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CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 181-183

Tulipalin A induced phytotoxicity


Center for Environmental/Occupational Risk Analysis and Management, College of Public Health, University of South Florida, Tampa, Florida, USA

Date of Web Publication9-Jun-2014

Correspondence Address:
James McCluskey
Center for Environmental and Occupational Risk Analysis and Management, College of Public Health, University of South Florida, Tampa, Florida 33612
USA
James McCluskey
Center for Environmental and Occupational Risk Analysis and Management, College of Public Health, University of South Florida, Tampa, Florida 33612
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.134187

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   Abstract 

Tulipalin A induced phytotoxicity is a persistent allergic contact dermatitides documented in floral workers exposed to Alstroemeria and its cultivars. [1] The causative allergen is tulipalin A, a toxic glycoside named for the tulip bulbs from which it was first isolated. [2] The condition is characterized by fissured acropulpitis, often accompanied by hyperpigmentation, onychorrhexis, and paronychia. More of the volar surface may be affected in sensitized florists. Dermatitis and paronychia are extremely common conditions and diagnostic errors may occur. A thorough patient history, in conjunction with confirmatory patch testing with a bulb sliver and tuliposide A exposure, can prevent misdiagnosis. We report a case of Tulipalin A induced phytotoxicity misdiagnosed as an unresolved tinea manuum infection in a patient evaluated for occupational exposure.

Keywords: Allergic contact dermatitides, cryptococcus, dermatitis, phytotoxicity, tuliposide A


How to cite this article:
McCluskey J, Bourgeois M, Harbison R, McCluskey J, Bourgeois M, Harbison R. Tulipalin A induced phytotoxicity. Int J Crit Illn Inj Sci 2014;4:181-3

How to cite this URL:
McCluskey J, Bourgeois M, Harbison R, McCluskey J, Bourgeois M, Harbison R. Tulipalin A induced phytotoxicity. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2019 May 23];4:181-3. Available from: http://www.ijciis.org/text.asp?2014/4/2/181/134187


   Introduction Top


Adverse reactions resulting from recreational and occupational plant exposures are fairly ubiquitous. [3],[4],[5],[6] Injuries range from mild respiratory complaints, phytodermatitis, irritant contact dermatitis, and allergic contact dermatitis to toxin-induced injuries and mechanical damage. [7] Tulipalin A induced phytotoxicity, also Tulip Fingers and Alstroemeria dermatitis, is a common occupational allergy in floral workers exposed to Tulip and Alstroemeria cultivars. Similar phytotoxicity results from allyl isothiocyanate compounds present in the Cruciferae plant family. [3],[8] Tulipalin A (a-methylene-g-butyrolactone) and its parent compound tuliposide A (a-methylene-g-hydroxybutyric acid) are concentrated in the outer layers of the plant bulbs and the pistils. In the plant, they are protective antibiotics exerting a fungicidal effect in flower bulbs. [9],[10] Both compounds were evaluated along with 240+ chemicals for inclusion on the 'Allergen List' compiled by Germany's Federal Institute for Risk Assessment (BfR). They were assigned to Category B: Solid-based indication for contact allergenic effects, because there is evidence of contact allergenic effects in animals and humans as well as induction of cross reactions in humans. [11] They can also be considered skin sensitizers because under The Globally Harmonized System for Classification and Labeling of Chemicals (GHS), a human skin sensitizer is "a substance that will induce an allergic response following skin contact". [12],[13]

Although there are multiple forms of dermatitis, the clinical presentation is often similar. [3] Common symptoms include erythema, pruritus, edema, lichenification, and vesiculation. This may make accurate diagnosis challenging. Tulip Fingers and Alstroemeria dermatitis, the latter in particular due to the popularity of the inexpensive Alstroemeria in lower cost floral arrangements, should be considered as a differential diagnosis in cases of unresolved dermatitis in floral workers. [2],[14] In this article we highlight the importance of comprehensive patient histories in a case of Tulipalin A induced phytotoxicity misdiagnosed as a tinea manuum infection in an individual with suspected occupational fungal exposure and a review of the relevant scientific literature necessary to evaluate risk factors for the disease.


   Case Report Top


An immunocompetent 30-year-old female, was referred for a medical examination to assess persistent unresolved tinea manuum, possibly related to occupational fungal exposure. The patient complained of "little bumps" on the dorsal surface of her right index finger around the distal interphalangeal joint. The bumps erupted across the dorsal surface of her right hand between digits #1 and #2, progressed up to her wrists, popped, dried, and flaked off the residual skin. The condition recurred several times over the next few months.

All physical examination outcomes were normal with the exception of lichenification and peeling of multiple fingers, including the palmar and dorsal surface, ulcers on several fingertips of each hand, pain, and discoloration of hands. Apart from the ongoing issue with her hands, the patient's medical history was unremarkable. No one in her immediate family has any history of persistent dermatologic complaints.

The patient was initially diagnosed with tinea manis and prescribed a lengthy course of prescription antifungal treatment in 2010 after a nail culture indicated yeast, later identified as Cryptococcus. Tinea manis is unlikely, given the absence of the characteristic ring-like pattern. The presence of a Cryptococcus species was likely a skin contaminant as it is unlikely that she would have an infection since the vast majority of Cryptococcal infections occur in immunocompromised individuals. The antifungal medication did not significantly change the course of the disease process. The lesions seem to worsen over time, and then get better. Over time, the skin on her finger pads has thinned greatly. She has resorted to wearing a band-aid over her right index finger tip because it is continuously tender and depigmented. At night, the dorsal surfaces of her fingers seem to itch a great deal with no relief. The patient was instructed not to wear gloves at work because the gloves reportedly "trap" the fungus underneath and expose her skin.

The patient mentioned that she works a great deal with the ornamental plant and flower Alstroemeria, which has a moderate literature database detailing cases of persistent allergic contact dermatitis in florists. As previously noted, the causative allergen is known as tulipalin A (a-methylene-g-butyrolactone). The glycoside and its parent compound are named for the tulip bulbs from which they were originally derived. There is also a moderate literature database describing "tulip fingers", an allergic contact dermatitis found in tulip workers primarily in the Netherlands. Interestingly, areas of depigmentation often follow the characteristic lesions that are similar to the initial bumps that this patient reported at the first visit.

The patient was instructed to wear nitrile gloves at work, as her condition is not a fungal problem. She should not wear vinyl gloves, as the causative allergen crosses every type of common gloves except nitrile. She was referred to a dermatologist who may elect to take a skin biopsy and/or perform patch testing. Diagnosis of tulipalin A induced phytotoxicity requires patch testing with the routine TRUE TEST, as well as a number of plant extracts including: Sesquiterpene lactone mix 0.1%, parthenolide 0.1%, 2,6-ditert-butyl-p-cresol 2%, and at least one preparation of tulipalin A.


   Discussion Top


First described as 'tulip fingers' in the European tulip industry, tulipalin A induced phytotoxicity results in severe dermatitis. Similar phytotoxicity, termed Alstroemeria dermatitis, has been described in florists who use Alstroemeria. [15],[16] Contact with plants containing tulipalin A may result in persistent allergic contact dermatitis. [1],[17] It is a common occupational complaint in floral workers who handle Alstoemeria and Tulip cultivars. [5],[18] The toxin is most concentrated in the flower bulbs and stems, although smaller amounts may be found in other parts of the plant. [2],[10]

Effects of tulipalin A exposure may be immediate or delayed. [19] Manifestations of phototoxicity include pruritus and edema in the fingers and along the palmar surface of the hand. Lesions develop and gradually exfoliate. Repeated exposures may lead to significant thinning of the skin and pigmentation changes. [20] Paronychia is commonly seen along with nail splitting and ulceration of the nail bed in more severe cases. [21] Patients typically report significant pain associated with the outbreaks. Sensitive individuals may also develop rhinitis following airborne exposures. [22],[23] Facial swelling may result if the worker touches their face after handling the bulbs. The only effective treatment is to reduce contact with tulipaside and using nitrile gloves. [15] Vinyl gloves are not an effective barrier.


   Conclusion Top


Differentiating tulipalin A induced phytotoxicity from the innumerable other dermatoses makes diagnosis difficult. [24] A suspected case of contact dermatitis requires meticulous history taking and physical examination. [11] Typically, a sensitized individual will develop acute symptoms 12-24 h after any subsequent exposures. [6] Patch testing is used to demonstrate contact with the allergenic tulipaside A. [7],[25] Given the occupational history of this patient, a diagnosis of tulipalin A phytotoxicity is far more appropriate than tinea manis or Cryptococcus. Follow-up with a dermatologist for skin biopsy and/or patch testing with TRUE TEST is recommended.

 
   References Top

1.McGovern TW. Alstroemeria L. (Peruvian lily). Am J Contact Dermat 1999;10:172-6.  Back to cited text no. 1
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2.Caulfeild AH. "Tulip Fingers": Ragweed Dermatitis. Can Med Assoc J 1936;34:506-10.  Back to cited text no. 2
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3.Sasseville D. Clinical patterns of phytodermatitis. Dermatol Clin 2009;27:299-308.  Back to cited text no. 3
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4.Cook DK, Freeman S. Allergic contact dermatitis to plants: An analysis of 68 patients tested at the Skin and Cancer Foundation. Australas J Dermatol 1997;38:129-31.  Back to cited text no. 4
    
5.Tavares B, Loureiro G, Pereira C, Chieira C. Home gardening may be a risk factor for contact dermatitis to Alstroemeria. Allergol Immunopathol (Madr) 2006;34:73-5.  Back to cited text no. 5
    
6.Goon AT, Goh CL. Plant dermatitis: Asian perspective. Indian J Dermatol 2011;56:707-10.  Back to cited text no. 6
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7.de Jong NW, Vermeulen AM, Gerth van Wijk R, de Groot H. Occupational allergy caused by flowers. Allergy 1998;53:204-9.  Back to cited text no. 7
    
8.Lerbaek A, Rastogi SC, Menne T. Allergic contact dermatitis from allyl isothiocyanate in a Danish cohort of 259 selected patients. Contact Dermatitis 2004;51:79-83.  Back to cited text no. 8
    
9.BergmanBH. Presence of a substance in the white skin of young tulip bulbs which inhibits growth of fusarium oxysporum. Neth J Plant Pathol 1966:72:222-30.  Back to cited text no. 9
    
10.Bergman BH, Beijersbergen JC. A fungitoxic substance extracted from tulips and its possible role as a protectant against disease. Neth J Plant Pathol 1968;74 Suppl 1 :157-62.  Back to cited text no. 10
    
11.Schlede E, Aberer W, Fuchs T, Gerner I, Lessmann H, Maurer T, et al. Chemical substances and contact allergy--244 substances ranked according to allergenic potency. Toxicology 2003;193:219-59.  Back to cited text no. 11
    
12.UNECE. Globally Harmonized System of Classification and Labelling of Chemicals (GHS). In: UNECE, editor. 4 th ed., United Nations New York: 2011. p. 15.  Back to cited text no. 12
    
13.Holzhutter HG, Genschow E, Diener W, Schlede E. Dermal and inhalation acute toxic class methods: Test procedures and biometric evaluations for the Globally Harmonized Classification System. Arch Toxicol 2003;77:243-54.  Back to cited text no. 13
    
14.Gette MT, Marks JE, Jr. Tulip fingers. Arch Dermatol 1990;126:203-5.  Back to cited text no. 14
    
15.Marks JG Jr. Allergic contact dermatitis to Alstroemeria. Arch Dermatol 1988;124:914-6.  Back to cited text no. 15
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16.Apted JH. Contact dermatitis due to Alstroemeria (Peruvian lily). Australas J Dermatol 1990;31:111-3.  Back to cited text no. 16
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17.Guin JD, Franks H. Fingertip dermatitis in a retail florist. Cutis 2001;67:328-30.  Back to cited text no. 17
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18.Bangha E, Elsner P. Occupational contact dermatitis toward sesquiterpene lactones in a florist. Am J Contact Dermat 1996;7:188-90.  Back to cited text no. 18
    
19.Mascarenhas R, Robalo-Cordeiro M, Fernandes B, Oliveira HS, Goncalo M, Figueiredo A. Allergic and irritant occupational contact dermatitis from Alstroemeria. Contact Dermatitis 2001;44:196-7.  Back to cited text no. 19
    
20.Bjorkner BE. Contact allergy and depigmentation from alstroemeria. Contact Dermatitis 1982;8:178-84.  Back to cited text no. 20
    
21.Adams RM, Daily AD, Brancaccio RR, Dhillon IP, Gendler EC. Alstroemeria. A new and potent allergen for florists. Dermatol Clin 1990;8:73-6.  Back to cited text no. 21
    
22.Chan RY, Oppenheimer JJ. Occupational allergy caused by Peruvian lily (Alstroemeria). Ann Allergy Asthma Immunol 2002;88:638-9.  Back to cited text no. 22
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23.Christensen LP. Direct release of the allergen tulipalin A from Alstroemeria cut flowers: A possible source of airborne contact dermatitis? Contact Dermatitis 1999;41:320-4.  Back to cited text no. 23
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24.Rozas-Munoz E, Lepoittevin JP, Pujol RM, Gimenez-Arnau A. Allergic contact dermatitis to plants: Understanding the chemistry will help our diagnostic approach. Actas Dermosifiliogr 2012;103:456-77.  Back to cited text no. 24
    
25.Thiboutot DM, Hamory BH, Marks JG Jr. Dermatoses among floral shop workers. J Am Acad Dermatol 1990;22:54-8.  Back to cited text no. 25
    



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