics, outbreaks of dermatitis linearis are more common among western expatriates than among indigenous populations because the westerners typically use more lights at night, which then attract Paederus. (18) Similarly, outbreaks of dermatitis linearis that have affected military operations often involve the creation of well-illuminated camps in Paederus endemic areas. Outbreaks have occurred among British troops conducting operations in northern Kenya, (16) Canadian forces serving in the Central African Republic and in Sierra Leone, (21) and the Indian military during a training exercise in northern India. (22)
Dermatitis linearis was recently observed among US military members serving in central and southwest Asia. From December 2001 to March 2002, 191 cases of dermatitis linearis were observed among military personnel serving at a remote military base in Pakistan. (23) Most of the affected individuals worked near artificial lights at night. In May 2002, more than 30 cases of dermatitis linearis were observed among Special Operations Forces serving in Afghanistan. (24) The majority of affected Soldiers were night shift maintenance personnel.
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There are few reports of Paederus species collected in Iraq. Paederus mesopotamicus (Eppelsheim) was described near Baghdad in 1889. (25) Paederus fuscipes (Curtis) and Paederus ilsae (Bernhauer) were included among a list of Iraqi insects published in 1965. (26) P ilsae has been found in cotton and clover fields near the city of Mosul in northern Iraq. (27) The first report of dermatitis linearis occurring in Iraq was recently published by an Iraqi doctor. (28) His report described 87 cases among Iraqi civilians that were treated at a hospital in the Najaf province of southern Iraq from April 2006 to April 2007, with the majority of cases occurring in May and June. The Iraqi doctor noted that dermatitis linearis has been a well known skin disease in the area for several years.
This article describes Paederus activity that occurred in 2007 at Joint Base Balad in Iraq. Although dermatitis linearis in Iraq is not limited to Joint Base Balad, it is the only location where the species of Paederus causing dermatitis linearis was identified. Information presented here can be used to help prevent and identify future outbreaks at other locations.
Materials and Methods
Joint Base Balad is approximately 110 km north of Baghdad in north central Iraq (Figure 4). The base is surrounded by agricultural areas that are supplied with water from the Tigris River through an extensive system of canals. There are no large urban areas in close proximity to the base.
In early May 2007, information was presented at a Multi-National Corps-Iraq Surgeon's Conference held in Baghdad about the possibility of vesicating beetles causing dermatitis in Iraq. Several military dermatologists had observed cases over the previous 4 years that they suspected might have been caused by beetles. At that time, no Meloid blister beetles or Paederus beetles had been collected and linked to cases of dermatitis occurring among Soldiers in Iraq. Based on the information presented at the Surgeon's Conference in Baghdad, a short presentation about vesicating beetles was made at a monthly Preventive Medicine Forum hosted at Joint Base Balad by the 133rd Medical Detachment on May 31, 2007. Within 24 hours, the 133rd Medical Detachment was contacted by medical personnel from 2 separate medical treatment facilities on base stating that they had recently treated Soldiers and Airmen with blisters that matched the clinical signs and locations on the body associated with vesicating beetles. One medical provider noted that he assumed he was treating classical burns since his patients were mechanics and may have accidentally came into contact with hot vehicle parts or had hot fluids drip on their skin while working.
A survey was conducted on June 2, 2007, at a site where 5 Airmen worked and who had sought treatment for blisters on their necks the previous week. Sampling during the day at this site did not identify any beetles, however, 2 Paederus beetles were found the next morning on cockroach sticky traps that were placed overnight in the area. These beetles were sent for identification to Dr Howard Frank, an entomologist at the University of Florida who is a leading authority on Paederus, along with other specimens collected later during the summer.
During the following week, sampling for Paederus was conducted throughout the base and was focused around bodies of water because many species of Paederus are known to live in wet places, such as the edges of lakes, marshes, and floodplains. (12) Visual searches for beetles were conducted among plants and rocks surrounding retention ponds and other areas with standing water on base. Also dozens of cockroach sticky traps were placed around the edges of bodies of water.
Starting on June 6, 2007, sampling was conducted near portable light towers because many of the Soldiers and Airmen who developed blisters worked near bright lights at night. More than 100 generator-powered portable light towers were located throughout the base. Portable light towers were set at heights from 6 m to 9 m and had 1,000 watt metal halide lamps. White plastic dinner plates 26 cm in diameter were placed on the ground under the towers. The plates were filled with water and 3 to 4 drops of commercial dishwashing soap were added to each plate to break the surface tension. The plates were collected the following morning and the beetles counted.
Sampling was conducted each night from June 6 through June 9, 2007, at 20 light towers located throughout the base. After June 10 only light towers near the perimeter were used and sampling was conducted 3 times a week until the end of October 2007. An index for nightly beetle activity was determined by dividing the total number of beetles caught per night by the number of plates set out.
Sampling was conducted for 3 nights during the week of June 10 to June 16, 2007, to determine how proximity to the light source affected the number of beetles captured. On each night, 5 light towers were selected and 3 plates were placed at each light tower at fixed distances. One plate was placed directly underneath the light source, another at 2 meters, and a third 6 meters away.
Sampling was conducted on June 5 and June 20, 2007, to determine what times of the night beetles were actively flying. A particular light tower near the base's perimeter was selected based on high beetle collection counts during previous sampling periods. A white bed sheet was spread on the ground and visually observed from dusk and throughout the night. The observers counted beetles that actually landed on the sheet and recorded these tallies in one hour increments.
There were many questions asked by Soldiers and medical personnel as to whether permethrin treated uniforms would function to repel Paederus. To answer their questions, 10 live beetles were collected on the night of June 20, 2007, and placed in clean Petri dishes that were kept inside an air conditioned building until the following day. Three of the beetles were individually placed on an Army Combat Uniform field jacket that was treated with permethrin 2 weeks earlier with an Individual Dynamic Application Absorption Kit. The beetles were left on the jacket for 15 minutes, their activity was recorded, and then they were placed back into Petri dishes and monitored until they died.
Results and Discussion
Twenty Soldiers and Airmen sought treatment at Joint Base Balad in 2007 for symptoms related to dermatitis linearis. It is possible that more individuals were affected but did not seek medical treatment. All cases occurred between late April and early June 2007. The most commonly affected body region was the neck followed by the hands and forearms (Table 1). The neck was the most affected region because it is one of the few exposed areas of skin when a Soldier is wearing a uniform. The hands were less commonly affected although they were probably involved with crushing beetles on the neck. The thick epidermis of the palms often prevents lesions from forming even when a beetle is crushed. (12) There were no reports of conjunctivitis caused by pederin contacting the eye. There was one case where a "kissing" lesion formed on a Soldier's neck and another Soldier developed a blister near the waistline which most likely occurred when a beetle fell down into his shirt and was crushed against his body.
The beetles collected at Joint Base Balad were identified by Dr Frank as Paederus (Heteropaederus) iliensis (Coiffait) and Paederus (Dioncopaederus) ilsae (Bernhauer). Paederus ilsae has been identified in 2 previous collections from Iraq. (26,27) This is the first known report of P iliensis occurring in Iraq. However, it is possible that this species was misidentified as another species in earlier studies. A report from 1965 listed P fuscipes in Iraq. (26) P fuscipes is closely related to P iliensis, and since P iliensis was not described until 1970, (29) it is possible that the earlier described P fuscipes was actually P iliensis. Both of the identified species are known in other countries to cause blister dermatitis. P ilsae has been identified as causing dermatitis in Israel (30) and P ilsae and P iliensis in southern Iran. (31,32)
The severity of dermatitis and amount of pederin contained by each species was not determined in this study. In Iran, P ilsae is known to cause more severe and longer lasting dermatitis than P iliensis. (31) In southern Iran, P ilsae was also more abundant than P iliensis. (32) In 2007, P iliensis was the most common species collected at Joint Base Balad. On the nights of 24 July and 25 July, 269 P iliensis and 9 P ilsae were collected, for a ratio of 30:1.
The period when beetles initially became active was not determined because surveillance did not begin until early June when cases of dermatitis were being noticed. Sampling showed that beetles became less active in mid-July and the last beetle was collected on October 8, 2007 (Figure 5). Since all cases of dermatitis occurred between late April and early June, beetle activity might have been greater during those months. Paederus activity at Joint Base Balad was consistent with previous reports showing that P ilsae and P iliensis were most active in the spring and early summer. P ilsae adults have been collected in northern Iraq in early June (27) and in Israel from May to July. (30) P ilsae and P iliensis were found in southern Iran from late April to early September. (31) Even though the species of Paederus were not identified, dermatitis linearis occurred in the Najaf province of Iraq from April to August with a peak incidence in May. (28)
There were no obvious peaks during sampling that indicated distinct generations of beetle emergence. Paederus beetles have one to 3 generations per year with more generations occurring in the tropics. (12) P ilsae is thought to have 2 generations per year in Iran. (32) A late start of sampling and overlap of generations may have masked generation peaks.
Flight activity by Paederus is often considered to follow rain showers or the rainy season. (12) Beetles most likely fly after rain showers because the higher humidity helps the beetle avoid becoming desiccated during dispersal flights. (12) Cases of dermatitis in southern Iraq have been attributed to beetles beginning to fly after the rainy season ends in late March or early April. (28) At Joint Base Balad in 2007, there was no significant rainfall that immediately preceded beetle activity. However, it is possible that extensive irrigation in the area could have created conditions favorable for beetle flight.
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During the night time sampling, observers first noticed beetles flying one hour after sunset (Figure 6). Beetle activity peaked before midnight and did not continue throughout the night. Reports from Israel indicated that P ilsae actively flies after sunset when the sky is completely dark. (30)
Beetles were most commonly collected directly beneath light sources. Placing plastic plates filled with water at fixed distances from light towers showed that significantly more beetles were found directly under lights than at distances only a few meters away (Table 2). Beetles were observed to have a positive phototaxis whether flying or running. Flying beetles fell to the ground as they approached a light source. Once beetles were on the ground, they moved rapidly to the spot of greatest illumination directly below the light source. This strong attraction to light greatly influences which individuals come into contact with the beetles. Many of the Soldiers who developed dermatitis were mechanics who worked at night on vehicles and other equipment that were directly illuminated by overhead light sources. Security guards were also commonly affected, especially those who had placed ultraviolet electrocution devices (Bug Zappers[R]) near their guard posts. In contrast, other Soldiers who worked at the same time, but not directly under a light source, were not affected.
The following 3 conditions are most often associated with outbreaks of dermatitis linearis (18):
* People working in agricultural areas where beetles are active
* Beetles entering a building where people are working or sleeping
* People working at night in illuminated areas.
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It appeared that all cases in 2007 at Joint Base Balad resulted from Soldiers working under lights at night. Mass aggregations of beetles were never observed inside buildings as sometimes happens during outbreaks. Sometimes Paederus can be so numerous inside buildings that white walls appear black. (33)
Observed Paederus spp were most likely flying in from fields surrounding the base and were not found breeding around bodies of water on the base. On base, live beetles were found only near light sources at night. Dead beetles were found during the day under rocks or concrete barriers close to light towers. Another indication that beetles were flying onto the base was that they were more common near the perimeter of the base compared to the interior. The majority of Soldiers who developed dermatitis worked or lived near the base perimeter.
Joint Base Balad is an ideal environment for attracting Paederus because it has a large quantity of bright lights in a rural area with few competing light sources. It is unclear how common dermatitis linearis is among the communities surrounding the base. In southern Iraq, dermatitis linearis is commonly called phosphorous insect rash due to the beetles' attraction to fluorescent lights. (28)
To answer Soldiers' questions as to whether permethrin-treated uniforms repelled Paederus, 3 P iliensis were placed on a permethrin treated field jacket (Figure 7). The beetles showed no obvious aversion to being on the jacket and moved to concealed places, such as under the collar, where they remained until removed. We do not know if permethrin-treated uniforms will effectively cause beetles to quickly fly or drop off after they have landed on a Soldier. Nevertheless, we noticed that when a small sample of 3 beetles were placed on the treated uniform, they died sooner than the other beetles, ie, 2 to 3 days sooner, while the other beetles lived from 5 to 12 days in their Petri dishes. It is possible that the exposure to permethrin caused them to die sooner after being placed on the uniform. The efficacy of N,N-diethyl-3-methylbenzamide (deet) was not evaluated, although it might be useful, since it repels other types of beetles. (34) More studies are needed to determine if permethrin and deet repel Paederus.
Paederus beetles are highly susceptible to insecticides and there are many reports of controlling outbreaks with insecticides. (12) Most reports describe situations where Paederus enter buildings or form large aggregations and are clearly visible crawling on the walls. Permethrin was applied with an ultralow volume sprayer to control Paederus in a US military fitness center in Pakistan. (23) However, it does not seem practical to use insecticides to control Paederus in situations where they are attracted to lights and fly in from unknown distances away. The area that would need to be treated is too large and the sites where the beetles are breeding are often unknown.
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The best strategy to prevent outbreaks of dermatitis linearis when Paederus are flying into an area based on their attraction to light is to modify the attracting light sources. Staphylinid beetles are attracted to ultraviolet and white light, but are relatively insensitive to orange and yellow light. (35) An outbreak of dermatitis linearis at a game reserve in Tanzania was quickly halted after all mercury tube lights, which emit ultraviolet light, were replaced by incandescent light bulbs, which emit mainly yellow and orange light. (36) If possible, switch to sodium vapor and halogen lights because they emit only orange and yellow light and are therefore the least attractive to flying insects. (37) Another method of prevention would be to remove unnecessary lights from an area to reduce the number of beetles attracted. At Joint Base Balad in 2007, Paederus were a problem at guard posts where ultraviolet insect electrocution devices were used but ceased to be a problem when those devices were removed. Rest and work areas can be relocated farther away from bright lights. There were several cases of dermatitis linearis among a group of night-shift mechanics who took smoke breaks at a table located directly under a light tower, but new cases of dermatitis ceased once the table was moved.
Sampling for Paederus was performed by placing water-filled plastic plates under light towers near the perimeter of base. This sampling method was efficient because it collected a large number of beetles, did not require special equipment, and was easily implemented by preventive medicine personnel during their routine mosquito and sand fly surveillance. Using light towers or other bright lights to determine if Paederus are present would be worthwhile at other locations because outbreaks are often unpredictable. When large outbreaks do occur, they can have a major impact on public health. In 1966, more than 2,000 patients sought treatment for dermatitis linearis at a US Army hospital in Okinawa, (38) and outbreaks among Australian aboriginal communities have forced the evacuation of entire villages. (39) Early detection of Paederus through sampling will allow implementation of preventive measures to lessen the effects of an outbreak. Notification of medical personnel of the presence of Paederus enables prompt education on diagnosis and management of cases of dermatitis and averts or dispels needless concern that chemical weapons have been released. (19) Information from entomologic surveillance can help educate Soldiers about the time periods when beetles are active and what to do if they work in an area infested with Paederus. Soldiers should be instructed to try to avoid crushing any insects crawling on their skin, and if a Paederus beetle is crushed, to immediately wash the area with soap and water to prevent skin blistering. (12)
We thank Dr Howard Frank at the University of Florida's Department of Entomology and Nematology for identifying Paederus specimens and his suggestions of methods for beetle collection.
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CPT Davidson is an instructor and course writer at the Medical Zoology Branch in the Department of Preventive Health Services, Academy of Health Sciences, US Army Medical Department Center and School, Fort Sam Houston, Texas.
COL (Ret) Norton, is an Associate Professor, Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
LTC Carder is an instructor and course writer at the Medical Zoology Branch in the Department of Preventive Health Services, Academy of Health Sciences, US Army Medical Department Center and School, Fort Sam Houston, Texas.
COL Debboun is Director, Center for Health Education and Training, Academy of Health Sciences, US Army Medical Department Center & School, Fort Sam Houston, Texas.
CPT Silas A. Davidson, MS, USA COL (Ret) Scott A. Norton, MC, USA LTC Mark C. Carder, MS, USA COL Mustapha Debboun, MS, USA
Table 1. Most commonly affected body regions among 20 individuals at Joint Base Balad in 2007. Note: total percentage is greater than 100 because some patients had more than one region affected. Affected Body Region Number % Face 1 5 Neck 14 67 Torso 1 5 Arm and forearm 2 10 Hand 6 28 Total 24 115 Table 2. Paederus spp collections at different distances from a light source at Joint Base Balad in 2007. Distance from Da Light Source 10 June 12 June 0 meters 35.8 [+ or -] 15.6 27.8 [+ or -] 15.4 2 meters 1.8 [+ or -] 1.5 2.2 [+ or -] 1.9 6 meters 0.2 [+ or -] 0.4 0.4 [+ or -] 0.9 Distance from e Light Source 16 June Average 0 meters 44 [+ or -] 21.7 35.9 [+ or -] 17.6 2 meters 3 [+ or -] 2.3 2.3 [+ or -] 1.9 6 meters 0.2 [+ or -] 0.4 0.3 [+ or -] 0.6