The tree is on the endangered species list in Florida due to eradication efforts; however, it continues to be valued in Wnt inhibitor coastal regions for the excellent shade it provides and root system which helps prevent beach erosion.1,2 We report four cases of Manchineel dermatitis and ophthalmitis that occurred when four students (100% attack rate) took shelter under a Manchineel tree during a rain storm. A 22-year-old Caucasian male had direct exposure with the bark and leaves of the Manchineel tree

as well as leaf runoff from the rain while taking refuge. He was wearing bathing trunks, sun glasses, and a brimmed cap. His exposure lasted 1 hour and his onset of symptoms was approximately 12 hours. The symptoms included “burning” of the skin, erythema, ITF2357 cell line swelling of the affected areas, and some blistering at areas of direct contact (face, abdomen, arms, and legs). There was no conjunctival irritation noted. He applied “Benadryl” cream shortly after the “rash” appeared and had resolution of all symptoms and lesions in 5 days with no scarring. A 23-year-old Caucasian female had direct contact with the bark and leaves of the Manchineel while repairing from the rain, leaning against the tree trunk, and touching the leaves. She was wearing a bikini and strapless dress during her exposure of 1 hour. She did

not have a brimmed cap during that time. Twelve hours after her exposure she noted the onset of severe pain, Thymidylate synthase erythema, and swelling of her eyelids and face. This extended rapidly to all of her exposed skin including chest, arms, and legs with accompanying burning and irritation. The lesions progressed

with conjunctivitis and blisters including the eyelids (Figure 1) and several of her body surfaces. Healing occurred in about 5 days with mild scarring of the left upper eyelid. She was treated with oral corticosteroid and bathing of the skin to remove remaining toxin. A 23-year-old Caucasian male stood under the Manchineel tree for approximately 40 minutes. He made no direct contact with the tree or its leaves. His onset of symptoms was about 30 minutes after the exposure. His initial symptoms included facial burning, erythema, and itching followed by swelling of his lips and ears. The lesions progressed to his anterior neck and chest. He noticed itching of his eyes, but no erythema. The symptoms subsided after approximately 2 hours. He applied vinegar at the recommendation of a local restaurateur with rapid resolution of his “rash” and symptoms. A 25-year-old Caucasian male took refuge under the same tree as subjects 1, 2, and 3 during a heavy rain storm. He was wearing bathing trunks and brimmed cap. The duration of exposure was approximately 40 minutes and he denied direct contact with the tree. Onset of mild burning of his face, nose, and forehead accompanied by mild erythema occurred about 30 minutes after the exposure. He did not develop itching or erythema of his conjunctiva.