Report

An outbreak of paederus dermatitis in a suburban hospital in

Sri Lanka
Satheeka D. Kamaladasa, MBBS, MD, W.D.H. Perera MBBS, FRCP, and L. Weeratunge

From the Department of Dermatology, Abstract

Colombo North Teaching Hospital,
Ragama, and the National Museum,
Sri Lanka
Correspondence
W.D.H. Perera, MBBS, FRCP
Department of Dermatology
Colombo North Teaching Hospital
Ragama, Sri Lanka
Background In a modern hospital built recently in Sri Lanka the staff members on night
shifts and some patients in the open wards were known to be affected by an acute
vesicating dermatitis. The study was carried out to identify the cause of the dermatitis and
recommend preventive measures. • ..•
Methods Members of the hospital staff and patients who developed an acute vesicating
dermatitis over a period of 2 years were studied using a questionnaire. The clinical features,
relationship to night shifts and the month of occurrence were noted. Insects were caught at
night on several occasions and identified. Lesions were reproduced in volunteers.
Results Out of a total of 124 patients studied, 108 were members of the hospital staff
and it was noted that they had all been on night shifts within 2 days prior to the onset of
the lesions. The insect caught belongs to class Coleoptera, family Staphylinidae, genus
Paederus, and species fuscipes. The incidence was seasonal with clustering of cases
seen to occur twice a year. • • '
Conclusions This is an outbreak of dermatitis due to Paederus fuscipes. Awareness of
the condition and its clinical features will prevent misdiagnosis and the simple preventive
measures suggested are based on the behavioral pattern of this nocturnal beetle.

Beetles belonging to the genus Paederus and causing an
acute vesicating dermatitis have been reported from many
parts of the world.' The vesicant paederin is released from
the hemolymph when the beetles are crushed. These beetles
live in damp, moist areas and are attracted to artificial
light. ^ The study was carried out in a large modern iooo-
bed hospital, situated away from the city of Colombo and
surrounded by rice fields and coconut plantations. Since
the inception of this hospital, the staff members on night
shifts and the patients in open wards were known to be
affected by an acute vesicating dermatitis without an
identifiable cause. This study was carried out to identify
the cause of the dermatitis, to record the clinical and
histological features and to recommend preventive meas-
ures. This is the first report of an outbreak of paederus
dermatitis in Sri lanka.
Patients and methods
Members of the staff of this hospital and in-patients who
developed an acute vesicating dermatitis during a 2-year period
were studied. The details of the skin lesions, the constitutional
symptoms, the duration, the months of occurrence and the time
relationship to night shifts were recorded with the use of a
34 qusstionnaire.
Insects were caught at night on several occasions by using a
net tied under the fluorescent lights. The insects were identified
and lesions were reproduced in volunteers by using the body
fluid of the insect. Skin biopsies were carried out in some of the
patients. ' ' '' ' ' '
Results •'•'
Out of a total of 124 cases there were jz nurses, 25
ancillary staff, 11 doctors of the junior grades (interns and
senior house officers) and 16 ward patients. Symptoms and
signs and their frequency are shown in Table i.
Acute lesions lasted for 3-7 days and the exposed areas
were mainly involved (Figs 1,2): face and neck, 84%; limbs,
26%; periorbital area, 7%; and trunk, 5%. A seasonal
incidence was noted with cases being clustered in the
months of December and January (22 in the first year and
24 in the second) and May, June and July (37 in the first
year and 41 in the second). The members of staff who
were affected had all been on night shifts within 2 days
prior to the development of the lesions. The patients
affected were all in the open wards and not in enclosed
areas like the intensive care units.
The insect belongs to class Coleoptera, family Stapbylini-
dae, genus Paederus, and species fuscipes (Fig. 3). The

© 1997 Blackwell Science Lid

Kamaladasa. Perera, and Weeratunge Paederus dermatitis in Sri Lanka Report 35

Table 1 Symptoms and signs and their frequency " insects measure about 10 mm in length and can be identified
by tbeir dull red coloured thorax and abdomen and dark
Severe pain and burning sensation 82% brown antennae. Skin lesions were reproduced on volun-
Erythema, swelling and itching 90%
teers by applying minor quantities of the body fluid of the
Blistering 80%
Kissing ulcers ii% insect (Fig. 4). Histology of the skin lesions showed massive
Drip marks 18% necrosis of the epidermis extending to the dermis; cellular
Fever with constitutional symptoms 8% and nuclear debris were seen and the inflammatory cell
Pigmentation 68% infiltrate was minimal. The findings were compatible with
Regional lympadenopathy 6%
direct toxic damage to the skin.

Discussion
Outbreaks of vesicating dermatitis of this nature due to
Paederus fuscipes have been previously reported from other
parts of the world.' It is commonly believed that a red or
an orange belly in an insect is a warning signal and therefore
such an insect should be avoided.
These insects breed in damp soil and become active after
heavy rains. The rice fields surrounding the hospital are an
ideal breeding ground and the seasonal incidence of this
dermatitis coincides with the rainy season of the area. At
night the insects are attracted to the artificial lights. In our

Figure 1 Linear marks due to accidental rubbing of insect

fluid - ' '
Figure 2 A linear lesion with a drip mark

Figure 3 Paederus fuscipes

International Journal of Dermatology 1997, 36, 34-36

36 Report Paederus dermatitis in Sri Lanka
Figure 4 Lesion reproduced in a volunteer
Figure 5 "Kissing" lesion
study people were affected who worked or slept under the
lights in the open wards. It was noted that ward nurses
and senior medical staff who work mostly during the day
were not affected. The vesicant paederin is released when
the insect is accidently crushed on the skin due to the reflex
of brushing away of the insect. The dermatitis tends to
occur after an incubation period of i8-Z4 h.
The clinical appearance of this vesicating dermatitis may
sometimes be confused with the following conditions: liquid
burns, herpes simplex, herpes zoster, periorbital cellulitis,
and acute allergic contact dermatitis. Linear lesions due to
accidental rubbing of the body fluid, kissing ulcers (Fig. 5),
drip marks, and blisters associated with burning pain are
Kamaiadasa, Perera, and Weeratunge
Figure 6 Protective net
typical of paederus dermatitis. In a few cases (8%) the
lesions were severe with constitutional symptoms and
kept the affected person away from work for 5-7 days.
Pigmentation which lasted up to 2. years in some cases was
a definite cosmetic problem, especially to the young nurses.
Few simple measures can be carried out to prevent these
outbreaks of dermatitis. Closing the windows of the wards
before switching the lights on and reducing the number of
burning lights will prevent the insects getting into the
wards. A net or a mesh can be tied under these lights to
prevent the beetles dropping on to humans (Fig. 6). In
the study presented here the above simple measures will
eradicate or minimize this recurring and annoying derma-
titis which has plagued the staff and patients of the hospital
for the past 8 years.
Acknowledgments
The Director of the Sri Jayawardanapura General Hospital,
Kotte, Sri Lanka, permitted us to carry out this study. Dr
A. Saparamadu, Consultant Pathologist, General Hospital,
Ragama, and Mr R. Subasinghe, Senior Lecturer, Depart-
ment of Zoology, University of Colombo, contributed to
this study.
References
1 Rook A, Wilkinson DS, Ebling FTGE. Diseases caused
hy arthropods and other noxious animals. In: Champion
RH, Burton JL, Ebling ETGE, eds. Textbook of
Dermatology. London: Blackwell Scientific, 1992: 12.90.
2 Cameron M. Coleoptera Staphylinidae. The Eauna of
British India including Ceylon and Burma, Vol. z.
London: Taylor and Francis, Fehruary, 1931.
3 Armstrong RK, WinHeld JL. Staphylinidae dermatitis in
Okinawa. /. Med Entotttol 1968; 5: 36Z.
International Journai of Dermatology 1997, 36, 34-36