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PAEDERUS BLISTER BEETLES

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Paederus species are found worldwide. There are over 600 species of the genus Paederus that have been described. At least 30 species in this genus may cause eye lesions and dermatitis in animals.

Specific Substances

    A) SYNONYMS FOR THE GROUP
    1) Blister beetle, Paederus
    2) Rove Beetles
    3) Whiplash Beetles
    4) Finch Hatton Bug
    5) Fuetazo
    6) Skirt and Blouse
    CONSTITUENTS OF THE GROUP
    1) P. alfierii koch
    2) P. alternams
    3) P. australis (Guerin.)
    4) P. columbinus
    5) P. crebre punctatus
    6) P. cruenticollis (Germar)
    7) P. fuscipes (Curt.)
    8) P. goeldii
    9) P. peregrinus
    10) P. sabaeus (Erichs)
    11) Pederine
    12) Paederine
    13) CAS 27973-72-4 (Pederine)

Available Forms Sources

    A) SOURCES
    1) Paederus beetles are found worldwide, but are more common in tropical than temperate regions.
    B) USES
    1) In animal studies in rats and mice, ascetic tumors were effectively treated with pederin based on its ability to inhibit mitosis without affecting RNA synthesis (Morsy et al, 1996). This agent continues to be used in cellular biology and cancer research.

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) BACKGROUND: Paederus beetles are 7 to 8 mm long, slim, weigh about 4 mg, and somewhat resemble an ant. They usually have bright banded color markings of black, blue, or orange. There are over 600 species of the genus Paederus that have been described. At least 30 species in this genus have caused eye lesions and dermatitis in animals. Many exposures occur at night. These beetles are attracted to the lights of houses, camps, ships, or work areas. The beetles fall onto skin or inside of clothing or blankets. When the insects are crushed or swatted, the toxin is released in linear "whiplash" streaks that are characteristic.
    B) TOXICOLOGY: Pederin is an alkaloid with toxicity greater than Latrodectus venom and/or parathion. Pederin is a powerful inhibitor of protein biosynthesis and mitosis. Exposure results in epidermal necrosis and blistering, and can cause acanthosis with mitotic figures.
    C) EPIDEMIOLOGY: Exposure is rare. Paederus beetles are found worldwide, but most species are mainly distributed in temperate climates and tropical continents.
    D) WITH POISONING/EXPOSURE
    1) Paederus beetles do NOT bite or sting, but secrete irritants that cause both skin and eye lesions. This dermatitis is characterized by erythemato-bullous lesions of sudden onset. A typical lesion will start with a linear streak or "whiplash" and progresses to a rash within 12 to 48 hours. A wheal develops that is covered with small, non-joining blisters. The lesion is usually very pruritic and painful with scab formation that falls off by the tenth to twelfth day, leaving a darkly-pigmented area that may persist for weeks or months. The irritants may be spread from one body part to another, occasionally causing "kissing lesions" at places like the joints of the elbow, back of the knee, or in skin folds. Systemic effects have NOT been noted. Oral irritation, nausea, and vomiting have not been reported, but might be expected if these beetles or their hemolymph were to be ingested. Conjunctivitis has been reported after rubbing the crushed beetles or their hemolymph into the eye. The eyelids may become edematous, and blindness has been reported in children.

Laboratory Monitoring

    A) There is no specific clinical laboratory test which is helpful in identifying this toxin once a patient has been exposed. Pederin may be identified by gas chromatography.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF EXPOSURE
    1) Treatment is symptomatic and supportive. Symptoms generally are NOT seen for at least 12 hours post exposure, at which time tissue death has occurred and few treatments are effective. Antihistamines and steroids have NOT been shown to be useful. Analgesics or soothing creams may be of some use. Wounds and lesions should be kept clean to prevent secondary infection. Systemic effects have NOT been noted. Oral irritation, nausea, and vomiting have not been reported, but might be expected if these beetles or their hemolymph were to be ingested.
    B) DECONTAMINATION
    1) Immediate decontamination is important if an individual knows they have been exposed. It is unclear how much washing reduces the reaction. Although there have been no reports of ingestions, the Paederus blister beetles secrete a substance that may cause oral, esophageal, or gastric irritation. Emesis and activated charcoal are NOT recommended. DILUTION: Administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting.
    C) AIRWAY MANAGEMENTS
    1) Should not be required in these cases.
    D) ANTIDOTE
    1) None.
    E) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients who are asymptomatic or with minimal symptoms after exposure to Paederus beetles and are otherwise improving may be managed at home.
    2) OBSERVATION CRITERIA: Patients who are symptomatic need to be monitored until they are clearly improving and clinically stable.
    3) ADMISSION CRITERIA: Only patients with systemic toxicity may require admission.
    4) CONSULT CRITERIA: Consult a regional poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    F) PITFALLS
    1) Common errors occur in misdiagnosis. Failure to obtain adequate history of exposure.
    G) DIFFERENTIAL DIAGNOSIS
    1) Impetigo, herpes simplex, Rhus dermatitis, herpes zoster, thermal dermatitis, and factitial dermatitis are possible misdiagnoses.
    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.
    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) It is unclear how much washing reduces the reaction. Analgesics or soothing creams may be of some use. Antihistamines and corticosteroids have been of little or NO use. Wounds should be kept clean to prevent secondary infection.

Range Of Toxicity

    A) TOXICITY: Any contact with these irritants may cause rash, wheal, or blistering. Excessive material may spread to other skin surfaces.

Clinical Effects

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Rubbing the crushed beetle or hemolymph into the eye may cause conjunctivitis. The problem is frequent in Africa and has been called "Nairobi Eye" (James & Harwood, 1969). Edema of the eyelids may also occur (McCrae & Visser, 1963).
    2) BLINDNESS has been reported in children exposed in Africa (McCrae & Visser, 1963).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) GASTRITIS
    1) WITH POISONING/EXPOSURE
    a) Oral irritation, nausea, and vomiting have NOT been reported, but might be expected. It is unclear if oral and/or gastrointestinal effects would develop if this beetle or its hemolymph were to be ingested.

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) DISORDER OF SKIN
    1) WITH POISONING/EXPOSURE
    a) TYPICAL LESION: Is usually a linear streak or "whiplash" lesion known as dermatitis linearis. Initial contact is painless. Onset of symptoms occurs 12 to 48 hours after exposure with a duration of 10 to 12 days (Gelmetti & Grimalt, 1993; George & Falope, 1989).
    b) The irritants may be spread from one body part to another, occasionally causing mirror image or "kissing lesions" at places like joints (elbows, back of knees, skin folds) where contaminated skin may contact other skin surfaces (Monteith & Argent, 1987; James & Harwood, 1969).
    c) INCIDENCE: Of the more than 600 Paederus species, approximately 5% may cause dermatitis linearis (Kellner, 2000).
    B) ERUPTION
    1) WITH POISONING/EXPOSURE
    a) Rash is the first symptom, generally, developing within 12 to 48 hours (Monteith & Argent, 1987; George & Falope, 1989).
    C) URTICARIA
    1) WITH POISONING/EXPOSURE
    a) WHEAL FORMATION is the second observable symptom, generally occurring within 2 to 4 days (Monteith & Argent, 1987).
    D) BULLOUS ERUPTION
    1) WITH POISONING/EXPOSURE
    a) BLISTERS are generally seen on the wheal. They usually do NOT form into a single blister, but consist of a number of smaller blisters.
    b) CASE REPORT: A 61-year-old woman crushed over 200 Paederus fuscipes (collected by the patient) and mixed them with an ointment as an alternative treatment for her vitiligo. Approximately 3 to 4 hours after applying the ointment, redness and severe tingling occurred, which progressed to vesiculobullous eruptions over the next 24 hours. The lesions were successfully treated with systemic corticosteroids and antihistamines, along with wet dressings and silver sulfadiazine cream (You et al, 2003).
    E) DISCOLORATION OF SKIN
    1) WITH POISONING/EXPOSURE
    a) Post-inflammatory hyperpigmentation often occurs (George & Falope, 1989).

Summary Of Exposure

    A) BACKGROUND: Paederus beetles are 7 to 8 mm long, slim, weigh about 4 mg, and somewhat resemble an ant. They usually have bright banded color markings of black, blue, or orange. There are over 600 species of the genus Paederus that have been described. At least 30 species in this genus have caused eye lesions and dermatitis in animals. Many exposures occur at night. These beetles are attracted to the lights of houses, camps, ships, or work areas. The beetles fall onto skin or inside of clothing or blankets. When the insects are crushed or swatted, the toxin is released in linear "whiplash" streaks that are characteristic.
    B) TOXICOLOGY: Pederin is an alkaloid with toxicity greater than Latrodectus venom and/or parathion. Pederin is a powerful inhibitor of protein biosynthesis and mitosis. Exposure results in epidermal necrosis and blistering, and can cause acanthosis with mitotic figures.
    C) EPIDEMIOLOGY: Exposure is rare. Paederus beetles are found worldwide, but most species are mainly distributed in temperate climates and tropical continents.
    D) WITH POISONING/EXPOSURE
    1) Paederus beetles do NOT bite or sting, but secrete irritants that cause both skin and eye lesions. This dermatitis is characterized by erythemato-bullous lesions of sudden onset. A typical lesion will start with a linear streak or "whiplash" and progresses to a rash within 12 to 48 hours. A wheal develops that is covered with small, non-joining blisters. The lesion is usually very pruritic and painful with scab formation that falls off by the tenth to twelfth day, leaving a darkly-pigmented area that may persist for weeks or months. The irritants may be spread from one body part to another, occasionally causing "kissing lesions" at places like the joints of the elbow, back of the knee, or in skin folds. Systemic effects have NOT been noted. Oral irritation, nausea, and vomiting have not been reported, but might be expected if these beetles or their hemolymph were to be ingested. Conjunctivitis has been reported after rubbing the crushed beetles or their hemolymph into the eye. The eyelids may become edematous, and blindness has been reported in children.

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) There is no specific clinical laboratory test which is helpful in identifying this toxin once a patient has been exposed. Pederin may be identified by gas chromatography.
    4.1.2) SERUM/BLOOD
    A) OTHER
    1) There are no useful specific clinical laboratory tests.

Methods

    A) CHROMATOGRAPHY
    1) Pederin and its derivatives may be identified with gas chromatography, but this is seldom done in the clinical setting.

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) Only patients with systemic toxicity may require admission.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients who are asymptomatic or with minimal symptoms after exposure to Paederus beetles and are otherwise improving may be managed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a regional poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients who are symptomatic need to be monitored until they are clearly improving and clinically stable.

Monitoring

    A) There is no specific clinical laboratory test which is helpful in identifying this toxin once a patient has been exposed. Pederin may be identified by gas chromatography.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Immediate decontamination is important if an individual knows they have been exposed. It is unclear how much washing reduces the reaction. Although there have been no reports of ingestions, the Paederus blister beetles secrete a substance that may cause oral, esophageal, or gastric irritation. Emesis and activated charcoal are NOT recommended.
    B) DILUTION
    1) If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    2) USE OF DILUENTS IS CONTROVERSIAL: While experimental models have suggested that immediate dilution may lessen caustic injury (Homan et al, 1993; Homan et al, 1994; Homan et al, 1995), this has not been adequately studied in humans.
    3) DILUENT TYPE: Use any readily available nontoxic, cool liquid. Both milk and water have been shown to be effective in experimental studies of caustic ingestion (Maull et al, 1985; Rumack & Burrington, 1977; Homan et al, 1995; Homan et al, 1994; Homan et al, 1993).
    4) ADVERSE EFFECTS: Potential adverse effects include vomiting and airway compromise (Caravati, 2004).
    5) CONTRAINDICATIONS: Do NOT attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Diluents should not be force fed to any patient who refuses to swallow (Rao & Hoffman, 2002).
    6.5.2) PREVENTION OF ABSORPTION
    A) Although there have been no reports of ingestions, the Paederus blister beetles secrete a substance that may cause oral, esophageal, or gastric irritation. Emesis and activated charcoal are NOT recommended.
    B) DILUTION
    1) If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. The exact ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    2) USE OF DILUENTS IS CONTROVERSIAL: While experimental models have suggested that immediate dilution may lessen caustic injury (Homan et al, 1993; Homan et al, 1994; Homan et al, 1995), this has not been adequately studied in humans.
    3) DILUENT TYPE: Use any readily available nontoxic, cool liquid. Both milk and water have been shown to be effective in experimental studies of caustic ingestion (Maull et al, 1985; Rumack & Burrington, 1977; Homan et al, 1995; Homan et al, 1994; Homan et al, 1993).
    4) ADVERSE EFFECTS: Potential adverse effects include vomiting and airway compromise (Caravati, 2004).
    5) CONTRAINDICATIONS: Do NOT attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Diluents should not be force fed to any patient who refuses to swallow (Rao & Hoffman, 2002).
    6.5.3) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF EXPOSURE
    a) Treatment is symptomatic and supportive.
    b) Symptoms generally are NOT seen for at least 12 hours post exposure, at which time tissue death has occurred and few treatments are effective (Monteith & Argent, 1987).
    c) ANTIHISTAMINES AND CORTICOSTEROIDS have been tested with little or no success (Deneys & Zumpt, 1963).
    d) ANALGESIC OR SOOTHING CREAMS may be of some use (Monteith & Argent, 1987).
    e) Wounds and lesions should be kept clean to prevent secondary infection.
    B) MONITORING OF PATIENT
    1) There is no specific clinical laboratory test which is helpful in identifying this toxin once a patient has been exposed. Pederin may be identified by gas chromatography.

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).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    6.9.2) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF EXPOSURE
    a) Treatment is symptomatic and supportive.
    b) Symptoms generally are NOT seen for at least 12 hours post exposure, at which time tissue death has occurred and few treatments are effective (Monteith & Argent, 1987).
    c) ANTIHISTAMINES AND CORTICOSTEROIDS have been tested with little or no success (Deneys & Zumpt, 1963).
    d) ANALGESIC OR SOOTHING CREAMS may be of some use (Monteith & Argent, 1987).
    e) Wounds and lesions should be kept clean to prevent secondary infection.
    B) MONITORING OF PATIENT
    1) There is no specific clinical laboratory test which is helpful in identifying this toxin once a patient has been exposed. Pederin may be identified by gas chromatography.
    C) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Abstracts

Case Reports

    A) A typical case would involve a usually painless initial contact which is often unnoticed by the patient. Within 12 to 48 hours, a red rash is formed. This rash generally stays about the same size. By the second to fourth day a wheal raises over the rash and the surface develops small blisters which do NOT form into a single blister. At this point, the lesion is generally painful and weepy, until about the seventh day when it begins to reduce in size and become pruritic. The itching may be intense and prolonged. The lesion forms a scab which is discarded by the 10th and 12th day, leaving a darkly pigmented area that may persist for weeks or months (Monteith & Argent, 1987).

Range Of Toxicity

Summary

    A) TOXICITY: Any contact with these irritants may cause rash, wheal, or blistering. Excessive material may spread to other skin surfaces.

Maximum Tolerated Exposure

    A) Any contact with these irritants will cause rash, wheal, or blistering. Excessive material may spread to other skin surfaces.

Pharmacology Toxicology

Toxicologic Mechanism

    A) TOXIN IDENTIFICATION
    1) The vesicating toxins are found in the hemolymph of the insect. At first it was thought to be cantharidin, but this was disproved by McCrae & Visser (1963) using gas chromatography (McCrae & Visser, 1963).
    2) Pavan & Bo (1953) isolated a chemical they called pederin from Paederus fuscipes (Curt.), as well as derivatives pseudopederin and pederone (Pavan & Bo, 1953; Cardani et al, 1965).
    3) Pederin is an alkaloid with toxicity greater than Latrodectus venom and/or parathion (Pavan, 1959).
    B) ACTIONS
    1) Pederin is a powerful inhibitor of protein biosynthesis and mitosis (Budavari, 1996).
    2) Exposure results in epidermal necrosis and blistering, and can cause acanthosis with mitotic figures (Borroni et al, 1991).

Physicochemical

Physical Characteristics

    A) Crystals of pederin are extracted with hexane.

Molecular Weight

    A) 503.63

References

General Bibliography

    1) Borroni G, Brazzelli V, & Rosso R: Paederus fusipes dermatitis: a histopathological study. Am J Dermatopathol 1991; 13:467-474.
    2) Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Whitehouse Station, NJ, 1996.
    3) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    4) Caravati EM: Alkali. In: Dart RC, ed. Medical Toxicology, Lippincott Williams & Wilkins, Philadelphia, PA, 2004.
    5) Cardani C, Ghiringhelli D, & Mondelli R: Proprietes biologiques et composition chimique de la pederine [French]. Ann Soc Entom Fr (NS) 1965; 1:813-816.
    6) Dallas ED: Coleopteros que originan dermatitis en la Republica Argentina [Spanish]. Proc 7th Intern Cong Entom, 678-682, 1938.
    7) Deneys JB & Zumpt F: Rove beetle dermatitis in South West Africa. S Afr Med J 1963; 37:1284-1285.
    8) Gelmetti C & Grimalt R: Paederus dermatitis: an easy diagnosable but misdiagnosed eruption. Eur J Pediatr 1993; 152:6-8.
    9) George AO & Falope ZF: An epidemic of Paederus dermatitis in southern Nigeria. Contact Dermatitis 1989; 20:314-315.
    10) Homan CS, Maitra SR, & Lane BP: Effective treatment of acute alkali injury of the esopahgus with early saline dilution therapy. Ann Emerg Med 1993; 22:178-182.
    11) Homan CS, Maitra SR, & Lane BP: Histopathologic evaluation of the therapeutic efficacy of water and mild dilution for esophageal acid injury. Acad Emerg Med 1995; 2:587-591.
    12) Homan CS, Maitra SR, & Lane BP: Therapeutic effects of water and milk for acute alkali injury of the esophagus. Ann Emerg Med 1994; 24:14-19.
    13) James MT & Harwood RF: Herms's Medical Entomology, 6th ed, Macmillan Publishing Co, New York, NY, 1969.
    14) Kellner RLL: Possible genetic basis of pederin polymorphism in rove beetles (paederus riparius). J Heredity 2000; 91:158-162.
    15) Maull KI, Osman AP, & Maull CD: Liquid caustic ingestions: an in vitro study of the effects of buffer, neutralization, and dilution. Ann Emerg Med 1985; 4:1160-1162.
    16) McCrae AWR & Visser SA: Recent "Nairobi eye" beetle (Paederus sabaeus (Er)) outbreaks in Uganda and studies on the vesicating toxin. Biochem J 1963; 89:79.
    17) McKeown KC: Dermatitis apparently caused by staphylinid beetles in Australia. Med J Aust 1951; 2:772-773.
    18) Monteith G & Argent C: In Covacevich J, Davie P, Pearn J (Eds), Toxic Plants and Animals: A Guide for Australia, QLD Museum, Queensland, Australia, 1987.
    19) Morsy TA, Arafa MAS, & Younis TA: Studies on paederus alfierii koch (coleoptera: staphylinidae) with special reference to the medical importance. J Egypt Soc of Parasitology 1996; 26:337-351.
    20) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    21) Papasarathorn T, Areekul S, & Chermsirivatana S: A study of the rove beetle (Paederus fuscipes Curt.) causing vesicular dermatitis in Thailand. J Med Assoc Thailand 1961; 44:60-81.
    22) Pavan M & Bo G: Pederin, toxic principle obtained in the crystalline state from the beetle Paederus fuscipes (Curt.). Physiol Comp Oecol 1953; 3:307-312.
    23) Pavan M: Biochemical aspects of insect poisons. 4th Intern. Congr Biochem 1959; 12:15-36.
    24) Pavlovsky EN & Stein AK: The cutaneous poison of the beetle Paederus fuscipes. Trans Roy Soc Trop Med Hyg 1927; 20:450-451.
    25) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    26) Rao RB & Hoffman RS: Caustics and Batteries, in Goldfrank LR, Flomenbaum NE, Lewin NA et al (eds): Goldfrank's Toxicologic Emergencies, 7th ed, McGraw-Hill, New York, NY, 2002.
    27) Rumack BH & Burrington JD: Caustic ingestions: a rational look at diluents. J Toxicol Clin Toxicol 1977; 11:27-34.
    28) Theodorides J: Considerations sur les Paederus vesicants (Coleoptera, Staphylinidae) et essais de vesication avec des especes de France [French]. Bull Soc Path Exot 1950; 43:100.
    29) You DO, Kang JD, Youn NH, et al: Bullous contact dermatitis caused by self-applied crushed paederus fuscipes for the treatment of vitiligo. Cutis 2003; 72:385-388.