SAN FRANCISCO Diseases are lurking in our waters, according to Ricardo M. Mandojana, MD, who spoke at the annual meeting of the American Academy of Dermatology held here.
The most frequent of the aquatic dermatoses is "swimmer's ear." There are three main factors that can interact to cause infection of the ear:
Other factors, such as a narrow ear canal, foreign material and too much (or not enough) cerumen can also contribute to infection. Signs and symptoms may appear hours or days after swimming, which include pain and suppuration in the canal.
Have the child tilt his or her head to one side and use a hair dryer to lessen the moisture in the canal. Do not use cotton-tipped applicators and don't use ear plugs, petroleum jelly or cerumen softening products. Treatment after infection usually requires antibiotic ear drops (colistin sulfate) and oral antibiotics.
Many of the aquatic diseases are more serious than swimmer's ear. Mandojana presented material that suggests clinicians ought to be more alert for signs and symptoms of potential life-threatening aquatic-borne cutaneous infections and aquatic dermatoses because aquatic infections are on the rise. "There are many reasons for the growth of this particular population," Mandojana said when referring to the increased number of skin diseases found in association with exposure to water.
"One example is the tendency of swimmers to wear smaller [or no] garments, which exposes a larger cutaneous surface to aquatic denizens. Also, there is a national trend to move to coastal areas," Mandojana continued. This, coupled with the popularity of water activities, makes the risk for developing an injury or aquatic-borne infection greater.
Physicians should remember that people are "on the move" these days more than ever before, and the differential may include an unusual organism. Always ask about recent vacations or travel. "It's not uncommon for me to see a patient in my office in Tennessee who sustained an aquatic related wound, such as a coral cut, in Hawaii," Mandojana reported.
|--- "Immersion foot" in teenager. Patient had tinea pedis, Pseudomonas intertrigo in feet and crural erythema.|
|--- Public swimming pools or hotel hot tubs are two of the best sources of plantar verrucae infection.|
|--- A sick Atlantic bottle-nosed dolphin was the source of this rare case of Blastomycosis dermatitides, the first to be transmitted to a human by a marine mammal.|
|--- Verrucous atypical mycobacteria (Mycobacterium marinum) on dorsal aspect of left foot. Fish tanks, aquariums and swimming pools are the main sources of this infection.|
According to Mandojana, of Maryville Dermatology Associates, Maryville, Tenn., "marine creatures have the most potent venoms known to man and there are many aquatic-borne cutaneous infections with guarded prognosis that require hospitalization for management."
Children are very susceptible to these types of infections. While in the more shallow waters of beaches and ponds, children can acquire an aquatic-borne infection or become injured from a number of different species of marine life. Even the simplest cut can lead to danger. Knowing how to treat them might save their life.
The pollution of fresh and salt water environments appears to have resulted in increased virulence and frequency of infections, skin cancers and other illnesses.
"We aren't sure what will happen in time," Mandojana hinted at the conference. He continued by saying, "while we already know of some skin eruptions and the increase of cutaneous infections, the whole spectrum needs revision."
Vibrio vulnificus is a virulent marine Vibrio isolated frequently from warm coastal water during the summer. A child may be predisposed by handling crabs or fish, especially if a wound is present. Symptomatology is quite severe; the area becomes erythematous, edematous and painful, spreading cellulitis to adjacent areas rapidly with hemorrhagic vesicles or bullae appearing at the primary site. The child can present with fever, chills and sepsis.
Treatment requires early intervention with intravenous antibiotics. Tetracycline appears to be a first choice for children older than 8 years, with chloramphenicol, penicillin, bactrim (Roche) or even third-generation cepha losporins as second choices.
Prototheca wikerhamii is a dangerous but rare infection caused by alga in wounds that are contaminated by dirty water or soil. These infections can involve the skin, subcutaneous tissues, olecranon bursa or even deep organs. In a child with normal immunity, the olecranon bursa is usually infected while children who are immunosuppressed may have skin lesions. Treatment requires bursectomy.
Fish handler's disease is caused by Erysipelothrix rhusiopahiae, a
gram-positive, facultatively aerobic bacillus. It occurs mostly in the coastal
United States where crabs are handled, with the most frequent reaction being a
dermatitis. A hallmark lesion can appear within one to seven days after a
puncture wound. Treatment usually requires penicillin, erythromycin or
first-generation cephalosporins; if arthritis, septicemia, or endocarditis is a
complication, aqueous penicillin-G is used, 2 million to 4 million units IV
every four hours for four to six weeks (as indicated).
Finally, there are jellyfish. Children play in shallow waters where the jellyfish tend to stay. These creatures have millions of microscopic stinging cells called nematocysts that inject toxins to capture and paralyze prey as well as to defend themselves.
"Inside the nematocysts," said Mandojana, "are tiny springs which are injected into the dermis, carrying the venom into the skin and systema." He added that sometimes it is possible to identify the culprit jellyfish by the pattern of the sting. For example, the Atlantic Portugese man-of-war is equipped with many stingers and tentacles, whereas the Pacific Portugese man-of-war generally has only one.
"If you look at the papules [dots] made by the jellyfish," Mandojana said, "and there are many 'dots' but only one line, the sting was made by a Pacific Portugese man-of-war; whereas if there are many lines, the sting was from the Atlantic species."
The Box jellyfish are dangerous, as the lesions become necrotic and some children have died within minutes after being stung. "The marks made by these jellyfish have many sharp angles; you don't see that with other jellyfish," Mandojana added.
There are two different kinds of reactions to jellyfish stings. The local reaction can occasionally cause angio edema, fat atrophy or gangrene. The systemic reactions are toxin-induced and can be rather severe. There are reports of delayed reactions. "A woman showed up in my clinic in Knoxville after being stung by a jellyfish a week before the sting markings had disappeared; now she presented with itching and a hyperpigmented 'recurrence' without re-envenomation at the site of the sting," Mandojana said. These delayed reactions, Mandojana said, are not uncommon.
Treatment for a Portugese man-of-war (Atlantic or Pacific) sting is a vinegar soak on the site, with occasional topical application of baking soda. If you recognize the animal, however, you can provide a more specific treatment. It is important that the victim gets medical attention early if any systemic symptoms develop. idc
For more information:
- Mandojana RM. Aquatic Dermatologic Hazards. Presented at the 55th Annual Meeting of the American Academy of Dermatology. March 21-26. San Francisco.
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