Research

JAMA Dermatology | Brief Report

Outbreak of Occupational Dermatitis Associated

With Pyemotes ventricosus
Martyna Tomczyk-Socha, MD; Katarzyna Jędrzejewska-Jurga, MD;
Joanna Limburska, MD; Jarosław Tomczyk, MD, PhD

IMPORTANCE Although Pyemotes species have been known to cause dermatitis, recent
reports are rare. During the past 30 years, only 3 outbreaks of dermatitis caused by Pyemotes
ventricosus have been reported.

OBJECTIVE To analyze the causative agent of skin changes in employees of a company that
produced herbal medicines.

DESIGN, SETTING, AND PARTICIPANTS This case series includes 18 patients (8 men, 10 women;
mean age, 44 years) who contracted unusual dermatitis after an occupational exposure in
July and August of 2012 while working for a company that produced herbal medicines. The
patients were examined at the Lower Silesia Regional Centre of Occupational Medicine in
Wroclaw, Poland.

EXPOSURES Workers weighed and packed 1 part of the Helichrysum arenarium herb.

MAIN OUTCOMES AND MEASURES We hypothesized the causative agent to be

P ventricosus. An examination of the herbal specimens for ectoparasites confirmed
the diagnosis.

RESULTS Initially 16 employees developed pruritic skin changes. Skin lesions with pruritic
vesicles on an erythematous base with surrounding swelling and edema were observed.
Several employees also developed a flulike illness. After 44 days, 2 new employees presented Author Affiliations: Department of
with the same skin changes. The analysis of working conditions showed that the same part of Ophthalmology, Wroclaw Medical
the H arenarium herb was weighed and packed at that time. University, Wroclaw, Poland
(Tomczyk-Socha); Lower Silesia
Regional Centre of Occupational
CONCLUSIONS AND RELEVANCE We found that changing the time when the herbs were Medicine, Wroclaw, Poland
weighed and abandoning gas fumigation containing methyl bromide resulted in the (Jędrzejewska-Jurga, Limburska,
Tomczyk).
recurrence of an almost forgotten disease.
Corresponding Author: Martyna
Tomczyk-Socha, MD, Wroclaw
JAMA Dermatol. 2017;153(7):686-688. doi:10.1001/jamadermatol.2017.0323 Medical University, Borowska 213,
Published online April 26, 2017. 50-556, Wroclaw, Poland (martyna
_tomczyk@wp.pl).

S
everal outbreaks of occupational dermatitis caused by
Pyemotes ventricosus have been observed in the 19th and
20th centuries. In 1981 Betz et al1 described an out-
break of occupational dermatitis associated with straw itch
mites. Since then, to our knowledge, only 3 outbreaks of der-
matitis caused by P ventricosus have been reported.1-5
Pyemotes ventricosus, one of the pyemotid mites, which
can temporally infest humans as incidental hosts, was first de-
scribed by Newport in 1853 (Figure 1). These mites, also known
as grain itch mite, hay itch mite, or straw itch mite, can cause
a pruritic dermatitis.6-8
Numerous patches of intensely pruritic dermatitis ap-
peared on the trunk and proximal extremities. Vesicular urti-
carial lesions on an erythematous base may present 24 hours
after contact with P ventricosus. This eruption is self-limited
and typically resolves in 1 to 3 weeks.3,8 Patients may also de-
velop systemic symptoms, such as fever, chills, vomiting, or
intense headache.1,9
The diagnosis can be challenging to make because the mites
are not visible to the naked eye and its bites are painless. There
is also a delay of several hours between the bite and the ap-
pearance of the pruritic skin changes. Therefore, the patient
does not correlate the dermatitis with the insect bites and the
diagnosis has to be made based on the patient’s history and
identification of the mites.9,10
In this report, we present a case series of 18 patients
with pyemotid-induced dermatitis after an occupational
exposure.

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 Occupational Dermatitis Associated With Pyemotes ventricosus
Report of Cases
In August 2012, the Regional Centre of Occupational Medi-
cine was asked to help clarify the cause of skin lesions
appearing in employees of a company that produced herbal
medicines.
In July 2012, 16 employees developed pruritic skin changes.
Initially, 7 employees noticed skin changes presenting on the
trunk (7/7), hands (4/7), neck (3/7) and, in individual cases, on
the groin, face, and ears. Over the next 4 days, 9 other em-
ployees developed similar symptoms. Several employees also
developed a flulike illness. None attributed the symptoms to
an occupational exposure, and patients visited physicians from
various specialties looking for a diagnosis.
General practitioners, internists, dermatologists, and emer-
gency medicine specialists described the skin lesions as ex-
tremely pruritic vesicles on an erythematous base with sur-
rounding swelling and edema. A central, darker lesion was
often present (Figure 2).
Owing to the nonspecific clinical picture, patients were
given various diagnoses. Some were treated as an allergic der-
matitis with oral antihistamines. Those who were suspected
of having an inflammatory etiology were treated with topical
steroids. Some were treated with antibiotics. Most of the
changes disappeared within 2 weeks of exposure for 11 of 16
patients.
Because multiple workers noticed the same changes over
a short period of time, a search for a causative factor was un-
dertaken. Contact and allergic triggers were first suspected.
However, the employer denied the introduction of any new
substances, materials, or allergens, and stressed that all em-
ployees were wearing protective equipment. It was puzzling
that the symptoms were occurring in different anatomical lo-
cations. An infectious agent was also suspected, but the symp-
toms did not appear to be contagious because they were not
transmitted to family members.
After 44 days, 2 new employees presented with the same
skin changes. Based on the medical history, physical exami-
nation, and photographic evidence collected, it was thought
that the skin changes may be from bites. An initial diagnosis
of toxic allergic dermatitis from contact with P ventricosus was
established.
The working conditions at the herbal medicines com-
pany were evaluated between July 6 and July 10 and on Au-
gust 23, 2012. Analysis showed that the same part of the
Helichrysum arenarium herb was weighed and packed at that
time. The intensity of symptoms reported by the workers de-
pended on their role, position during handling, and time of ex-
posure. Of note, not all employees who developed symptoms
actually had direct contact with the herb. Symptoms also
presented in workers who only had airborne exposure to
the mite. This unusual pattern helped direct the team to the
correct diagnosis.
To confirm the proposed etiology, 2 samples of inflorescence
H arenarium were obtained and sent to the laboratory. Living
samples of Liposcelis bostrychophilus, Acaridae (Tyrophagus pu-
trescentiae, Carpoglyphus lactis), and also P ventricosus were iso-
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Brief Report Research
Key Points
Question What caused unusual pruritic dermatitis after an
occupational exposure in employees of a company that produced
herbal medicines?
Findings In this case series of 18 employees we hypothesized the
causative agent to be Pyemotes ventricosus and an examination of
the herbal specimens for ectoparasites confirmed the diagnosis.
We found that changing the time when the herbs were weighed
and abandoning gas fumigation containing methyl bromide led to
a recurrence of an almost forgotten disease.
Meaning This case series demonstrates the importance of
examining environmental specimens for ectoparasites in cases of
unexplained dermatoses.
lated. Experts at the laboratory suggested that the most likely
cause of the skin lesions in workers exposed to the herbs was
P ventricosus. This confirmed the diagnosis and the implemen-
tation of fumigation with phosphine gas was recommended.
Discussion
This article describes a case series of 18 occupational-related
cases of unusual dermatitis caused by P ventricosus. The di-
agnosis initially raised many doubts, both for physicians and
for the management of the company. Medical examinations
were carried out up to 2 months after the changes occurred.
The documentation of various symptoms was taken from an
interview with patients and physicians conducting the early
research.
After the diagnosis was made, it was necessary to ex-
plain why these symptoms had never presented before.
Helichrysum arenarium had been used at this workplace for de-
cades. Many of the employees who presented with the skin
changes weighed and were in contact with this herb in previ-
ous years and never experienced any symptoms. The crucial
change that led to the development of symptoms was the sea-
son during which the herbs were sorted. In previous years, sort-
ing of H arenarium was done in the winter months, whereas
in 2012, sorting was done in July.
Principato11 examined the spread of the P ventricosus and
found that the mite has a characteristic cycle of occurrence in
the natural environment. Higher population density of the mite
is seen between May and August, and it is virtually undetect-
able between September and November. In 2012, the sorting
of the herb happened in July, when the population of the P ven-
tricosus was highest.11
The presence of P ventricosus and Acaridae indicates that
the material was stored in humid conditions. Isolated pests
(T putrescentiae, C lactis) can cause skin allergic reaction, but
usually the course of the disease is milder. The most danger-
ous for humans is P ventricosus, which can cause severe pru-
ritic skin reactions and general symptoms (as described in this
case series). However, we cannot be 100% sure that the clini-
cal picture is produced by P ventricosus because the parasitic
analysis also showed the presence of other mites.
(Reprinted) JAMA Dermatology July 2017 Volume 153, Number 7 687
 Research Brief Report Occupational Dermatitis Associated With Pyemotes ventricosus

Figure 1. Pyemotes ventricosus Figure 2. Pruritic Changes in 1 of 18 Employees

A Clinical image B Clinical image

1 mm

The mite feeds on the larva of other pests. In the absence of other pests, these
mites will attach themselves to humans. From the Centers for Disease Control Skin lesions on an erythematous base with surrounding swelling and edema.
and Prevention (https://phil.cdc.gov/phil/details.asp?pid=5492).

lead to the reemergence of cases or even outbreaks of largely

To our knowledge, there have been almost no reports of
occupational-related pyemotid dermatitis published in the past
30 years. This could be largely related to an effective pest con-
trol process using methyl bromide as a gas fumigant. Methyl
bromide was first registered in the United States in 1961 to con-
trol insects as a space fumigant, and has a rapid onset of ac-
tion and broad spectrum of activity. It has been used as an acari-
cide, fungicide, herbicide, insecticide, nematicide, and
rodenticide.12,13
However, the chemical was banned because it was found
to deplete ozone levels in the atmosphere.12 It is very likely that
removing methyl bromide from the process of pest control will
forgotten diseases, such as the one described in this case.
Conclusions
The combination of abandoning gas fumigation with methyl
bromide and changing the time of weighing herbs led to an out-
break of a pruritic skin lesions among 18 employees of a medi-
cal herb company. This resulted in the reemergence of an al-
most forgotten disease. Our case series demonstrates the
importance of examining environmental specimens for ecto-
parasites in cases of unexplained dermatoses.

ARTICLE INFORMATION associated with straw itch mites (Pyemotes 8. Fine RM, Scott HG. Straw itch mite dermatitis
Published Online: April 26, 2017. ventricosus). JAMA. 1982;247(20):2821-2823. caused by pyemotes ventricosus: comparative
doi:10.1001/jamadermatol.2017.0323 2. Czarnecki N, Kraus H. [Occupational dermatitis aspects. South Med J. 1965;58:416-420.

Author Contributions: Drs Tomczyk-Socha and
Tomczyk had full access to all of the data in the
study and take responsibility for the integrity of the
data and the accuracy of the data analysis.
Concept and design: Tomczyk-Socha, Tomczyk.
Acquisition, analysis, or interpretation of data:
Jędrzejewska-Jurga, Limburska.
Drafting of the manuscript: Tomczyk-Socha.
Critical revision of the manuscript for important
intellectual content: Jędrzejewska-Jurga,
Limburska, Tomczyk.
Statistical analysis: Tomczyk-Socha.
Administrative, technical, or material support: All
authors.
Study supervision: Tomczyk.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patients
for granting permission to publish this information.
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