A 33-year-old man presented with very itchy red papules on the back of his hands and forearms. These papules appeared about 90 min after he had cleaned his aquarium in which he kept native fish and watersnails. He had obtained the watersnails some weeks before from a nearby pond. Examination of water from the aquarium revealed cercariae. The clinical diagnosis of cercarial dermatitis was corroborated. Cercarial dermatitis has repeatedly been seen in swimmers but not in aquarists keeping fish in a home aquarium

Bastert, J.

Korting, Hans Christian

Sing, A.

Wollenberg, A.

English

Open Access LMU

© 1998 S. KargerAG, Basel1018–8665/98/1971–0084$15.00/0Fax+ 41 61 306 12 34E-Mail karger@karger.ch This article is also accessible online at:www.karger.com http://BioMedNet.com/kargerJ. Bastert aA. Sing bA. Wollenberg aH.C. Korting aa Dermatologische Klinik und Poliklinik undb Max-von-Pettenkofer-Institut für Hygiene undMedizinische Mikrobiologie derLudwig-Maximilians-Universität München,DeutschlandCase ReportDermatology 1998;197:84–86Aquarium Dermatitis:Cercarial Dermatitis in an AquaristIntroductionThe frequency of dermatitis caused bycontact with water contaminated by cercariaein Central Europe has not yet been finally es-tablished. On the one hand there is no duty tonotify such cases to a special authority, andon the other hand cercarial dermatitis is oftenmisdiagnosed. Midsummer is the main sea-son for this type of dermatitis. In most casesthe patients show disseminated red papulesspread over the entire integument which pre-sent after swimming in warm water. In ourcase the patient came to the out-patients’clinic in spring. He presented with lesions re-stricted to the back of his hands and forearmsafter contact with his aquarium’s water. Thisis the first case published in the literature ofcercarial dermatitis in an aquarist.Case ReportA 33-year-old patient came to the out-patients’ department in May. One day beforehe had cleaned his aquarium without usinggloves. It was a so-called cold water aquar-ium with native fish and watersnails. Twoweeks before the patient had collected thesnails in a little pond. A few days before hecleaned the basin the radiator of the aquariumhad broken down. The temperature of thewater had risen above 17°C. About 90 minafter the cleaning had been finished the pa-tient noted red itchy papules on the back ofhis hands and his forearms, restricted to thoseparts of his arms which had been exposed tothe water. During the following hours the red-ness of the papules and the itch increased.The patient presented himself with mul-tiple, erythematous seropapules and papulo-vesicles up to 3 mm in diameter, on the backof both hands and forearms (fig.1).Histologically a slightly broadened epi-thelium and subepidermal edema were found.Moreover there was perivascular lympho-histiocytic infiltration in the dermis (fig.2).Special stains for microbial pathogens werenot of diagnostic relevance.The patient brought one of the snails in abowl containing water from the aquariumupon request (fig.3). Macroscopically cer-cariae could be seen swimming in the water.Microscopic examination of the water re-vealed cercariae of the genus Trichobilharzia(fig.4).On day 1 and day 14 after developmentof the dermal manifestations, serum was ob-tained and analyzed by the cercaria-hullenreaction and the circumoval precipitin test,respectively. Both serological tests yieldednegative results. As expected, an indirecthemagglutination assay detecting Schisto-soma mansoni antigen (Cellognost Schis-tosomiasis, Behringwerke, Marburg, Ger-many) of a human pathogenic trematodespecies was also negative.DiscussionCercarial dermatitis or swimmer’s itch iscaused by the larval stages (cercariae) of thetrematode family Schistosomatidae whosedefinitive hosts are water birds and whoseintermediate hosts are watersnails [1–4]. Be-cause man is not the definitive host, the cer-cariae die within hours after penetration ofthe skin. The cercariae can be found in freshwater (swimmer’s itch) and in salt water (seabather’s eruption) [5–8]. In Central Europeespecially Trichobilharzia szidati and Tri-chobilharzia ocellata are found. The adulttrematodes live in the mesenterial blood ves-sels of ducks, where they produce eggs. Afterthe passage from the blood system to the in-testinal lumen, the trematode eggs reach thewater with the host’s feces [1, 3, 6, 9–11]. Inthe water short-lived miracidiae hatch fromthe eggs and penetrate an intermediate host,in our case a snail of the species Lymnaeastagnalis. The middle gland of the snails iswhere they gather and develop into cercariaewithin 2–3 months [12, 13]. At a water tem-perature ‡ 17°C infectious cercariae leave thesnails, gather in the top 5 cm of the water andProf. Hans Christian KortingDermatologische Klinik und Poliklinik der Ludwig-Maximilians-Universität MünchenFrauenlobstrasse 9–11D–80337 Munich (Germany)ooooooooooooooooooooooooooooooooooooooooooooKey WordsCercarial dermatitisAquariumWatersnailoooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooAbstractA 33-year-old man presented with very itchy red papules on the back of his hands and forearms.These papules appeared about 90 min after he had cleaned his aquarium in which he kept nativefish and watersnails. He had obtained the watersnails some weeks before from a nearby pond.Examination of water from the aquarium revealed cercariae. The clinical diagnosis of cercar-ial dermatitis was corroborated. Cercarial dermatitis has repeatedly been seen in swimmers butnot in aquarists keeping fish in a home aquarium.ooooooooooooooooooooReceived: November 26, 1997Accepted: February 22, 199885Aquarist’s Cercarial Dermatitis Dermatology 1998;197:84–86Fig. 1. Cercarial dermatitis. Forearm with red papules, 3 daysafter infestation.Fig. 2. Cercarial dermatitis. Histology of a papule from the fore-arm. HE. · 25.Fig. 3. Watersnail from the aquarium.Fig. 4. Cercaria from the aquarium.1 342again infest water birds [12, 14]. Cercariaereact very unselectively to chemo- or photo-tactic stimulation [13–15]. This means thatthey do not only recognize ducks as their de-finitive host, but also rather unspecifically in-fest other occasional hosts, humans forexample. While the cercariae are able to enterthe blood vessels of their definitive host, afterpenetration of their skin, they are not adaptedto complete their life cycle in occasional hostswhere they die within a few hours after pene-tration of the skin without reaching deeper tissue. In humans the first infestation doesnormally not lead to a reaction but causes sen-sitization. Thereafter all further exposurescause local inflammation with erythematouspapules and papulovesicles [2, 12]. The dis-ease can also present as an exanthema.In our case there are two points to con-sider. On the one hand we do not exactlyknow if the patient ever had any contact withcercariae before, on the other hand it couldbe the first infestation with cercariae with aquantitiy of parasites that would normallynever occur in the natural environment, thusdramatically accelerating development ofhypersensitivity. People who have contactwith contaminated water at work are espe-cially endangered. It is acknowledged as anoccupational disease in carp fishermen inEurope and in rice farmers in Asia [16].The diagnosis can easily be made byknowing the exact medical history. The pos-sibility of contaminated water has always tobe considered. The routine laboratory inves-tigations are not indicative. In some labora-tories there is the possibility to detect anti-bodies by the cercaria-hullen reaction or thecircumoval precipitin test 2 weeks after theinfestation [17]. Both tests, however, onlyvery rarely yield positive results.The histology of the papules only showsan unspecific picture which is comparable tothat of an insect bite.The differential diagnosis comprises‘whirl-pool dermatitis’ caused by Pseudo-monas spp. Also contact dermatitis has to beexcluded. A useful treatment is the local ap-plication of glucocorticoids or peroral dosesof antihistamines.In our case it should be pointed out thatthe unusual localization of the lesions, the un-usual extent of the erythema and the unusualseason in which the dermatitis developedmade the diagnosis more difficult. In mostcases, cercarial dermatitis appears dissemi-nated over the entire body or is restricted tothe legs after standing in a natural waterreservoir [17]. Our patient, however, pre-sented with a cutaneous reaction localized tothe hands and forearms. Interestingly, thepalms were spared. An explanation for thismight be that the cercariae were not able topenetrate the skin in this area due to its differ-ent skin quality. The unusual intensity of thelesions may be best explained by the fact thatkeeping 5 contaminated watersnails in a nor-mal-sized home aquarium led to an accumu-lation of the cercariae which is not the case ina pond or lake.The main season for cercarial dermatitisis midsummer. When the water temperaturerises above 17°C the cercariae which undernatural conditions hibernate in their interme-diate host leave the snails to complete theirlife cycle in ducks [14, 18]. By the break-down of the radiator of the aquarium thewater temperature dramatically rose and amidsummer day was simulated. The cerca-riae left the infested snails, appeared in thewater and could thus attach themselves to theskin of an occasional host [19, 20].Since cercariae cannot survive without ahost for longer than a few hours the aquariumcould have been decontaminated by remov-ing the snails [12, 15]. Also heating the waterto a temperature above 45°C would havekilled the larval trematodes. Yet our patientpreferred to start a new less contagious hobbyand took all fish and snails back to the ruralpond where he had caught them.86 Dermatology 1998;197:84–86 Bastert/Sing/Wollenberg/Korting1 Haeusser M, Ippen H: Dermatosen inSchwimmbädern. Hautarzt 1981;36:436–440.2 Hohorst W: Schnecken als Brutstätten para-sitischer Würmer. Nat Mus 1981;111:60–69.3 Kimmig P, Meier M: Parasitologische Untersu-chungen, Diagnose und Klinik der Zerkarien-dermatitis. Zentralbl Bakteriol Mikrobiol Hyg1985;181:390–408.4 Kirschenbaum MB: Swimmer’s itch: A reviewand case report. Cutis 1979;23:212–216.5 Baird JK, Wear DJ: Cercarial dermatitis: Theswimmer’s itch. Clin Dermatol 1987;5:88–91.6 Kolarova L, Gottwaldova V, Cechova D, Sev-cova M: The occurrence of cercarial dermatitisin Central Bohemia. Zentralbl Hyg 1989;189:1–13.7 Oyoo AO, Donnell D, Pendergast TJ: Epi-demic of ‘swimmer’s itch’ traced to cercarialtrematodes. Mo Med 1977;74:218–219.8 Schmidt B, Kerner H, Kampf WD: Dermatitisdurch Schistosomenlarven. Dtsch Ärztebl 1965;62:1174–1182.9 Allgöwer R, Effelsberg W: Badedermatitis-epidemie im Baggersee – ein Anlass zur Zu-standsanalyse des Gewässers und Vorbereitungeiner naturverträglichen Nutzungskonzeption.Öff Gesundheitswes 1991;53:138–143.10 Allgöwer R: Die Zerkarien- oder Badedermati-tis. Biol Zeit 1990;3:144–148.11 Müller V: Untersuchungen zur Bilharziose derEnten in Süddeutschland; Diplomarbeit Uni-versität Hohenheim, 1991.12 Allgöwer R, Matuschka F-R: Zur Epidemio-logie der Zerkariendermatitis. Bundesgesund-heitsblatt 1993;10:399–404.13 Neuhaus W: Biologie und Entwicklung vonTrichobilharzia szidati (Trematoda, Schistoso-matidae), einem Erreger von Dermatitis beimMenschen. Z Parasitenkd 1952;15:203–206.14 Picher O, Aspoeck H, Wiedermann G: Die Zer-karien-Dermatitis – eine Parasitose einheimi-scher Badegewässer. Münch Med Wochenschr1974;116:1452.15 Freiler W: Wirtsfindung und Wirtserkennungder Cercarie von Trichobilharzia ocellata;Dissertation, Universität Frankfurt am Main,1985.16 Landmann H, Thai DD, Ngoan TV, Nga VB:Cercarien-Dermatitis bei Reispflanzern inVietnam. Zentralbl Bakteriol I Abt Orig1961;182:410–416.17 Pilz J, Eisele S, Disko R: Zerkariendermatitis(swimmer’s itch). Hautarzt 1995;46:335–338.18 Dönges J: Schistosomatiden-Cercarien Süd-deutschlands, ein Beitrag zur Kenntnis derma-titiserregender Trematodenlarven. Z Tropen-med Parasitol 1965;16:304–320.19 Dönges J: Hautreaktionen bei Schistosomeninvasionen. Dtsch Med Wochenschr 1964;89:1512–1516.20 Kimmig W: Zerkarien-Badedermatitis. Z AllgMed 1984;60:967–973.References

Aquarium dermatitis: Cercarial dermatitis in an aquarist

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Aquarium dermatitis: Cercarial dermatitis in an aquarist

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