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International Journal of Medical Science and Innovative Research (IJMSIR) IJMSIR : A Medical Publication Hub Available Online at: www.ijmsir.com Volume – 4, Issue – 1, January - 2019, Page No. : 183 - 187

Outbreak of Insect exposed Dermatitis in Yavatmal District Dr. Anand Saraswat, Dr. Amar Surjushe Department of Dermatology, Venereology and Leprology, Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India- 445001 Corresponding Author: Dr. Amar Surjushe, Address- Dr Amar Surjushe, Rachana Skin and Cosmetic Clinic Veer Wamanrao Square Yavatmal- 445001, Type of Publication: Original Research Article Conflicts of Interest: Nil Abstract the main cause of skin allergy. Patients were treated with Background: Cotton related issues are the prime focus in oral antihistamines, topical steroid, calamine lotion and if the farmers’ suicide district of Yavatmal. Sudden required oral coticosteroids. outbreaks of skin related issues affects morbidity of the Conclusions: Insect exposed dermattitis is not uncommon farmers. We came across such skin related outbreak in our entity, but till date there are no literature found to report Department of Dermatology, Venereology and Leprosy, this entity as an epidemic in the farmer in the rural part of at Shri Vasantrao Naik Government Medical College, Maharashtra. Proper personal care, proper stoarage of Yavatmal. cotton, mass education can to some extent prevent such Aims and Objectives: To study the demography, types of epidemic in future. morphology, cause and treatment of sudden outbreak of Keywords: Outbreak, Insect, Dermatitis, Itching, Cotton, insect exposed dermatitis. Biopsy, Antihistamines, Coticosteroids Methods: Total 437 patients, who complaining of itching Introduction after exposed to cotton, were included in the study. Cotton is one of the most important economic crops Detailed history regarding exposure to cotton, other worldwide. In 2006, it was grown in 75 countries with a family members or neighbours affected were taken. A total production of 27 billion kilograms, and supplied detailed clinical examination, skin scrapping and biopsy almost 40% of the global demand for fiber [1,2]. of patients were done. Field surveys were done to assess However, India ranks third in global cotton production the cause of dermatitis. Patients were managed with after USA and China. India accounts for approximately 25 proper treatment and follow up done at regular interval. percent of world's total cotton area and 16 percent of Results: Out of total patients, 247 were male and 190 global cotton production [3]. were female. Age of the patients ranged from 5-55 years. Cotton area was on the decline in India because of The main presenting symptoms were itching to affected

frequent bollworm infestation and outbreaks. The area parts or whole body part, appearance of red spots, bumps

declined from an average of 87 lakh hectares upto 2001 to 183 or swelling. Clinical examination found that insect was a meager 78 lakh hectares in 2002 and 2003. With the Page Corresponding Author: Dr. Amar Surjushe, Volume – 4 Issue - 1, Page No. 183 - 187 Dr. Amar Surjushe, et al. International Journal of Medical Sciences and Innovative Research (IJMSIR) advent of Bt-cotton, the area increased to 121.91 lakh reported allergic reactions to Bt cotton, (Image 2), such hectares in 2011. Thus there was an additional increase of reaction are severe itching of the skin, swollen apparatus, at least 30 lakh hectares because of the introduction of Bt- white eruptions on the skin, upper respiratory problems. cotton. Bt cotton is genetically modified cotton crop that Insect exposed dermattitis is not uncommon entity, but it expresses an insecticidal protein whose gene has been has never been reported as an epidemic in the literature. derived from a soil bacterium called Bacillus We are the first to report this entity as an epidemic in the thuringiensis, commonly referred as Bt, (Image 1) [4]. Bt farmer in the rural part of Maharashtra. cotton was introduced in North India in 2005 and the Image 2: Allergic Reactions from BT Crops in yields were already high in these states. However biggest Farmers gains were made in Gujarat, Maharashtra and AP. There is a huge demand characterized by long farmer queues each year for Bt-cotton seeds of specific brands. Image 1: BT Cotton

Materials and Methods All the patients visiting Dermatology outpatient Department of SVNGMC, Yavatmal and who were attending Special camp at Ralegaon Rural Hospital, with

complaint of itching after exposed to cotton were included Maharashtra is the largest cotton growing state in the in the study. Total 437 patients were included in this country. It covers about 34% of total cotton area and study. A detailed history regarding exposure to cotton, contributes 17% of the production [srmh.pdf]. In other family members or neighbours affected were taken. Maharashtra cotton is cultivated in 27 districts out of Complete and detailed clinical examination, skin which Bt. Cotton seeds were distributed in 19 districts [3]. scrapping and Biopsy of patients were done. Field surveys Vidarbha region is considered as the major cotton- were done to assess the cause of dermatitis. Management growing region in Maharashtra state, because it covers of patients was done and patients were following up at nearly half of the area of cotton in Maharashtra. Among regular intervals. Vidarbha region Yavatmal is the main district of Results and Discussion cultivation of cotton [5]. The cotton production in In the present study, total 437 patients presented with the Yavatmal faces many constrains most important of which complaint of itching after exposed to cotton (Image 3- is the problem of insect pests. Farmworkers and mill some patients with itching) were included, out of which employes have experienced arthopod (insect) borne 247 were male and 190 were female. The age of the

urticarial/allergic reaction, bite reaction, borne papular patients were ranged from 5-55 years. urticarial and insect exposed dermatitis. Many farmers 184 184 184 184 184

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Image 3: Patients with complaint of itching after the present study were shown in table 1 with their exposed to cotton symptoms. Table 1: Infected person and symptoms Infected Persons Symptoms • Farmers and their • Itching to affected parts family members or whole body part • Cotton handling • Appearance of red spots, farmworkers bumps or swelling • Farmers who stored • Appearance of above cotton in their symptoms to other

homes or their family members or Act of Bt Cotton on Farmers' Health in Barwani and Dhar neighbors neighbors District of Madhya Pradesh, was conducted between • Labours working in October and December 2005. From this press report: Dr. ginning factory or Gurpiar Singh told that poisonous types of genes have mills been used in the Bt cotton that’s why the farmers and the A detailed clinical examination was done for all the laborers are affected most. The team further revealed, the patients to find out the causes of itching, (Image 4). toxins inside the Bt cotton seed which helps the cotton Itching occurs may be exposed to cotton, pink bollworm, plant fight the deadly American Bollworm, was the main insecticide, and insect. The clinical examination reveals reason behind the allergy. Dr Gupta said that all that the insect was the main cause of skin allergy. respondents had itching of skin, while 86 pct of them had Image 4: Clinical Examination eruptions on body and 56 pct had swelling of face where as in some cases, the itching was so severe that they had to discontinue their work, or had to work after taking anti- allergy medicine [6]. The survey resulted in a report which concluded [6]: “All the evidence gathered during the investigation shows that Bt has been causing skin, upper respiratory tract and eye allergy among persons exposed to cotton. The allergy is not restricted to farm labourers involved in Insects are arthropods of the class Insecta. Insects can be picking cotton but has affected labourers involved in distinguished from other arthropods by the presence of 3 loading and unloading Bt from villages to market, those body segments, a pair of antennae, and 6 legs [7]. It involved in its weighing, labourers working in ginning represents more than half of all known living organisms factories, people who carried out other operations in the and potentially represents more than 90% of the differing field of Bt cotton, or farmers who stored cotton in their life forms on Earth. Hence, human contact with insects is homes etc.” Similar to this report, the infected patients in unavoidable. Exposure to biting or stinging insects or to 185 185 185 185 185

Dr. Amar Surjushe, et al. International Journal of Medical Sciences and Innovative Research (IJMSIR) their remains can range in severity from benign or barely generalized reaction to an insect bite as with the bites of noticeable to life threatening [8]. sand fly, chigger bite, ticks, kissing bugs, etc., but none Insect bites and stings can be divided into two groups’ i.e. such case was reported in our study [10]. Yet many venomous and non-venomous. Non-venomous insects species inject saliva while biting. Most lesions are the (Mosquito, Flea, Tick, Bed bug, Louse, Scabies, result of the victim's immune response to these secretions. Caterpillars and moths) pierce the skin to feed on blood, Most cases are not even reported. Most does not require this usually results in intense itching. Some caterpillars hospital care as well. Most insects are minor and cause and moths have irritating hairs and sharp spines, causing only superficial puncture wounds to the skin. Papular stinging, short-lasting papular urticaria, and dermatitis. Urticaria presents with clusters or crop of itchy red The clinical features of arthropod bites and stings shows papules with / without vesiculation on top of it (urticated the allergic reaction depends on the species involved, papules). Few may have bullous lesions especially those whether it carries disease, and individual factors such as exposed to new insects. Also these eruptions may be host immunity. A venomous sting from a bee or wasp seasonal. usually causes a stinging sensation or pain with redness Image 5: Insect Exposed Dermatitis and swelling of the area. Sensitization to the venom affects response. A large localized reaction causes swelling to spread more widely over several hours. Anaphylaxis results in immediate angioedema, urticaria and bronchospasm and can be life-threatening. An insect bite presents as one or more intensely itchy papules on a body site exposed to the insect. Insect bites often arise in crops. The papule usually subsides within a few hours. It may have a central clear or haemorrhagic blister and persist for several days. Scratching results in an open sore A complication of arthropod bites includes secondary [9]. infection with staphylococci and/or streptococci Arthropod-related skin diseases have been reported in (impetigo, cellulitis), papular urticarial, persistent insect frequent travelers up to the extent of 31% of all skin bite reaction and arthropod-borne infection. Papular diagnosis and insect bite including super infected bites urticaria is hypersensitivity reaction, due to insects, abscesses, and allergic reactions account for 38% of the fleabites, and/or mosquito bites. New bites are cases [7]. However, such a co-relation was not a part of accompanied by reactivation of old ones and present as our study. Moreover, insect exposed dermattitis is the symmetrical crops of itchy urticated papules, resolves type of hypersensitivity reaction to insect bite, (Image 5) with the development of immunological tolerance. and this dermatitis needs to be differentiated from other Solitary persistent insect bite reactions can be Urticarial, dermatological conditions like atopic dermatitis, contact

Bullous, Vasculitic and Granulomatous [9]. dermatitis, impetigo, mycosis fungoides, scabies etc. There have been reports of patients developing a 186 186 186 186 186

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Generally people are aware of bites, especially if they programs. Springer Science+Business Media B.V. have observed the arthropod, but occasionally they are 2008;159–194. not. The clinical appearance is usually typical. Skin 2. Naranjo SE. Impacts of Bt transgenic cotton on biopsy is suggestive if it shows central punctum, integrated pest management. Journal of Agricultural eosinophilic spongiosis and wedge-shaped mixed dermal and Food Chemistry, 2010. DOI: 10.1021/jf102939c. infiltrate distributed around the sweat ducts/glands. 3. Performance of Bt. Cotton Cultivation in Maharashtra Mostly diagnosis is made on clinical features and history. Report of State Department of Agriculture, available The main treatment aim of insect bites is to prevent at itching and cool the affected area [9]. In the present study, http://www.envfor.nic.in/divisions/csurv/geac/srmh.p patients were treated with oral antihistamines, topical df steroid, calamine lotion and if required oral coticosteroids. 4. Kranthi KR. Bt Cotton. Indian Society for Cotton Oral antihistamine reduces itch and wheals (Mainstay of Improvement, Mumbai , 2012 treatment). The moderate potency topical steroids were 5. Khade PK. Study of Bt cotton area, trend and pricing used for papular urticaria or persistent reactions. in Yavatmal district- A project report submitted to the Conclusion Jawaharlal Nehru Krishi Vishwa Vidyalaya, Jabalpur Insect exposed dermattitis is not uncommon entity, but till (M.P.), 2007. date there are no literature found to report this entity as an 6. “INDIA: BT cotton seeds cause allergy: NGO”, 20 epidemic in the farmer in the rural part of Maharashtra. February 2006, Personal and surrounding hygiene (Garbage odours can http://www.bharattextile.com/newsitems/1998748 attract insect), proper storage of cotton, wearing of fully 7. Kar S, Dongre A, Krishnan A, Godse S, and Singh N. covering cloths, keeping windows and doors closed at Epidemiological Study of Insect Bite Reactions from night and mass education can to some extent prevent such Central India. Indian J Dermatol. 2013; 58(5): 337– types of epidemic in future. If possible, consult doctor 341. immediately, if such itching symptoms occur. 8. https://emedicine.medscape.com/article/769067- The present study suggested that there is a need to spread overview awareness in cotton growing regions about the allergic 9. https://www.dermnetnz.org/topics/arthropod-bites- characteristic of the plant so that people can identify the and-stings/ cause and take preventive measures. Also suggested to 10. Torsney PJ. Generalized reaction to insect bites. conduct a detailed investigation into the matter and take Pediatrics. 1969;4:583. necessary measures to stop the allergies eruption. References 1. Naranjo SE, Ruberson JR, Sharma HC, Wilson L, Wu K. The present and future role of insect-resistant genetically modified cotton in IPM. In: Romeis J,

Shelton AM, Kennedy GG, eds. Integration of insect- 87 resistant genetically modified crops within IPM 187 187 1 187 187 187