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(The following article was published in EXPLORE! VOLUME 7, NUMBER 2, 1996) FACIAL CUTANEOUS DERMATITIS ASSOCIATED WITH ARTHROPOD PRESENCE Copyright 1996 by Omar M. Amin, Institute of Parasitic Diseases, Dept. of Zoology, Arizona State University. ABSTRACT After moving to a rural home in a wooded area in Oklahoma in 1991, a 59 year old white female presented with facial lesions associated with an assortment of arachnids and non-parasitic insects. A complete case history and an interpretation of findings is presented. The subject of this report (S.P.) is a well-nourished, 185 lb. white American female born on March 1, 1936 who had lived in the Middle Eastern country of Dubai from 1975 to 1985 and in 1988 and had traveled extensively farther east into India, Pakistan, Malaysia, Bangkok, and Singapore during earlier years. No episodes of hirsuitism were noted while in any of these countries in some of which leishmaniasis is endemic. Her hormonal history includes hysterectomy and oophorectomy in 1983. She was treated with a combination of testosterone and estrogen in 1986 after which perioral black facial hairs with unusual subcutaneous processes started appearing in 1991. She had fibrocystic disease, 3 breast biopsies in 1975, 1984, and 1991, one episode of pneumonia, one episode of left-sided hemianopsia times two while living in Dubai, and an apparent penicillin reaction. S.P. moved to a wooded rural area 3 miles from a toxic waste dump in Oklahoma in April 1991 where at one time she kept chickens, pigs, 3 dogs and 10 cats as outdoor pets. She admits to having had frequent facial contact with the cats. The house sat vacant for 8 years until revamped for residence in 1991. One morning in August, 1991, S.P. woke up with a raised red large painful welt in the left perioral area. Within one week, 5 or 6 similar welts appeared between the initial site and the right perioral area with ultimate spread to the right cheek within a few months. (fig. 1) During this period, S.P. was seen by 6 dermatologists, took a wide variety of oral antibiotics, used various standard topical acne treatments and topical antibiotic preparations, and was injected with cortisone 23 times into the lesions by one physician. The lesions got worse and a new sensation of subcutaneous "movement" at the affected area was felt. S.P. was told she had fungal overgrowth and anti-fungal preparations, e.g. lotrosone, were used. In November, 1991, a hematological study demonstrated elevated monocyte count (13.0%)(reference 2.5-19.0) By March, 1992, S.P. was on Prozac, Xanax, tetracycline, estrogen, (Estrace.Naproxyn,odox, and used topical cleocin, retin A, and esiraderm. In June, 1992, a bacterial culture from the lesions established coagulase negative Staphyloccus infection (persisting at least through May, 1994) and a histological section from the right chin area demonstrated keratinizing stratified squamous epithelium with areas of hyperkeratosis, parakeratosis, psoriaform hyperplasia, and a central area of ulceration. In July, 1991, S.P. was diagnosed with "chronic dermatitis." She was treated with Keflex for the Staphyloccus infection. By November, 1992 she presented with allergic bronchitis and mental stress wihen a hematological profile demonstrated elevated WBC (12.7/cmm) (reference 4.3-11.) and eosinophil counts )24%) (reference 0.5-11.0) and low lymphocyte count (15.7%) (reference 18 - 44.0). The marked eosinophilia and skin lesions suggested possible cutaneous leishmaniasis. In September, 1993, she had a negative ANA and anti-DNA in spite of a history of malar rash that comes on when she is exposed to the sun which along with a history ofpolyarthralgia suggested possible lupus erythemaqtosus. The above concerns were tested in June, 1994 and S.P. was found negative for the 4 most common types of leishmaniasis; ANA, anti-DNA, and other lupus-type antibodies, SSA, SSB, etc., C3, C4, and anti-thyroid antibodies; and any signs of inflammatory disease or intradermal cysts (sedimentation rate normal at 4 mm/hr.) The above findings were supported histologically during the same month. The first documentation of arthropod presence in the lesion was evidenced when a very small tick nymph (probably Ambyomma americanus) emerged from the left perioral lesion was trapped on Scotch tape on July 1, 1994. (Table 1.) By that time, S.P. developed acute observartional skills and tools and noted what appeared to be "tunnels" and "breathing holes" in and around the lesions and "burrow lines" connecting them. The possible presence of other arthropods in lesions prior to that date can not be documented. More specimens were subsequently collected (Table 1). The small ant collected on June 29, 1994, was from a lesion on the right side of the face. A 3 mm long caterpillar (Fig.2) emerged on August 11, 1994, from a very red and painful lesion in the right perioral area. Other materials from the same lesion included insect antennae and fungal spores. It was not dertermined if the latter belonged to pathogenic species or were just environmental contaminants. However, S.P. began a course of anti-fungal treatments using Nizoral in tables, shampoo, and creme forms after trying rotenone topically with no success. A stool examination on September 21, 1994 was negative for parasites, but a chemistry panel and a BCC screen on the same day showed elevated blood urea nitrogen at 25 (reference 520) and a high eosinophil differential and asolute counts of 6% (reference 15%) and 0.6 K/uL (reference 0.05-0.55) respectively. The hymenopteran identified on October 10, 1994 (Fig. 3) was collected from the edge of a chin lesions. A homeopathic treatment starting on October 10, 1994, involved essential oils, gels, antimonium and procaine injections, electrical stimulation, and hypnosis therapy, but provided no relief. On November 21, 1994, sections of excised lift and right nasolabial and labial mental fold and chin areas demonstrated benign epidermal hyperplasia with hyperkeratosis and focal excoriation but no "parasites." At that time, S.P. was using panosyl, doxepin, benzate wash, Xanax, lindane lotion, estrac4, and elemite cream, but arthropods continued to be present in her lesions causing considerable pain, irritation, unsightly appearance, and psychological stress. Parts of a formicid (ant) were identified in December, 1994, and additional specimens were collected from lesions in August, September, and October, 1995. (Table 1). The insect femur identified on October 25, 1995, (Fig. 4) was similar to another one collected earlier on August 21, 1995. (Table 1.) but the hymenopteran (Fig. 5), was different than that of October 10, 1994 (Fig. 3). The continued recovery of these specimens, however, contrasted with normal chemistry and CBC panels on April 14, May 19, and September 28, 1995. S.P. stopped using Prozac, Xanac, estrace, and naproxyn in early 1995 and takes no oral medication except for nizoral and an occasional 1/2 tablet of Prosom for sleep. At all times, debris, fibers, hair-like filaments, and black specks (perhaps fecal pellets) were also associated with lesions. Healing was noted to be proportional to exit of remaining fibers from lesions. By August 15, 1995, many of these lesions were being resolved with largely one remaining active lesion in the right perioral area. S.P. commenced a course of praziquantel in October, 1995, and a second one on November 15, which are causing marked improvements. An additional course of Ivomec (counterpart of Ivermectin for treatment of Demodex mites in dogs) appears to be accelerating the progress. As of the end of December, 1995, however, the remaining lesion has not healed.