Outbreak of Phototoxic Dermatitis from Limes -- Maryland
On August 8, 1984, the Office of Disease Control and
Epidemiology,
Maryland Department of Health and Mental Hygiene, was notified by a
nurse at a day camp in Owings Mills, Maryland, of a rash illness
reported among 12 children during the previous week. The rash,
confined to the dorsa of the hands and extensor and flexor surfaces
of
the forearms and in the form of blotches, speckles, and streaks,
was
macular, hyperpigmented, and nonpruritic. No other signs or
symptoms
were noted. Dermatologists diagnosed the rash as a phototoxic
contact
dermatitis. Investigation disclosed that limes used in an art
class
to make pomander balls were incriminated as the cause of the rash.
All children and counselors at the day camp were examined for
evidence of the characteristic rash. A case was defined as a
day-camp
member with the rash noted by the examiner between August 8 and
August
14. Ninety-seven (16%) of 622 children and seven (7%) of 104
counselors were affected. None of the 57 adult staff members
reported
a rash. Analysis of rash in children and counselors by sex and
race
showed no disproportionate representation. Since most children
were
too young to remember a date of onset, parents of children with
rash
were telephoned and asked for the date they first discovered the
rash
(Figure 1). Of the 82 (85%) mothers contacted, 23 (28%) had not
noticed the rash or had thought it was dirt.
Several activities involving work with hands were investigated.
Five activities that involved more than two-thirds (65) of affected
children were significantly associated with illness (p less than
or
equal to 0.004). These activities were making wallpaper,
pomanders,
tissue wine-paper cups, and burlap covers and participating in a
nature scavenger hunt. However, when controlling for each of the
other four activities, only exposure to making pomanders in arts
and
crafts class was significantly associated with illness (p less
than
or equal to 0.03). Of the 17 counselors who had helped children
make
the pomanders, seven had the rash (p 0.001), whereas none of the
34
counselors who were not exposed to the pomanders had the rash (p
0.001). The pomanders were made from July 23 to July 27 by camp
units
A and B (approximately 60 children per unit) and by some members of
units D and H on July 31. Discovery of the rash for most cases
correlates with the time of exposure (Figure 1).
In making pomanders, the children received one lime each during
class, poked several holes in it with scissors, filled the holes
with
cloves, sprinkled cinnamon over the lime, and placed the product in
cloth later tied with a pipecleaner. During the process, oil
glands
in the lime skin probably ruptured, releasing chemicals in the oil
known to cause phototoxicity on exposure to the sun (1-5).
The limes were purchased from a supermarket, part of a
nationwide
chain, that purchases its limes from Florida. After harvesting the
limes, the processors wash off any insecticides (all water-soluble)
and later coat the limes with an inert vegetable wax.
Environmental
and botanical survey of the camp did not reveal other chemicals or
plants with phototoxic potential with which camp members may have
come
into contact.
Reported by E Israel, MD, State Epidemiologist, Maryland State Dept
of
Health and Mental Hygiene; Div of Field Svcs, Epidemiology Program
Office, Chronic Diseases Div, Center for Environmental Health, CDC.
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