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LEPIDOPTERISM

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Lepidopterism refers to diseases caused by lepidopterans (adult stages of moths and butterflies). Erucism refers to illness caused by the larval and pupal stages of moths and butterflies.
    B) The lonomia species is from the Saturniidae family of moths and two species (L. obliqua and L. achelous) are capable of producing severe coagulation disorders. Because of their unique and potentially serious clinical effects they are discussed in a separate title. Please refer to the LONOMIA CATERPILLAR management for further information.

Specific Substances

    A) MOTH FAMILIES CAUSING LEPIDOPTERISM
    1) Arctiidae
    2) Anthelidae
    3) Eucliedae
    4) Hemileucidac
    5) Hickory tussock moths
    6) Hypsidae
    7) Lasiocampidae
    8) Limacodidae
    9) Lymantriidae
    10) Megalopygidae
    11) Morphoidae
    12) Noctuidae
    13) Notodontidae
    14) Phycitidae
    15) Saturniidae
    16) Thaumetopoeidae
    17) Thosea penthima
    18) Thosea penthima Turner (Limacodidae)
    19) Zygaenidae
    20) MOTH TOXICITY
    CATERPILLAR
    1) Billygoat plum stinging caterpillar (Thosea penthima)
    2) Caterpillar, Pine Processionary
    3) Euproctis edwardsi (Mistletoe browntail moth)
    4) Lophocampa caryae (Hickory tussock moths)
    5) Mistletoe browntail moth (Euproctis edwardsi)
    6) Pine Processionary caterpillar
    7) Processionary caterpillar
    8) Processionary Pine caterpillar
    9) Processionary Tree caterpillar
    10) Tree Processionary caterpillar
    BUTTERLFLY FAMILIES CAUSING LEPIDOPTERISM
    1) Nymphalidae
    2) BUTTERFLY TOXICITY
    3) CATERPILLAR (TOXICITY)

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) GENERAL INFORMATION: Lepidopterism refers to diseases caused by lepidopterans (adult stages of moths and butterflies). Erucism refers to illness caused by the larval and pupal stages of moths and butterflies. Lonomia caterpillars are covered in a separate management.
    B) TOXICOLOGY: There are two types of urticating hairs seen on caterpillars, itchy hairs (non-venomous that cause localized dermatitis by mechanical irritation and foreign-body reactions) and stinging hairs (hollow spines with poison-secreting cells at the base that cause local or systemic effects after spines enter the skin and break off leading to injection of venom). Reactions may be due to local effects, or due to allergic or hypersensitivity reactions.
    C) EPIDEMIOLOGY: Over 40 genera worldwide may cause lepidopterism. Irritant species represent 0.1% of known moth and butterfly species; more than 200 irritative species are spread out over tropical, subtropical, and temperate areas of the world including the United States. Exposures most commonly occur due to dermal contact, however, oral exposure may occur if caterpillars are eaten and inhalational exposures may occur due to airborne hairs.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: DERMAL: Erucism, or caterpillar dermatitis, is characterized by localized pruritic maculopapular to bullous lesion and urticaria produced by contact or airborne exposure to caterpillar urticating hairs, spines, or toxic hemolymph. Signs and symptoms most commonly consist of rash, pruritus, local pain, erythema, and edema. The rash is often a maculopapular contact dermatitis, which may be accompanied by vesicles and wheals. The onset of symptoms may be within minutes to hours and may last hours to days. Less commonly, patients may experience conjunctivitis, rhinopharyngitis, and vomiting. Rarely, patients may experience lymphangitis and lymphadenopathy after exposure to Megalopyge lanata caterpillars.
    2) SEVERE TOXICITY: Lepidopterism is a term for systemic illness from direct or aerosol contact with caterpillar, cocoon, or moth urticating hairs, spines, or body fluids. In severe cases, systemic toxicity from caterpillar exposure can include systemic allergic reactions including asthma and anaphylaxis, muscle cramping, eosinophilia, leukocytosis, headache, malaise, and irritability. Rarely, patients exposed to Megalopyge opercularis have had seizures.
    3) INGESTION: In patients who ingest caterpillars or hairs, drooling, difficulty swallowing, gastritis, esophagitis, enteritis, and tongue, lip, and oral irritations can develop due to embedded caterpillar hairs.
    4) INHALATION: Can cause dyspnea and cough.
    5) DERMAL: Rarely, severe dermal reactions can progress from the more typical rashes described to desquamation and necrosis. Dendrolimiasis is caused by direct contact with living or dead central Asian pine-tree lappet moth caterpillars (Dendrolimus pini) or their cocoons characterized by maculopapular dermatitis, migratory inflammatory polyarthritis and polychondritis, and chronic osteoarthritis.
    6) OCULAR: Ophthalmia nodosa, is a chronic condition with initial conjunctivitis with pan-uveitis caused by corneal penetration and eventual intraocular migration of urticating hairs from lymantriid caterpillars and moths.
    0.2.20) REPRODUCTIVE
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
    0.2.21) CARCINOGENICITY
    A) At the time of this review, no data were available to assess the carcinogenic or mutagenic potential of this agent.

Laboratory Monitoring

    A) There are no specific laboratory tests required for the evaluation of patients with lepidopterism or erucism.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment consists of predominantly symptomatic and supportive care. Local pain, pruritus, and rash can be treated with antihistamines and topical corticosteroids. An attempt should be made to remove hairs/spines from the skin with scotch tape applied and then peeled off; occasionally large spines may be removed with forceps.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Patients who develop severe toxicity with systemic allergic reactions should be treated with antihistamines, corticosteroids, and if needed, epinephrine for anaphylaxis. Patients with seizures should be treated with benzodiazepines. Patients with oral or GI symptoms after ingesting a caterpillar may require endoscopy for hair or spine removal. Patients with ocular exposure who have hairs visualized on exam, or signs or symptoms of ophthalmia nodosa, should be referred to an ophthalmologist for hair removal and further management. Patients with dendrolimiasis should be treated with systemic corticosteroids and may require a referral to a rheumatologist.
    C) DECONTAMINATION
    1) An attempt may be made to remove hairs/spines from the skin with scotch tape applied and then peeled off. There is no role for GI decontamination.
    D) AIRWAY MANAGEMENT
    1) Rarely, patients with signs and symptoms of respiratory failure due to systemic allergic reaction or asthma may need intubation for respiratory support.
    E) ANTIDOTE
    1) None
    F) ENHANCED ELIMINATION PROCEDURE
    1) There is no role for hemodialysis or other methods of enhanced elimination in these patients.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with known exposure to caterpillars, portions of cocoons, or moths/butterflies who are asymptomatic and have no signs or symptoms of systemic allergic reactions can be managed at home and do not require observation or admission. Patients with mild irritation or dermatitis after skin exposure, or mild oral irritation after ingestion can be managed at home.
    2) OBSERVATION CRITERIA: Patients with more severe dermatitis or oral irritation, and patients with systemic symptoms or allergic reaction should be referred to healthcare facility for evaluation.
    3) ADMISSION CRITERIA: Patients with evidence of systemic toxicity including asthma, systemic allergic reaction, or seizures should be admitted to the hospital. Those with severe respiratory symptoms, anaphylaxis, or difficult to control seizures should be admitted to an ICU.
    4) CONSULT CRITERIA: Contact your local poison center or a medical toxicologist for any patient with suspected severe lepidopterism or erucism. For patients with ocular exposures and concern for retained ocular hair or symptoms of ophthalmia nodosa, consult an ophthalmologist. For patients with severe oral or GI symptoms, gastroenterology should be consulted for possible endoscopy and hair removal. Patients with dendrolimiasis should be referred to a rheumatologist.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    B) Patients with ocular exposure who have hairs visualized on exam, or signs or symptoms of ophthalmia nodosa, should be referred to an ophthalmologist for hair removal and further management.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    2) Therapy is directed at removing the hairs from the skin (or eyes) and symptomatic care thereafter. An attempt may be made to remove hairs/spines from the skin with scotch tape applied and then peeled off. There are no specific antidotes for the venoms found in the hairs, spicules or spikes. Depending on the severity of the exposure, antihistamines, corticosteroids, and pain relievers may be required.
    3) ALLERGIC REACTION: MILD/MODERATE: Antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, corticosteroids, ECG monitoring, and IV fluids.

Range Of Toxicity

    A) TOXICITY: Acute signs and symptoms have been described after exposure to a single caterpillar, cocoon, or moth or butterfly. Symptoms have been described in patients without direct dermal contact; these patients are typically thought to be affected by airborne hairs from these species, and symptoms typically include respiratory, nasopharyngeal, conjunctival, and dermal irritation.

Clinical Effects

Summary Of Exposure

    A) GENERAL INFORMATION: Lepidopterism refers to diseases caused by lepidopterans (adult stages of moths and butterflies). Erucism refers to illness caused by the larval and pupal stages of moths and butterflies. Lonomia caterpillars are covered in a separate management.
    B) TOXICOLOGY: There are two types of urticating hairs seen on caterpillars, itchy hairs (non-venomous that cause localized dermatitis by mechanical irritation and foreign-body reactions) and stinging hairs (hollow spines with poison-secreting cells at the base that cause local or systemic effects after spines enter the skin and break off leading to injection of venom). Reactions may be due to local effects, or due to allergic or hypersensitivity reactions.
    C) EPIDEMIOLOGY: Over 40 genera worldwide may cause lepidopterism. Irritant species represent 0.1% of known moth and butterfly species; more than 200 irritative species are spread out over tropical, subtropical, and temperate areas of the world including the United States. Exposures most commonly occur due to dermal contact, however, oral exposure may occur if caterpillars are eaten and inhalational exposures may occur due to airborne hairs.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: DERMAL: Erucism, or caterpillar dermatitis, is characterized by localized pruritic maculopapular to bullous lesion and urticaria produced by contact or airborne exposure to caterpillar urticating hairs, spines, or toxic hemolymph. Signs and symptoms most commonly consist of rash, pruritus, local pain, erythema, and edema. The rash is often a maculopapular contact dermatitis, which may be accompanied by vesicles and wheals. The onset of symptoms may be within minutes to hours and may last hours to days. Less commonly, patients may experience conjunctivitis, rhinopharyngitis, and vomiting. Rarely, patients may experience lymphangitis and lymphadenopathy after exposure to Megalopyge lanata caterpillars.
    2) SEVERE TOXICITY: Lepidopterism is a term for systemic illness from direct or aerosol contact with caterpillar, cocoon, or moth urticating hairs, spines, or body fluids. In severe cases, systemic toxicity from caterpillar exposure can include systemic allergic reactions including asthma and anaphylaxis, muscle cramping, eosinophilia, leukocytosis, headache, malaise, and irritability. Rarely, patients exposed to Megalopyge opercularis have had seizures.
    3) INGESTION: In patients who ingest caterpillars or hairs, drooling, difficulty swallowing, gastritis, esophagitis, enteritis, and tongue, lip, and oral irritations can develop due to embedded caterpillar hairs.
    4) INHALATION: Can cause dyspnea and cough.
    5) DERMAL: Rarely, severe dermal reactions can progress from the more typical rashes described to desquamation and necrosis. Dendrolimiasis is caused by direct contact with living or dead central Asian pine-tree lappet moth caterpillars (Dendrolimus pini) or their cocoons characterized by maculopapular dermatitis, migratory inflammatory polyarthritis and polychondritis, and chronic osteoarthritis.
    6) OCULAR: Ophthalmia nodosa, is a chronic condition with initial conjunctivitis with pan-uveitis caused by corneal penetration and eventual intraocular migration of urticating hairs from lymantriid caterpillars and moths.

Vital Signs

    3.3.3) TEMPERATURE
    A) Fever may occur after some exposures (Kawamoto & Kumada, 1984).
    B) OAK PROCESSIONARY CATERPILLARS: Fever has been reported following exposure to oak processionary caterpillars (Gottschling et al, 2007)
    C) HYLESIA MOTHS: Fever has been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Eye irritation has been noted after gypsy moth caterpillar, the Io moth, and Hyselia moth exposure (Shama et al, 1982; Dinehart et al, 1985). The urticating hairs may be on the moth, caterpillar, or may be airborne (James & Harwood, 1969).
    a) Numerous caterpillar setae were reported embedded in the deep cornea and anterior chamber after a caterpillar fell into an adult's eye. The patient presented with severe conjunctival injection, chemosis, and erosion of the cornea. Inflammation subsided and vision improved on removal of most of the setae (Horng et al, 2000). The authors suggest that setae venom was released at initial contact.
    2) KERATOCONJUNCTIVITIS
    a) Keratoconjunctivitis or just conjunctivitis may occur after ocular exposure to caterpillar hairs. Symptoms usually subside in 7 to 10 days (Bishop & Morton, 1967; Kawamoto & Kumada, 1984).
    b) HYLESIA MOTHS: Conjunctivitis and conjunctival granulomas have been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).
    3) PHOTOPHOBIA
    a) Photophobia may occur after moth or caterpillar hair exposures (Kawamoto & Kumada, 1984).
    4) LACRIMATION and ERYTHEMA
    a) Lacrimation may occur after moth or caterpillar hair exposures (Kawamoto & Kumada, 1984).
    b) Erythema and edema may be seen after moth or caterpillar hair exposures (Kawamoto & Kumada, 1984).
    5) OPHTHALMIA NODOSA
    a) Ophthalmia nodosa is a chronic condition which usually presents as conjunctivitis and may lead to pan-uveitis that is caused by corneal penetration and subsequent intraocular migration of urticating hairs from lymantriid caterpillars and moths (Diaz, 2005; Corkey, 1955; Watson & Sevel, 1966; Teske et al, 1991).
    6) CORNEAL ULCER
    a) HYLESIA MOTHS: Corneal ulcers have been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).
    7) BLINDNESS
    a) HYLESIA MOTHS: Blindness has been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).
    3.4.5) NOSE
    A) WITH POISONING/EXPOSURE
    1) Rhinitis, nasal congestion, and sneezing has been reported after exposure to the gypsy moth caterpillar (Shama et al, 1982; Allen et al, 1991).
    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) Rhinopharyngitis may occur after inhalation of air containing the minute spicules of some species (Kawamoto & Kumada, 1984).
    2) Following ingestions of caterpillars, drooling and dysphagia may occur due to the hairs or spines becoming embedded in the oropharynx (Pitetti et al, 1999).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) CHEST PAIN
    1) WITH POISONING/EXPOSURE
    a) CATERPILLAR (THOSEA PENTHIMA TURNER (LIMACODIDAE))
    1) CASE REPORT: A 29-year-old woman developed radiating and burning pain and local wheal formation immediately after envenomation on her forearm by the billygoat plum stinging caterpillar (Thosea penthima Turner [Limacodidae]). The radiating pain up her right arm became more severe after 30 minutes and "crushing" chest pain developed which lasted for 4 hours. An ECG revealed sinus rhythm and no abnormalities. Following supportive care, her local pain and swelling gradually resolved over the next 10 hours; however, an irritating, red rash at the sting site lasted a week (Isbister & Whelan, 2000).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) RESPIRATORY DISTRESS
    1) WITH POISONING/EXPOSURE
    a) Respiratory distress (bronchoconstriction, cough, and wheezing) has been reported following exposure to oak processionary caterpillars (Gottschling & Meyer, 2006; Gottschling et al, 2007).
    B) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) Shortness of breath was seen after exposure to the hairs of the gypsy moth caterpillar (Shama et al, 1982).
    C) PHARYNGITIS
    1) WITH POISONING/EXPOSURE
    a) Pharyngeal pain may occur if the minute spicule hairs are inhaled (Kawamoto & Kumada, 1984) or ingested (Pitetti et al, 1999).
    D) BRONCHITIS
    1) WITH POISONING/EXPOSURE
    a) Bronchitis and coughing have been noted in some cases where the minute spicules have been inhaled (Kawamoto & Kumada, 1984).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) CENTRAL STIMULANT ADVERSE REACTION
    1) WITH POISONING/EXPOSURE
    a) Megalopyge opercularis caterpillars have been shown to produce pain, irritability, excitement, and restlessness (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964).
    B) PAIN
    1) WITH POISONING/EXPOSURE
    a) Pain and numbness may occur at the sites of exposure to Megalopyge opercularis. The hallmark of these exposures is intense pain (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964; Stipetic et al, 1999). Standard pain management may not relieve the intense pain (Stipetic et al, 1999).
    b) WHITE STEMMED GUM MOTH (Chelepteryx Collesi)
    1) In 13 pediatric cases of C. collesi exposure, pain occurred in each case. Only one patient reported severe pain, while the majority of patients reported mild to moderate pain (Balit et al, 2004).
    c) CATERPILLAR (THOSEA PENTHIMA TURNER (LIMACODIDAE))
    1) CASE REPORT - A 29-year-old woman developed radiating and burning pain and local wheal formation immediately after envenomation on her forearm by the billygoat plum stinging caterpillar (Thosea penthima Turner [Limacodidae]). The radiating pain up her right arm became more severe after 30 minutes and "crushing" chest pain developed which lasted for 4 hours. An ECG revealed sinus rhythm and no abnormalities. Following supportive care, her local pain and swelling gradually resolved over the next 10 hours; however, an irritating, red rash at the sting site lasted a week (Isbister & Whelan, 2000).
    C) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) MISTLETOE BROWNTAIL MOTH (EUPROCTIS EDWARDSI)
    1) CASE REPORT: A 23-year-old woman with a past history of atopy, asthma and mild atopic dermatitis developed an itchy red skin area within 6 hours of exposure and a papulourticarial rash with intense pruritus over the next 24 hours. She also experienced dizziness and light-headedness after the initial exposure. Following supportive care, all symptoms resolved completely over the next several days (Balit et al, 2001).
    b) HYLESIA MOTHS: Dizziness has been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).
    D) HEADACHE
    1) WITH POISONING/EXPOSURE
    a) Headache may occur after Megalopyge opercularis exposures (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964).
    E) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) Shock-like symptoms and, rarely, seizures have been reported after exposure to Megalopyge opercularis (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964; Everson et al, 1990).
    F) MALAISE
    1) WITH POISONING/EXPOSURE
    a) Malaise may occur after exposure (Kawamoto & Kumada, 1984).
    G) DYSESTHESIA
    1) WITH POISONING/EXPOSURE
    a) HYLESIA MOTHS: Dysesthesia has been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) VOMITING
    1) WITH POISONING/EXPOSURE
    a) Vomiting has been noted in both humans and animals after oral exposure to several of these caterpillars (Paniz-Mondolfi et al, 2011; Arditt et al, 1988; McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964) and dermal exposure (Mulvaney et al, 1998).
    B) INFLAMMATORY DISEASE OF MUCOUS MEMBRANE
    1) WITH POISONING/EXPOSURE
    a) Stomatitis has been observed in both humans and animals that have ingested Thaumetapoea or Hemileuca species caterpillars (Pesce & Delgado, 1971; Harwood & James, 1979).
    b) HICKORY TUSSOCK MOTH (LOPHOCAMPA CARYAE) - Stomatitis with drooling has been observed following ingestion of Hickory Tussock moth caterpillars in children (Pitetti et al, 1999). In a study of 292 pediatric exposures to Lophocampa caryae, 8.2% of patients experienced oral/lip irritation and drooling immediately after oral exposure (Kuspis et al, 2001).
    C) GASTROENTERITIS
    1) WITH POISONING/EXPOSURE
    a) Enteritis has been observed in both humans and animals that have ingested Thaumetapoea or Hemileuca species caterpillars (Pesce & Delgado, 1971; Harwood & James, 1979).
    D) GASTROINTESTINAL TRACT FINDING
    1) WITH POISONING/EXPOSURE
    a) A few days of abdominal distress was reported by a woman who accidentally ingested a Phalaenidae caterpillar. No other symptoms were noted, and the caterpillar was discharged in the feces (Judd, 1953).
    b) In a retrospective review of 733 children exposed to caterpillars, 26 children (7 months to 7 years) had oropharyngeal exposure, including 8 ingestions. Lepidopterism symptoms included dysphagia (n=23; 88%), erythema at the site of contact (n=22; 85%), pain (n=18; 69%), edema (n=17; 65%), drooling (n=15; 58%), pruritus (n=15; 58%), and shortness of breath (n=1; 4%). Tongue (n=23; 88%), lips (n=12; 46%), buccal mucosa (n=12; 46%), and palate (n=11; 42%) were the most common sites of involvement. Laryngoscopy, bronchoscopy, and esophagoscopy with microscopic removal of the spines were performed in 8 children. Hypopharynx (n=6; 75%), esophagus (n=5; 63%), and larynx and trachea (n=1; 13%) were the most common sites of involvement in these 8 patients (Lee et al, 1999).
    c) HYLESIA MOTHS: Gastrointestinal upset has been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) EOSINOPHIL COUNT RAISED
    1) WITH POISONING/EXPOSURE
    a) Eosinophilia has been reported after exposure to the caterpillar Megalopyge lanata (James & Harwood, 1969).
    B) LEUKOCYTOSIS
    1) WITH POISONING/EXPOSURE
    a) Leukocytosis has been reported after exposure to the caterpillar Megalopyge lanata (James & Harwood, 1969).
    C) HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) Hemorrhage was observed in patients stung by various Megalopyge species (Picarelli & Valle, 1971). Ecchymosis has also been reported following stings by Megalopyge species (Stipetic et al, 1999).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) WITH POISONING/EXPOSURE
    a) The extent of symptoms will depend on the individual's sensitivity, the type of moth or butterfly, the types of hairs, and the conditions of exposure (Belding, 1964). Exposure may be to the caterpillar or airborne hairs, silken threads, or shed skins (Allen et al, 1991). There are THREE BASIC TYPES OF EXPOSURES (Kawamoto & Kumada, 1984; Kano, 1967):
    1) In TYPE 1 there is dermatitis and itching caused by the penetration of a spicule or spine. In response to the skin being broken by the spicule, and/or a irritant venom being released, histamine or histamine-like substances may be released (Pesce & Delgado, 1971). This causes erythema, pruritus, and edema.
    2) In TYPE 2 the poison-bearing spines and some of the larger spicules cause the symptoms. There is a pricking sensation due to severe mechanical injury. It is similar to a needle puncture. The sensation may be augmented by the venom in the spine.
    3) In TYPE 3 exposures there is severe pain and a strong burning sensation immediately on contact with the insect (Frazier, 1969). The toxic venom is usually the cause of these symptoms.
    b) Whatever the reaction, these initial penetration symptoms generally result in the formation of reddish or whitish papules surrounded by erythema. They may be isolated or grouped. They may develop into urticarial wheals surrounded by smaller papules. These lesions last anywhere from 14 hours to several days. Crusts form on the lesions, followed by desquamation and possible necrosis (Kawamoto & Kumada, 1984).
    c) ACRONYCTA AMERICANA (AMERICAN DAGGER MOTH)
    1) The caterpillar of Acronycta americana was shown to produce dermatitis. Thirty minutes postexposure the patient developed a severe rash. The skin was erythematous and swollen. Wheals developed and the area was pruritic within an hour. The pruritus continued for 4 days. The affected area developed blisters about 2 to 3 mm in area which did not heal completely for about 15 days. Local antipruritics provided only mild relief (Wray, 1963).
    d) ANAPHE SPECIES
    1) Symptoms seen with this species can be attributed to the adult insect (Kawamoto & Kumada, 1984).
    e) AUTOMERIS IO (IO MOTH)
    1) This moth produces a sharp stinging sensation and dermatitis which is similar to that seen with stinging nettles (James & Harwood, 1969).
    f) HYLESIA MOTHS
    1) CASE REPORT: A 40-year-old seaman presented with a 2-week history of severe pruritic skin reaction on his limbs and neck after exposure to Hylesia metabus moth during his visit to French Guyana. He had a papulovesicular dermatitis of the neck and squamous lesions with signs of irritation on the limbs. He was treated with hydrocortisone cream and clemastine tablets. An itchy skin reaction over whole body also developed in about 20 of the ship's crew (Hassing & Bauer, 2008).
    2) A papular urticarial eruption is the most common initial manifestation following Hylesia moth exposure. Erythematous papules and intense itching can develop. Monomorphic eruption of small hard papules surrounded by a small vesicle and serpiginous and confluent vesicular eruptions may also be observed (Paniz-Mondolfi et al, 2011).
    g) LYMANTRIA DISPAR (GYPSY MOTH-CATERPILLAR)
    1) The caterpillar of the gypsy moth (Lymantria dispar) has been shown to produce a mild to moderately pruritic eruption characterized by blotchy erythema, urticarial papules, and linear streaks. Onset is about 8 to 12 hours postexposure, duration 4 to 7 days. Rhinitis, eye irritation and shortness of breath has been seen in laboratory workers. The rash may develop due to contact with the caterpillar or contact with free, wind-blown setae (hairs) (Shama et al, 1982). The rash has been described as resembling tiny insect bites with 1 to 3 mm papules, some vesicular and some excoriated with tiny eschars (Beaucher & Farnham, 1982; CDC, 1982).
    2) Duration of dermatitis: 48 hours (Rosen, 1990) to several days.
    h) MEGALOPYGE LANATA (FLANNEL MOTH)
    1) This moth is found in Central America and has caused cases of serious illness, including symptoms of lymphangitis, leukocytosis, eosinophilia, numbness, vesication, and lymphadenopathy (James & Harwood, 1969).
    i) MEGALOPYGE OPERCULARIS (PUSS CATERPILLAR)
    1) The caterpillar of Megalopyge opercularis has been shown to produce both severe local and some systemic manifestation. Pain, burning, itching, redness and vesiculation, and numbness may be found as may irritability, excitement, restlessness, vomiting, headache, shock-like symptoms, and rarely, seizures (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964). In one case series, 3 patients developed severe sharp pain following envenomation by caterpillar of Megalopyge opercularis in French Guiana. No skin lesions were observed in any patients (Torrents et al, 2015). The hairs of this species penetrate the skin and inject the venom somewhat like a hypodermic syringe. The hallmark of these exposures is intense pain. Treatment includes antihistamines, analgesics, and steroids (Hunt, 1981), or the local application of a corticosteroid, antihistamine, and local anesthetic preparation (Russell, 1988).
    a) DURATION OF DERMATITIS - 7 to 10 days (Rosen, 1990).
    j) MISTLETOE BROWNTAIL MOTH (EUPROCTIS EDWARDSI)
    1) Dermatitis developed in several individuals exposed to airborne hairs of the mistletoe browntail moth caterpillar (Euproctis edwardsi) in a local community center. Seven of 14 employees and 5% of clients experienced recurrent papulourticarial rash during a 4-month period. One client with a past history of atopy, asthma and mild atopic dermatitis developed an itchy red skin area within 6 hours of exposure and a papulourticarial rash with intense pruritus over the next 24 hours. She also experienced dizziness and light-headedness after the initial exposure. Following supportive care, all symptoms resolved completely over the next several days (Balit et al, 2001).
    k) NYGMIA PHAEORRHOEA (BROWN TAIL MOTH)
    1) Ingestion of the hairs is expected to produce symptoms of irritation (James & Harwood, 1969).
    l) ORYIA PSEUDOSUGATA (TUSSOCK MOTH)
    1) This moth has been formerly known as Hemerocampa pseudotsugata.
    2) Occupational exposure has produced rash, urticarial welts, itching, blisters, edematous and itchy eyes, runny or bleeding nose, sore throat, cough or dyspnea, and burning lungs. Some of this reaction may be due to an allergic component (Perlman et al, 1976).
    m) THAUMETOPOEA PITYOCAMPA (PINE PROCESSING CATERPILLAR)
    1) Vomiting and symmetrical swelling of both hands were reported after a 4-year-old boy touched the larva of Thaumetopoea wilkinsoni. He was treated with antihistamines, but the swelling persisted for 2 days (Finkelstein et al, 1988).
    2) Between 1974 and 1988 the poison center in Maisville received 108 calls regarding 91 victims. Of these, 78 were dermal exposures, 4 were cases of ingestion, 5 ocular exposures, and some animal exposures. For the dermal exposures, there were 33 cases of rashes, and 24 of intense edema (area of contact). Most frequently seen areas of exposure were the hands, then the face, eyelid and tongue in descending order of frequency. In some cases the rashes last for 10 days. Some dogs who ate the caterpillar had vomiting, edema of the lids, and in 4 cases distal necrosis of the tongue (Arditt et al, 1988).
    3) DURATION OF DERMATITIS - 7 to 10 days (Rosen, 1990).
    n) THAUMETOPOEA PROCESSIONEA LEPIDOPTERA (OAK PROCESSINARY CATERPILLAR)
    1) Lepidopterism developed in 42 of 90 people (including 28 children) after exposure to an oak infested with oak processionary caterpillars. Patients complained of itching, visible weal and flare lesions, pin-sized red papules. One patient had Quincke's edema and 5 patients developed respiratory distress (bronchoconstriction, cough, and wheezing). All patients received antihistamines and 6 patients were treated with steroids (Gottschling & Meyer, 2006).
    2) In one study of caterpillar dermatitis in a kindergarten population, 10 of 24 (42%) children developed symptoms of lepidopterism. Dermatitis developed in 8 of 10 (80%) of children. Pruritus, respiratory distress, malaise and/or fever, and conjunctivitis developed in 5 (50%), 5 (50%), 4 (40%), and 1 (10%) of patients, respectively (Gottschling et al, 2007).
    3) Two children developed caterpillar dermatitis after exposure to Larvae of Thaumetopoea processionea, the oak processionary caterpillar. The first child, a 16-month-old girl developed weal and flare reactions with rash being sparsely distributed on the skin surface, including face and scalp. The second child, a 5-year-old boy developed dermatitis with toxic irritative character, pin-sized solid, red papules, pustules and erythematous streaks on the chest and both arms (Maier et al, 2004).
    4) In a study of exposure to Thaumetopoea processionea L, 1025 residents/employees of households/institutions located within 50 m of three caterpillar-infested oak trees were contacted by telephone and questioned; 57 (5.6%) people reported 1 or more symptoms of lepidopterism. Pruritus, dermatitis, conjunctivitis, pharyngitis, and respiratory distress were reported in 55 (96%), 54 (95%), 8 (14%), 8 (14%), and 2 (4%) of patients, respectively. A questionnaire was sent to these 57 patients and 37 responded. Weal formation (n=6; 16%), persistent itchy papules (n=18; 49%), toxic irritant dermatitis (n=8; 22%), single occurrence of dermatitis (n=13, 35%), repeated occurrence of dermatitis (n=16; 43%), and polymorphic light eruption (n=2; 5%) were reported (Maier et al, 2003).
    B) LYMPHANGITIS
    1) WITH POISONING/EXPOSURE
    a) Lymphangitis and lymphadenopathy have been seen after exposure to Megalopyge lanata caterpillars.
    C) ITCHING OF SKIN
    1) WITH POISONING/EXPOSURE
    a) ACRONYCTA AMERICANA was shown to produce dermatitis within thirty minutes postexposure. The skin was erythematous and swollen. Wheals developed and the area was pruritic within an hour. The pruritus continued for 4 days. The affected area developed blisters about 2 to 3 mm in area which did not heal completely for about 15 days (Wray, 1963).
    b) LYMANTRIA DISPAR has been shown to produce a mild to moderately pruritic eruption characterized by blotchy erythema, urticarial papules, and linear streaks. Onset is about 8 to 12 hours postexposure, duration 4 to 7 days. The rash may develop due to contact with the caterpillar or contact with free, wind-blown setae (hairs) (Shama et al, 1982; Allen et al, 1991).
    c) HYLESIA: The adult female moth of the genus Hylesia has urticating hairs which upon contact may cause "Caripito itch", a papulourticarial pruritic eruption. The eruption occurs within minutes to several hours after contact and resolves within 2 days (Dinehart et al, 1985; Jamieson et al, 1991).
    1) Symmetrical swelling of both hands were reported after a 4-year-old boy touched the larva of Thaumetopoea wilkinsoni (Finkelstein et al, 1988). One study showed 78 cases of dermal exposure. There were 33 cases of rashes, and 24 of intense edema (area of contact). In some cases the rashes last for 10 days (Arditt et al, 1988).
    d) MEGALOPYGE OPERCULARIS - These caterpillars have been shown to produce pain, burning, itching, redness, edema, vesiculation, and numbness. These caterpillars might also produce irritability, excitement, restlessness, vomiting, headache, shock-like symptoms, and rarely, seizures (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964; Stipetic et al, 1999).
    1) The hairs of this species penetrate the skin and inject the venom somewhat like a hypodermic syringe. The hallmark of these exposures is intense pain, in up to 99% of victims which is not relieved with standard pain management (Stipetic et al, 1999). There may be multiple non-blanching, hemorrhagic, pinpoint papules in a gridlike pattern caused by contact with the caterpillar hairs (Pinson & Morgan, 1991).
    e) AUTOMERIS IO produces a sharp stinging sensation and dermatitis which is similar to that seen with stinging nettles (James & Harwood, 1969).
    f) EUPROCTIS CHRYSORRHOEA
    1) The brown-tailed moth produces an acute dermatitis (James & Harwood, 1969). In a significant percentage of the lesions, the urticating hairs can be detected in the skin after exposure (de Jong et al, 1976).
    2) Most, but not all, patients complain of itching. The initial lesions are usually small erythematous macules and wheals which develop into a central papule and later into a vesicle on an erythematous base. Linear lesions were not seen. Eruptions took one week to heal, without treatment (de Jong et al, 1975).
    3) Early there is infiltration of neutrophils, eosinophils, and mononuclear leukocytes, but by 48 to 72 hours the perivascular infiltrate is primarily mononuclear cells (de Jong et al, 1976).
    4) Heat treating the setae before introduction does not significantly affect penetration, but does reduce some of the inflammatory response (de Jong et al, 1976). This is unlikely to be of clinical value in a normal exposure.
    g) SIBINE STIMULAE (SADDLEBACK CATERPILLAR) - A painful, edematous, white urticarial eruption was seen immediately after exposure to the saddleback caterpillar. In this patient the lesions cleared within 2 hours, but an acute vesicular eruption of the sting area was seen at 72 hours. The patient had been previously exposed, so it is unknown if the second reaction had an allergic component (Edwards et al, 1986).
    h) CHELEPTERYX COLLESI - Local swelling and vesicular eruptions have been reported from dermal contact with the cocoon. Systemic reactions consisting of widespread urticaria, limb swelling, dyspnea, lip numbness and angioedema have also been reported from contact with the cocoon (Mulvaney et al, 1998).
    i) HICKORY TUSSOCK MOTH (LOPHOCAMPA CARYAE) - Pediatric ingestions of caterpillars from the Hickory Tussock moth have resulted in systemic symptoms of urticarial rashes. This moth and its caterpillar are not normally associated with envenomations, since they are not known to have venom sacs and venom (Pitetti et al, 1999).
    1) In a study of 292 pediatric exposures, 94.2% of patients with dermal exposure experienced rash and/or pruritus. In some patients, hairs and spines could be observed in the skin. In all patients, symptoms resolved within 24 hours of exposure (Kuspis et al, 2001).
    D) ERUPTION
    1) WITH POISONING/EXPOSURE
    a) Vesication and an intense burning sensation has been seen after exposure to the caterpillar Megalopyge lanata (James & Harwood, 1969).
    b) CASE REPORT: Hemorrhagic papulovesicles and secondary crust across the dorsum of the fingers was found on physical examination in a 72-year-old male after a Megalopyge opercularis ("puss caterpillar") fell across his fingers. Immediate burning and erythema resulted from the caterpillar contact. The man sought medical attention when the area developed into multiple blood blisters (Gardner & Elston, 1997).
    c) WHITE CATERPILLAR: A 26-year-old man experienced a prickly sensation and widespread rash after being bit by a white caterpillar on the left side of the trunk. He presented with a distinct urticarial lesions on the left side of the chest and abdomen with surrounding erythema. Following treatment with diphenhydramine and dexamethasone, his symptoms gradually resolved (Paraska, 2009).
    E) SKIN FINDING
    1) WITH POISONING/EXPOSURE
    a) DENDROLIMIASIS
    1) Dendrolimiasis is a chronic form of lepidopterism caused by contact with the urticating hairs, spines, or hemolymph of living or dead central Asian pine-tree lappet moth caterpillars (dendrolimus pini) or their cocoons. Clinical features include: urticating maculopapular dermatitis, migratory inflammatory polyarthritis, migratory inflammatory polychondritis, chronic osteoarthritis, and acute scleritis (rare). Although the pathophysiology of this condition remains unknown, the acute phase may be due to IgE-mediated allergy and hypersensitivity to foreign proteins, and the chronic bone and joint disease may be an autoimmune-mediated response (Diaz, 2005).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) DISORDER OF BONE
    1) WITH POISONING/EXPOSURE
    a) Osteitis and ankylosis of the palm and fingers have been reported as chronic manifestations after caterpillar stings (Dias & Azevedo, 1973; Schmidt & Barfred, 1979).
    B) INCREASED MUSCLE TONE
    1) WITH POISONING/EXPOSURE
    a) Muscle cramps may occur after exposure to some caterpillars (Kawamoto & Kumada, 1984). Muscle spasms have been reported following Megalopyge Opercularis stings (Stipetic et al, 1999).
    b) HYLESIA MOTHS: Muscle cramps have been reported following Hylesia moth exposure (Paniz-Mondolfi et al, 2011).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ACUTE ALLERGIC REACTION
    1) WITH POISONING/EXPOSURE
    a) Allergic reactions to various parts of moths and butterflies have been reported. Bronchial asthma and dermal reactions have been attributed to these species (Stevenson & Mathews, 1967; Kino & Oshima, 1979).
    1) There is some clinical evidence that caterpillar hairs produce atopic reactions.
    2) The effect on mast cell degranulation is primarily a direct effect (non-IgE) but assays using enzyme-linked immunosorbent assay found IgE directed against pine-processionary and oak-processionary, but not brown-tail extracts (Werno et al, 1993).
    3) Perman et al (1976) found that 10 of 16 patients occupationally exposed produced significant reactions when tested with tussock moth (Oryia pseudotusugata) preparations. Those with allergic reactions experienced symptoms more frequently and with greater severity .
    4) CASE REPORT - An allergic reaction, consisting of urticaria, angioedema, and bronchospasm, requiring resuscitative measures, developed in an adult after accidental contact with a prickly cocoon (Chelepteryx collesi) (Mulvaney et al, 1998).
    5) CASE REPORT - A 12-year-old boy presented with a pruritic rash over his entire body, tightness and itching of the throat, conjunctival hyperemia, dyspnea, and wheezing after exposure to a caterpillar nest from a pine tree. Laboratory results showed mild eosinophilia (800/mm(3)) but normal serum IgE level (52 IU/mL). Following supportive care, he recovered completely. Two other boys developed mild pruritic rash during the same episode (Shkalim et al, 2008).
    B) ERYTHEMA MULTIFORME
    1) WITH POISONING/EXPOSURE
    a) Erythema multiforme was observed in a man who was skin-tested with an extract from Euproctis chrysorrhoea (brown-tailed moth). The symptoms lasted for a few days. The reaction was allergic-like but no direct evidence was seen (de Jong & Bleumink, 1977b).
    C) LYMPHANGITIS
    1) WITH POISONING/EXPOSURE
    a) Lymphangitis and lymphadenopathy have been reported after exposure to Megalopyge lanata caterpillars (James & Harwood, 1969).
    D) ANAPHYLAXIS
    1) WITH POISONING/EXPOSURE
    a) HYLESIA MOTHS: Anaphylaxis has been reported following Hylesia moth exposure. Patients may present with dyspnea due to glottic edema, vomiting, abdominal pain, and profuse sweating (Paniz-Mondolfi et al, 2011).

Reproductive

    3.20.1) SUMMARY
    A) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
    3.20.2) TERATOGENICITY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the teratogenic potential of this agent.
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Carcinogenicity

    3.21.2) SUMMARY/HUMAN
    A) At the time of this review, no data were available to assess the carcinogenic or mutagenic potential of this agent.
    3.21.3) HUMAN STUDIES
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the carcinogenic potential of this agent.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) There are no specific laboratory tests required for the evaluation of patients with lepidopterism or erucism.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients with evidence of systemic toxicity including asthma, systemic allergic reaction, or seizures should be admitted to the hospital. Those with severe respiratory symptoms, anaphylaxis, or difficult to control seizures should be admitted to an ICU.
    B) Patients that have been exposed to the Chelepteryx collesi (white-stemmed gum moth) should be examined for early signs of a systemic allergic reaction, if there is no evidence of allergy the patient can be safely discharged without the removal of all the spines. Removal of the spines may be quite distressing to a young child, and the parents or guardian need to be reassured that the spines can remain for weeks to months after envenomation with no adverse effects (Balit et al, 2004).
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients with known exposure to caterpillars, portions of cocoons, or moths/butterflies who are asymptomatic and have no signs or symptoms of systemic allergic reactions can be managed at home and do not require observation or admission. Patients with mild irritation or dermatitis after skin exposure, or mild oral irritation after ingestion can be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Contact your local poison center or a medical toxicologist for any patient with suspected severe lepidopterism or erucism. For patients with ocular exposures and concern for retained ocular hair or symptoms of ophthalmia nodosa, consult an ophthalmologist. For patients with severe oral or GI symptoms, gastroenterology should be consulted for possible endoscopy and hair removal. Patients with dendrolimiasis should be referred to a rheumatologist.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with more severe dermatitis or oral irritation, and patients with systemic symptoms or allergic reaction should be referred to healthcare facility for evaluation.

Monitoring

    A) There are no specific laboratory tests required for the evaluation of patients with lepidopterism or erucism.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) An attempt may be made to remove hairs/spines from the skin with scotch tape applied and then peeled off. There is no role for GI decontamination.
    6.5.2) PREVENTION OF ABSORPTION
    A) An attempt may be made to remove hairs/spines from the skin with scotch tape applied and then peeled off. There is no role for GI decontamination.
    6.5.3) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF MILD TO MODERATE TOXICITY
    a) Treatment consists of predominantly symptomatic and supportive care. Local pain, pruritus, and rash can be treated with antihistamines and topical corticosteroids. An attempt should be made to remove hairs/spines from the skin with scotch tape applied and then peeled off; occasionally large spines may be removed with forceps.
    2) MANAGEMENT OF SEVERE TOXICITY
    a) Patients who develop severe toxicity with systemic allergic reactions should be treated with antihistamines, corticosteroids, and if needed, epinephrine for anaphylaxis. Patients with seizures should be treated with benzodiazepines. Patients with oral or GI symptoms after ingesting a caterpillar may require endoscopy for hair or spine removal. Patients with ocular exposure who have hairs visualized on exam, or signs or symptoms of ophthalmia nodosa, should be referred to an ophthalmologist for hair removal and further management. Patients with dendrolimiasis should be treated with systemic corticosteroids and may require a referral to a rheumatologist.
    3) Antihistamines, analgesics, and steroids (Allen et al, 1991) have all been recommended as treatments for caterpillar reaction (Rosen, 1990), as have local, antipruritic soaks (Burnett et al, 1986). A combination of these appears most effective (Hunt, 1981) Wray, 1963).
    4) Urticaria that develops after ingestion of caterpillars may respond to antihistamines and/or corticosteroids (Pitetti et al, 1999).
    B) MONITORING OF PATIENT
    1) There are no specific laboratory tests required for the evaluation of patients with lepidopterism or erucism.
    C) REMOVAL OF FOREIGN BODY
    1) HAIR/SPINE REMOVAL: The hairs or broken spines sometimes left in the skin following contacts with caterpillars or moths can often be removed by the application and peeling of Scotch tape on the injured area (Burnett et al, 1986).
    2) Chelepteryx collesi (white stemmed gum moth): In a study of 13 pediatric cases of cutaneous exposure with envenomation of C. collesi, spine removal was attempted with multiple techniques (eg, tweezers, razor, topically applied drawing ointments, elastoplast or sticky tape) without successful removal of all spines left in the skin in any case. However, no cases of infection or ongoing pain were reported. The authors suggested that spine removal can be quite distressing to a young child and is not essential. Patients should be reassured that the spines will eventually fall out, but it may take weeks or months (Balit et al, 2004).
    D) REMOVAL OF FOREIGN BODY FROM MOUTH
    1) In a retrospective series of 10 children who ingested caterpillars (mostly those of the Hickory Tussock moth), 4 required endoscopy under general anesthesia to remove imbedded hairs from the oropharynx, lips, tongue, buccal mucosa and esophagus (Pitetti et al, 1999). Tape, gauze and gentle scraping with a tongue depressor were used to remove spines from the mouths ot two other children. Hairs or spines may be difficult to visualize without magnification (Pitetti et al, 1999).
    2) In a retrospective review of 733 children exposed to caterpillars, 26 children (7 months to 7 years) had oropharyngeal exposure, including 8 ingestions. Laryngoscopy, bronchoscopy, and esophagoscopy with microscopic removal of the spines were performed in 8 children. Hypopharynx (n=6; 75%), esophagus (n=5; 63%), and larynx and trachea (n=1; 13%) were the most common sites of involvement in these 8 patients (Lee et al, 1999).
    3) In a study of 292 pediatric exposures to Lophocampa caryae, direct laryngoscopy/esophagoscopy with hair removal was performed in 2 children (Kuspis et al, 2001).

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    6.8.2) TREATMENT
    A) OPHTHALMIC EXAMINATION AND EVALUATION
    1) A patient with intraocular hairs should be referred to an ophthalmologist for examination (Kawamoto & Kumada, 1984). Setae may need to be carefully removed under a microscope (Horng et al, 2000).
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) Scratching and rubbing should not be done because of the chance of causing the hairs to penetrate deeper into the skin (Kawamoto & Kumada, 1984).
    2) The first treatment should be washing the spicules out with running water (Goethe et al, 1967; Kawamoto & Kumada, 1984; Kuspis et al, 1998). When Hylesia species are involved, submerge the body in water (Delgado, 1978).
    3) Sometimes the spines are large enough to be seen with a hand lens, and can be removed with a forceps (Kuspis et al, 2001; Southcott, 1978; Kawamoto & Kumada, 1984; Kuspis et al, 1998).
    4) Occasionally the use of adhesive tape may aid in removal (McGovern et al, 1961). The problem may be similar to that of removing cactus spines.
    6.9.2) TREATMENT
    A) ANTIHISTAMINE
    1) Antihistamines have been used to relieve some of the dermal symptoms (Kuspis et al, 2001; Kawamoto & Kumada, 1984; Kuspis et al, 1998). Hypersensitivity reactions to the cocoon of the Chelepteryx species have been reported (Balit et al, 2004; Mulvaney et al, 1998). Therapy with antihistamines or epinephrine in severe cases should be started.
    B) CORTICOSTEROID
    1) Topical corticosteroids have been used for painful cases of dermatitis (Kuspis et al, 2001; Kawamoto & Kumada, 1984; Kuspis et al, 1998). Preparations with a corticosteroid and antihistamine may be of some use in relieving pain and itching. Corticosteroids may also be used for treatment of the systemic symptoms, often in conjunction with epinephrine or oral antihistamines (Hellier & Warin, 1967; Frazier, 1969)
    C) ANALGESIC
    1) Codeine has been used for severe pain (Randel & Doan, 1956; Daly & Derrick, 1975).
    D) LOCAL ANESTHETIC
    1) Tabrah (2007) recommends the injection of 0.25 or 0.50 mL of local anesthetic right into the bite, between the fang marks, to provide immediate relief of the pain. The use of lidocaine with epinephrine may slow the spread of the venom, possibly decreasing the risk of systemic reactions to the bite (Tabrah, 2007).
    E) SURGICAL PROCEDURE
    1) Hairs in the joints may require surgical removal (Kawamoto & Kumada, 1984).
    F) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Range Of Toxicity

Summary

    A) TOXICITY: Acute signs and symptoms have been described after exposure to a single caterpillar, cocoon, or moth or butterfly. Symptoms have been described in patients without direct dermal contact; these patients are typically thought to be affected by airborne hairs from these species, and symptoms typically include respiratory, nasopharyngeal, conjunctival, and dermal irritation.

Minimum Lethal Exposure

    A) Only a few fatalities have been reported, and a dose/symptoms relationship has not been established (Kawamoto & Kumada, 1984).

Maximum Tolerated Exposure

    A) Even one moth, butterfly, or caterpillar may produce a reaction. The reactions are variable, depending on the species involved, individual sensitivities, and the extent of the exposure.

Pharmacology Toxicology

Toxicologic Mechanism

    A) There are at least 11 types of spicules and spines found in these species. Types 1 to 7 are spicules, types 8 to 11 are spines (Kawamoto & Kumada, 1984). The reaction seen has both a mechanical irritation and toxic-irritant reaction component (de Jong et al, 1975).
    1) TYPE 1 - may be found from the egg stage through adulthood.
    2) TYPE 2 - found from the early larval stages through the cocoon stage.
    3) TYPE 3 - found in the first instar (just before the larval stage) through the cocoon stage.
    4) TYPE 4 - found from the last larval stages (last instar) through the cocoon stage.
    5) TYPE 5 - present at a time similar to the type threes.
    6) TYPE 6 - present at a time similar to the type threes.
    7) TYPE 7 - present from the egg stage to the first instar or early larval stages.
    8) TYPES 8 TO 11 - found in the larval (caterpillar) stage.
    B) Some of the skin irritation may be due to foreign body reaction. Radioenzyme assay has identified histamine in exposures to the gypsy moth caterpillar (Shama et al, 1982).
    C) TOXINS
    1) SUMMARY: The hairs do contain toxins whose properties are still being investigated. The toxins, in species studied, are thermolabile proteins which possess enzymatic and proteolytic activity. Hair toxins have been noted to possess trypsin and chymotrypsin-like activity, and plasminogen activation (Rosen, 1990).
    2) Euproctis chrysorrhoea (brown-tailed moth) venom:
    a) Contains an erythrocyte deforming substance which is probably phospolipase A enzyme. Spicule extracts also contain trypsin- and chymotrypsin-like enzymes (de Jong et al, 1982). Serine proteases, such as kallikrein play a major role in the development of clinical symptoms (Bleumink et al, 1982).
    3) Hylesia moths:
    a) Experimental studies have shown that histamine is at least partially responsible for the urticarial lesions. Other mediators were not ruled out (Dinehart et al, 1987).
    D) Megalopyge opercularis: The hairs of this species penetrate the skin and inject the venom somewhat like a hypodermic syringe (McGovern et al, 1961; Lucas, 1942; McMillan & Purcell, 1964).

Animal Toxicology

Clinical Effects

    11.1.2) BOVINE/CATTLE
    A) The rangeland caterpillar (Hemileuca oliviae) has been a menace to cattle who would develop blisters on their mouth due to accidental contact while feeding (James & Harwood, 1969).
    11.1.3) CANINE/DOG
    A) Some dogs who ate Thaumetopoea caterpillars had vomiting, edema of the lids, and in 4 cases distal necrosis of the tongue (Arditt et al, 1988).

References

General Bibliography

    1) Allen VT, Miller F, & Tyler WB: Gypsy moth caterpillar dermatitis - revisted. J Am Acad Dermatol 1991; 24:979-981.
    2) Arditt J, David JM, & Jean PH: Accidents provoques par la chenille processsonnaire du pin en Provence. J Toxicol Clin Exp 1988; 4:247-251.
    3) Asahina S & Ogata K: Recores of the outbreak of the Far Eastern urticating moth, Euproctis flava, in Japan. Jpn J Sanit Zool 1956; 7:104-106.
    4) Balit CR, Geary MJ, Russell RC, et al: Clinical effects of exposure to the white-stemmed gum moth (chelepteryx collesi). Emerg Med Aust 2004; 16:74-81.
    5) Balit CR, Ptolemy HC, Geary MJ, et al: Outbreak of caterpillar dermatitis caused by airborne hairs of the mistletoe browntail moth (Euproctis edwardsi). Med J Aust 2001; 175(11-12):641-643.
    6) Beaucher WN & Farnham JE: Gypsy-moth-caterpillar dermatitis. N Engl J Med 1982; 306:1301-1302.
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