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Skin Problems Related to Noninfectious Coastal Microorganisms

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Skin Problems Related to Noninfectious Coastal Microorganisms Dermatologic Therapy, Vol. 15, 2002, 10±17 Copyright # Blackwell Publishing, Inc., 2002 Printed in the United States Á All rights reserved DERMATOLOGIC THERAPY ISSN 1396-0296 Skin problems related to noninfectious coastal microorganisms y WILLIAM A. BURKE* & PATRICIA A. TESTER *Department of Dermatology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, and yNational Ocean Service, National Oceanic and Atmospheric Administration, Center for Coastal Fisheries and Habitat Research, Beaufort, North Carolina ABSTRACT: While there are a number of coastal microorganisms that can cause infections of the skin, there are many that can cause skin problems that are noninfectious in nature. From cyanobacterial dermatitis to skin problems related to dinoflagellates, to skin signs of ciguatera or scombroid fish poisonings, to ``sea lice''/``seabather's eruption,'' to ``swimmer's itch,'' this article attempts to separate these entities into distinct syndromes caused by a variety of bacteria, phytoplankton and zooplankton. Treatment and prevention of these diseases are also discussed. KEYWORDS: bites and stings, ciguatoxin, cyanobacteria, Dinoflagellata, marine toxins, Pfiesteria piscicida, schistosomatidae. There are many noninfectiouscutaneous Cyanobacteria (blue-green algae) problemsthat are causedby aquatic microor- ganisms such as bacteria, phytoplankton, and Cyanobacteria (blue-green algae) are prokaryotic, zooplankton. While some of these problems are chlorophyll-containing, microscopic filamentous relatively insignificant and require only sympto- and nonfilamentous organisms found in fresh- matic care and reassurance, a few may be fatal. water, estuarine, and marine environments. These It isimportant for cliniciansto recognize the organisms proliferate in areas of high nutrient varied signs and symptoms of these diseases overload and can form blue-green, milky-blue, based on a proper history and physical exam- green, red, or dark-brown ``blooms'' or ``scums'' (1). ination, as well as having a basic understanding While not all cyanobacteria are toxic, some of the causative microscopic flora and fauna. species such as Lyngbya, Microcystis, Anabaena, Skin problemsrelated to bacterial skin infections Aphanizomenon, Cylindrospermopsis, Nodularia, are covered elsewhere in this issue, and only and Oscillatoria/Trichodesmium (Fig. 1) have noninfectious microorganisms will be discussed been shown to produce toxins which may be here. relatively harmful (1±4). These toxins can be hazardousto human and animal health and have been responsible for sporadic animal (mammals, birds, fish) fatalities (5). Cyanobacterial toxins may be tumor promoters, hepatotoxins, neuro- Address correspondence and reprint requests to: William A. Burke, MD, Department of Dermatology, Brody School of toxins, or skin irritants (6,7). Medicine, East Carolina University, 600 Moye Blvd., Brody 3E- Human illness related to cyanobacteria and 113, Greenville, NC 27858-4354, or e-mail: burkew@mail. their toxinsmay be via direct contact (recrea- ecu.edu. tional or other) or ingestion (of water, fish, or 10 Noninfectious coastal microorganisms presumptive diagnosis. Recreational and occupa- tional exposure as well as possible ingestion need to be considered. There isno proven therapy for cyanobacterial toxicity. Treatment of systemic disease is with supportive care, and symptomatic care with antihistamines and topical steroid creams is often used for the cutaneous component (11,12). Re- moval of the bathing suit and showering quickly after leaving the water isimportant in prevention of the dermatitis. Eye stings should be treated with irrigation with tap water followed by ophthalmologic consultation (11). Fig. 1. Filaments of Trichodesmium, a cyanobacter- Skin stings and rashes from cyanobacteria have ium (blue-green alga) (original magnification 200Â). been given many names: ``algae dermatitis,'' ``seabather's eruption,'' ``stinging limu,'' and ``sea- weed dermatitis.'' To avoid confusion, it seems shellfish). In a hemodialysis unit in Brazil, 126 reasonable to term skin eruptions due to toxic patients became seriously ill and 60 of them died cyanobacteria simply ``cyanobacterial dermatitis.'' when water from a lake contaminated with cyanobacterial toxins(microcystins)wasusedat the unit (8). Deathswere primarily from liver Estuarine and marine phytoplankton failure, and ecchymoses were seen in some of these patients (8). Unicellular eukaryotic phytoplankton can cause Skin reactionsfrom cyanobacterial toxinswere skin reactionsÐsome when ingested and some on initially reported from the organism Lyngbya skin contact. A variety of intoxications may occur majuscula, which secretes lyngbyatoxins which when variousendotoxin-producing marine phy- can be irritating to skin and mucous membranes, toplankton (dinoflagellates, as well as a marine causing irritant dermatitis and conjunctivitis diatom) are filtered and concentrated by (9,10). Thisfilamentousorganismbloomsinto shellfish and later ingested by people. These algal matswhich cover surface waterswhen a shellfish poisoning syndromes include paralytic high nutrient load occurs. Periods of high winds shellfish poisoning, neurotoxic shellfish poison- and flooding rains can cause these mats to flow ing, amnesic shellfish poisoning, and diarrhetic into coastal and estuarine waters where wave shellfish poisoning. While these intoxications can action breaksthe matsapart into individual be severe and some may lead to death, they microscopic filaments. Bathing suits on persons generally do not affect the skin (13±15). swimming in affected waters filter and collect Ciguatera fish poisoning is caused by eating microscopic toxin-secreting cyanobacterial fila- fish which have bioconcentrated the tropical/ ments under the suits. As the swimmer leaves subtropical epiphytic reef-associated Gambierdis- the water and the water from the bathing suit cus toxicus dinoflagellate in their tissue. Several evaporates, toxins are concentrated and skin other epiphytic dinoflagellateshave alsobeen irritation (at timeswith blistering)may occur, implicated. With approximately 50,000 cases most commonly in areas covered by the bathing annually throughout the world, this disease has suit. Eye stings and conjunctivitis have also been become the most common illness related to reported (11). consumption of finfish, primarily due to exporta- Blistering skin reactions around the mouth tion of fish from tropical/subtropical areas to have also been reported possibly due to micro- other partsof the world (16,17). Fishcommonly cystins after contact with water containing toxic implicated include mackerel, jacks, coral trout, Microcystis aeruginosa (12). Affected individuals barracuda, grouper, flowery cod, snapper, reef had many other signs and symptoms, including sharks, moray eel, wrasse, and others (16±21). malaise, fever, cough, pleuritic chest pain, ab- Ciguatoxin, maitotoxin, and other toxins asso- dominal pain, nausea, vomiting, confusion, and ciated with G. toxicus are lipid soluble and cold/ pneumonia. It isimportant to take a careful heat stable. history when a patient presents with possible Ciguatera poisoning usually presents within cyanobacterial skin eruptions in order to make a 3±6 hours after ingestion as gastroenteritis 11 Burke & Tester (diarrhea, abdominal pain, nausea, and vomiting) and neurologic symptoms (weakness, headache, tremor, ataxia) (20,21). Paresthesia of the extre- mitiesand circumoral area aswell ashot-cold temperature reversal are symptoms frequently seen in ciguatera toxicity, and can help separate this illness from other causes of gastroenteritis. Skin problemsinclude severe pruritus(which isa common complaint and which can last for years) (16) and rarely chronic urticaria. Death isquite rare, but may occur due to cardiopulmonary arrest. Treatment of the acute toxicity iswith mannitol infusion (1 g/kg intravenously over 30±45 minutes) (22,23). Chronic symptoms are treated with ami- Fig. 3. Sea surface temperature satellite imageryof triptyline, tocainide, mexiletine, nifedipine, and the Gulf Stream (dark red) which serves as a method gabapentin (24±27). of transport to distribute Karenia brevis blooms from the Gulf of Mexico to the U.S. South Atlantic Bight. Another dinoflagellate, Karenia brevis (pre- (Photo courtesyof NOAA.) viously known as Gymnodinium breve) (Fig. 2), can develop into huge bloomscalled ``red tides,'' because of the reddish discoloration it causes in Unlike most dinoflagellates, K. brevis isa affected water. Thisorganismproducesendotox- ``naked'' dinoflagellate and lackspolysaccharide ins that have been classified as brevetoxins. These protective plates of armor. Because of this, heavy toxins can cause massive fish kills, and when wave action and surf can cause its cell mem- filtered and concentrated by shellfish and then branesto rupture, thereby releasingand aero- ingested, neurotoxic shellfish poisoning. K. brevis solizing the endotoxins (29). As the toxins are very migrate to the upper part of the water column and irritating to skin and mucous membranes, it can are transported throughout the Gulf of Mexico cause an irritant dermatitis, conjunctivitis, phar- and the U.S. South Atlantic Bight by major current yngitis, rhinorrhea, sneezing, coughing, and dys- systems (Fig. 3) (28). pnea (17,29). As the toxins also cause smooth muscle contraction, wheezing and asthma may also occur, and this can be a major problem for persons who have already been diagnosed with asthma (30±32). Asthere
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