Pyemotes ventricosus Dermatitis, Southeastern France

We investigated 42 patients who had unusual pruritic dermatitis associated with a specific clinical sign (comet sign) in 23 houses in southeastern France from May through September 2007. Pyemotes ventricosus, a parasite of the furniture beetle Anobium punctatum, was the cause of this condition.

I n 2006, we described an outbreak of unusual dermatitis in southeastern France (1). Patients affected had highly erythematous pruritic macules typical of arthropod bites, sometimes associated with a linear erythematous macular tract that we called the comet sign ( Figure 1). The cause of this outbreak remained unknown. In May 2007, during an entomologic ecoenvironmental investigation conducted inside the homes of some of these patients, we found wooden furniture, which harbored live furniture beetles (Anobium punctatum) ( Figure 2, panel A), and small amounts of wood dust on the fl oor. Because A. punctatum does not bite humans or cause contact dermatitis (2), it was not considered as the direct causative agent. However, stereomicroscope examination of the wood dust identifi ed the mite Pyemotes ventricosus (Figure 2, panel B). Because Pyemotes spp. can cause dermatitis (3), they were considered as the hypothetical agent causing the eruption. We then conducted an observational and entomologic study of the new cases.

The Study
From May through September 2007, all patients referred to the dermatology department at Fréjus Hospital (Fréjus, France) with suspected arthropod-bite dermatitis were examined; patients were also checked for the comet sign. Patients were asked about their outdoor activities (walking in the countryside, gardening), homes, and whether they had wooden furniture potentially infested with furniture beetles. Skin eruptions were photographed. Detailed clinical and histologic descriptions of the lesions have been reported (1).
Whenever possible, ecoenvironments (surrounding terrain and home interior) of patients with typical macules associated with the comet sign were investigated. Household pets were examined by veterinarians. When wormholes were found in wooden furniture, A. punctatum was noted as present in the immediate environment. Mites were collected and examined under a stereomicroscope (magnifi cation ×80). Removal of furniture was recommended if it was infested with A. punctatum.
From May through October 2007, 42 patients with typical eruption formed 23 clusters, comprising 1-5 patients each living in the same home. Nineteen patients lived <50 km from Fréjus and 23 were vacationing in this city. Among the 23 homes in the cluster, 14 were entomologically and ecoenvironmentally investigated. A. punctatum ( Figure 2, panel A) was found in all 14 homes and P. ventricosus was found in 12 (83%). Females ( Figure 2, panel B), some gravid, and rare males were seen. Entomologic investigations outside homes found no evidence of any other insect pests. Veterinarians who examined the 2 pets living in these homes excluded dog ectoparasites. Dermatitis persisted or recurred for weeks in all patients until infested furniture was removed or patients left their homes. Oral prednisone (0.5 mg/kg) rapidly (within 48 hours) attenuated the pruritus.
One of us (P.D.) volunteered to place P. ventricosusinfested wood dust on 1 cm 2 of abdominal skin under an occlusive bandage for 4 hours. Two negative controls consisted of placing uncontaminated wood dust under a bandage and the bandage alone. Twenty-four hours later, an erythematous macular pruritic lesion was observed that lasted for 7 days, but no comet sign developed. No cutaneous reaction was observed under the 2 negative-control bandages.
Natural dermatitis also occurred in 2 investigators during collection of ecoenvironmental samples. Typical lesions with the comet sign ( Figure 1, panels E and F) developed in these investigators after they touched wood dust and infested furniture (1 of the investigators had only entered a room with infested furniture but had not touched it). Skin scrapings of the investigators did not contain parasites. A skin-biopsy specimen from 1 investigator showed a sub-

Conclusions
In 2006, we described an outbreak of an unusual dermatitis associated with a specifi c clinical sign that we called the comet sign (1). In 2007, similar cases occurred and we demonstrated that the mite P. ventricosus was the causative agent of the condition. P. ventricosus (Newport, 1850) (phylum Arthropoda, class Arachnida, order Acarina, suborder Prostigmata, family Pyemotidae) is an ectoparasite of arthropod larvae. This mite has been reported to be associated with A. punctatum (De Geer, 1774), the common furniture beetle (2).
This mite was associated with 2 investigators' macular lesions that were acquired during experimental or natural infection. Natural infestation gave rise to macules frequently associated with the comet sign. We visualized, by using in vivo CLSM, a microvesicle, an ovoid foreign body with morphologic features suggestive of the mite. An entomologic ecoenvironmental investigation found P. ventricosus and its host (A. punctatum) in 83% of the patients' homes investigated. Although Pyemotes spp.-related dermatitis outbreaks have been described, the outbreak we describe showed an emergent pattern with documented intradomiciliary infestation and the comet sign.
The outbreak was associated with home interior infestations of P. ventricosus associated with A. punctatum. Fine and Scott described the fi rst cases of dermatitis caused by P. ventricosus parasitizing A. punctatum (8). In Great Britain, Hickin found that up to 60% of woodworm larvae in damp locations were parasitized with Pyemotes spp., which were considered responsible for some skin irritations in woodsmen (2). More recently, Rodriguez-Casado et al. and most of them were living in homes that had been closed for months (i.e., not cleaned regularly), making it likely that the interior mite concentration would be high. Pyemotes spp. dermatitis has been described as a pruritic erythematous rash with maculopapules with a central microvesicle (7). We initially reported that the typical pruritic erythematous macules were sometimes associated with a linear tract (comet sign) (1). Several hours after exposure, a linear erythematous macular tract arose from patients' lesions. Whether this sign is specifi c to Pyemotes spp. or P. ventricosus remains unknown. The epidermis along the linear tract was clinically and histologically intact (1), thereby making contact dermatitis or epidermal migration of P. ventricosus, as in human scabies, unlikely. In vivo CLSM detected features suggestive of the mite inside the cutaneous microvesicle. A comet sign might represent onset of specifi c lymphangitis, as suggested for 1 patient (Figure 1, panel D). Two recent similar cases in southern France, which were considered specifi c atypical lymphangitis (14,15), might have been P. ventricosus dermatitis.