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Outbreak of Phototoxic Dermatitis from Limes -- Maryland

On August 8, 1984, the Office of Disease Control and Epidemiology, Maryland Department of Health and Mental Hygiene, was notified by a nurse at a day camp in Owings Mills, Maryland, of a rash illness reported among 12 children during the previous week. The rash, confined to the dorsa of the hands and extensor and flexor surfaces of the forearms and in the form of blotches, speckles, and streaks, was macular, hyperpigmented, and nonpruritic. No other signs or symptoms were noted. Dermatologists diagnosed the rash as a phototoxic contact dermatitis. Investigation disclosed that limes used in an art class to make pomander balls were incriminated as the cause of the rash.

All children and counselors at the day camp were examined for evidence of the characteristic rash. A case was defined as a day-camp member with the rash noted by the examiner between August 8 and August 14. Ninety-seven (16%) of 622 children and seven (7%) of 104 counselors were affected. None of the 57 adult staff members reported a rash. Analysis of rash in children and counselors by sex and race showed no disproportionate representation. Since most children were too young to remember a date of onset, parents of children with rash were telephoned and asked for the date they first discovered the rash (Figure 1). Of the 82 (85%) mothers contacted, 23 (28%) had not noticed the rash or had thought it was dirt.

Several activities involving work with hands were investigated. Five activities that involved more than two-thirds (65) of affected children were significantly associated with illness (p less than or equal to 0.004). These activities were making wallpaper, pomanders, tissue wine-paper cups, and burlap covers and participating in a nature scavenger hunt. However, when controlling for each of the other four activities, only exposure to making pomanders in arts and crafts class was significantly associated with illness (p less than or equal to 0.03). Of the 17 counselors who had helped children make the pomanders, seven had the rash (p 0.001), whereas none of the 34 counselors who were not exposed to the pomanders had the rash (p 0.001). The pomanders were made from July 23 to July 27 by camp units A and B (approximately 60 children per unit) and by some members of units D and H on July 31. Discovery of the rash for most cases correlates with the time of exposure (Figure 1).

In making pomanders, the children received one lime each during class, poked several holes in it with scissors, filled the holes with cloves, sprinkled cinnamon over the lime, and placed the product in cloth later tied with a pipecleaner. During the process, oil glands in the lime skin probably ruptured, releasing chemicals in the oil known to cause phototoxicity on exposure to the sun (1-5).

The limes were purchased from a supermarket, part of a nationwide chain, that purchases its limes from Florida. After harvesting the limes, the processors wash off any insecticides (all water-soluble) and later coat the limes with an inert vegetable wax. Environmental and botanical survey of the camp did not reveal other chemicals or plants with phototoxic potential with which camp members may have come into contact.

Reported by E Israel, MD, State Epidemiologist, Maryland State Dept of Health and Mental Hygiene; Div of Field Svcs, Epidemiology Program Office, Chronic Diseases Div, Center for Environmental Health, CDC.

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