Case Report

Lepidopterism: A report from South India

S Daniel Sundar Singh1, Mohamed Thayub2, Sreeja Nyayakar3, Minu Kurian Joseph3 From 1Assistant Professor, Department of Pharmacy Practice, C. L. Baid Metha College of Pharmacy, Chennai, 2Clinical Pharmacist, Department of Clinical Pharmacy, Christian Medical College, Vellore, Tamil Nadu, 3Assistant Professor, Department of Pharmacy Practice, Hillside College of Pharmacy, Bengaluru, Karnataka, India

ABSTRACT Lepidopterism is a term that refers to a spectrum of medical conditions in humans that usually involve the skin and result from worm- like contact with an adult or larval form of specific butterflies and moths. Lepidopterism is isolated but certain people may be more prone to exposure to moths. Caterpillar’s sting is not an everyday diagnosis; however, the physician should be alert and make awareness regarding caterpillar envenomation. Herein, we present the case of a 31-year-old man who presented to the hospital with a history of a caterpillar’s sting associated with unilateral rashes and prickly sensation on his left thigh and lower extremity. On examination, his vitals were stable and he does not develop systemic manifestations or anaphylaxis. In view of his present compliance, he was successfully managed with antihistamines and steroids. This case is being presented not only as the event is rare but also to create awareness and it will help the clinicians to manage the case appropriately.

Key words: Caterpillar, Cutaneous reaction, Eupterote mollifera, Lepidopterism, Rashes

uman contact with caterpillars, adult forms of different extremity. He had no history of hypertension, diabetes mellitus, families of moths, or butterflies can be associated or any other chronic diseases. The man was otherwise healthy Hwith greater significance in morbidity. Manifestations and had no history of known drug allergy or adverse reaction to vary from urticarial dermatitis, atopic asthma to consumption insect bites. coagulopathy, and renal failure [1]. Lepidopterism or caterpillar On arrival to the hospital, he had urticarial lesions on his left dermatitis refers to the group of dermatological manifestations thigh and lower extremity. The vitals were found to be stable and allergic reactions in humans that result from contact with and there was no evidence of angioedema. No evidence of hair an adult or larval forms of certain butterflies and moths [2,3]. or spine was found on the site of exposure and its surroundings. Herein, we present the case of a 31-year-old man who presented He also reported that the rash continued to spread while he to the hospital with a history of a caterpillar’s sting associated was being assessed. During the assessment, he was conscious, with unilateral rashes and prickly sensation on his left thigh and oriented, and does not have slurring of speech. He did not lower extremity. develop any systemic manifestations or anaphylaxis. Chest auscultation revealed clear lungs with no wheezing or rhonchi CASE REPORT and had regular rhythm. In view of his present symptoms, he was given 50 mg A 31-year-old male presented to the Toxicology and Occupational diphenhydramine intramuscularly and administered 10 mg of Health Unit with 30 min history of unilateral rashes and prickly dexamethasone. He was monitored closely under nursing care sensation on his left thigh to the lower extremity. The man gives for 3 h after which the lesions had become smaller and his a history that he was stung by a hairy caterpillar (Eupterote prickly sensation was completely resolved. He was discharged mollifera) on his left thigh while plucking drumstick from a with an oral diphenhydramine every 6 h for 24 h for 3 days. Moringa tree (Moringa oleifera). Immediately after the sting The next day, he did not complain of rashes and a prickling event, widespread rashes developed over his left thigh to the lower sensation. All the red erythematous lesions were disappeared completely. Medications were subsequently stopped and the

Access this article online patient was discharged. Received - 18 February 2021 Quick Response code Initial Review - 05 March 2021 Accepted - 13 March 2021 Correspondence to: Dr. S Daniel Sundar Singh, 194/1, “Pullanai,” Indira Nagar, Rendadi Road, Thagarakuppam, Kondakuppam (Post), Melpadi (Via), Vellore - 632 520, Tamil Nadu, India. E-mail: [email protected]

DOI: 10.32677/IJCR.2021.v07.i03.010 © 2021 Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC-ND 4.0).

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“tram-track” pattern of hemorrhagic papules, which is sometimes helpful to diagnose Megalopyge stings [9]. Rarely, lepidopterism cases may be severe enough for the patient to present with systemic symptoms, including anaphylactic shock. One case report documented life-threatening facial edema caused by a pine caterpillar in a 15-month-old child [10]. This patient was treated according to the standard guidelines. Our patient was successfully treated with diphenhydramine. Diphenhydramine affects urticaria by blocking histamine Type 1 and inhibiting vasodilation. Dexamethasone was used due to the inhibition of mitosis and the cytotoxic effect on cells of lymphocytic origin. If the patient presents with systematic toxicity or anaphylactic shock, they should receive therapy according to the standardized treatment algorithms. In addition to this, proper Figure 1: Hairy caterpillar (Eupterote mollifera) supportive management such as supplemental oxygen, anti- histamines, beta-agonist inhalers, or nebulizer treatment can DISCUSSION control respiratory presentations and significantly improve better therapeutic outcomes. Allergic reactions associated with the caterpillar are due to the tiny hairs (setae) or spines present on the caterpillar’s body. CONCLUSION Some of these caterpillars contain toxins and can actually cause poisoning. We presented a case of lepidopterism where the In a clinical setting, when encountering acute cutaneous reactions, patient’s guardian has brought the specimen of caterpillar that it is important to get a complete history from patients or patient’s caused the skin rashes. guardians to make a clear diagnosis. The physician should educate Caterpillars are the larval forms of butterflies and moths of the the patients to be alert while visiting these places, especially in insect order Lepidoptera [4]. There are more than 165,000 species the summer months. During contact with the hair or spines of of insects but only 12 species are known to be harmful to humans these insects, prompt bathing and washing the area with soap and causing dermatological problems [5]. Lepidoptera (moths and water must be performed to avoid the further ensuing cutaneous butterflies) is the second-largest order in the class Insecta. Nearly, reactions. all lepidopteron larvae are called caterpillars. They have a well- developed head with chewing mouthparts. In addition to the three ACKNOWLEDGMENT pairs of legs on the thorax, they have two to eight pairs of fleshy abdominal prolegs that are structurally different from the thoracic The author would like to thank all the colleagues for the legs. Most lepidopteron larvae are herbivores; some species support. eat foliage, some burrow into stems or roots, and some are leaf miners (Fig. 1) [6]. REFERENCES Caterpillar’s sting is not an everyday diagnosis. Certain people especially of rural areas such as farm workers, people 1. Diaz J. The evolving global epidemiology, syndromic classification, visiting to park or jungle are more prone to exposure with management, and prevention of caterpillar envenoming. Am J Trop Med Hyg 2005;72:347-57. moths [7,8]. Although the diagnosis is clear, other differential 2. Lee D, Pitetti RD, Casselbrant ML. Oropharyngeal manifestations of diagnosis should be taken into consideration in such cases. lepidopterism. Arch Otolaryngol Head Neck Surg 1999;25:50-2. Differential diagnosis includes strophulus infantum, insect or 3. Benaim-Pinto C, Pernía-Rosales B, Rojas-Peralta R. 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Description of envenomation by the “gusano-pollo” caterpillar (Megalopyge opercularis) In general, the clinical presentation of lepidopterism varies in Venezuela. Invest Clin 2010;51:127-32. from species to species. Common symptoms include intense pain 6. General Entomology. Lepidoptera. Available from: https://www.projects. minutes after the sting, vomiting, nausea, and abdominal pain. The ncsu.edu/cals/course/ent425/library/compendium/lepidoptera.html. [Last accessed on 2021 Mar 05]. main clinical manifestation is the erythematous maculopapular 7. Available from: https://www.cabi.org/isc/datasheet/21610#tonaturalenemies. rashes that can last up to 5 days. There is a description of a classic [Last accessed on 2021 Mar 08].

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8. Vega J, Vega JM, Moneo I, Armentia A, Caballero ML, Miranda A. Saturniidae), the causative agent of caripito itch. Int J Dermatol Occupational immunologic contact urticaria from pine processionary 2011;50:535-41. caterpillar (Thaumetopoea pityocampa): Experience in 30 cases. Contact Dermatitis 2004;50:60-4. Funding: None; Conflicts of Interest: None Stated. 9. Gottschling S, Meyer S, Dill-Mueller D, Wurm D, Gortner L. Outbreak report of airborne caterpillar dermatitis in a kindergarten. Dermatology 2007;215:5-9. How to cite this article: Singh DS, Thayub M, Nyayakar S, Joseph 10. Paniz-Mondolfi AE, Pérez-Alvarez AM, Lundberg U, Fornés L, Reyes- MK. Lepidopterism: A report from South India. Indian J Case Jaimes O, Hernández-Pérez M, et al. Cutaneous lepidopterism: Dermatitis Reports. 2021;7(3):105-107. from contact with moths of Hylesia metabus (Cramer 1775) (Lepidoptera:

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