Dermatology Online Journal

Massive infestation of cutanea larva migrans
P Sugathan^*
Dermatology Online Journal 8(2): 21

* Consultant Dermatologist, Baby Memorial Hospital, Indira Gandhi Road, Kerala State, India

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Abstract

Cutaneous larva migrans is a tropical disease that typically is acquired on exposed surfaces in patients who have been sitting or lying on moist ground or other surfaces which have been contaminated by dog or cat feces. A patient is reported who presented with typical, severely pruritic, migratory plaques after sleeping on a wet, bus station floor.

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Case Report

A 45-year-old man, employed as a massage therapist by one of the local Ayurvedic Hospitals, applied for a job as a massage therapist in Dubai and was called to Cochin for a personal interview. Since the Queen of England was visiting the City that day, there was a restriction placed upon the movement of pedestrians and traffic. Therefore, soon after the interview he went to the State Government Bus Station to return home. He was told that the next available bus was due in three hours. To while away the time he went to a Bar across from the bus station and consumed a plate of mussels with a couple of drinks to wash it down. He returned to the bus station, and while waiting, he felt sleepy and so slept on a wet floor for two hours. He boarded the next available bus and reached Trichur, 100 kilometers north, two hours later. While waiting the next three hours for a bus transfer, he felt severe generalized itching of the trunk, arms, and face.

The first physician whom he consulted, suggested that his itching was probably due to an allergic reaction to the mussels he had consumed with his drinks and prescribed pheniramine maleate 25mg thrice a day, betamethasone 0.5 mg thrice daily, Ranitidine hydrochloride 150 mg twice a day, betamethasone 4 mg IM (one injection) and calamine lotion for external application. After three days there was no improvement and he also developed itching of the scalp and periorbital area. He consulted another internist who prescribed ciprofloxacin 0.5g twice a day and terfenadine tablet one daily. He felt that the internist did not understand his problem so he consulted an Ear Nose and Throat (ENT) surgeon. (It is a popular belief in this community that for any illness affecting the head, an ENT surgeon is the correct specialist). The ENT surgeon prescribed cetrizine 10 mg daily along with pheniramine maleate 75mg daily as well as injections of betamethasone sodium phosphate 4 mg IM daily. When he did not improve any further, a tablet of chlordiazepoxide 10mg at bedtime was added. His itching became worse and therefore he consulted a Dermatologist who prescribed him prednisolone 10 mg thrice a day with erythromycin 333mg thrice a day, ranitidine 150 mg once daily, dimethindene maleate 2.5mg thrice a day and liquid paraffin for external application. There was slight improvement but after reducing the dose of prednisolone his condition became aggravated. He consulted another dermatologist who prescribed ciprofloxacin 500 mg twice a day and pheniramine maleate 4 mg thrice a day. By now he was desperate and depressed.

Figure 1
Figure 1. Back view of Extensive larva migrans

On examination he was an obese man (75-Kg) in obvious discomfort. He had generalized erythematous and eczematous areas of the whole of the back and right side of the trunk extending to the right axilla and inner aspect of the arm and the right side of the face. The unusual distribution was probably related to the peculiar posture he adopted while sleeping on the floor - semi prone with the arm raised above the head.) There were also areas of eczematization on the bald patch of the scalp over the occipital area (Figure 1). There was minimal oozing and crusting. Some areas showed excoriation marks. On the right flank and loin one could discern serpigenous linear lesions with erythema (Figure 2).

Figure 2	Figure 3
Figure 2. Close up view of the lateral wall of the chest showing details of the larval tracks
Figure 3: Involvement of the bald areas of the scalp

Upon presentation to our clinic he exhibited multiple linear and serpiginous plaques. He was afebrile and had no systemic symptoms. Hematological examination showed mild leukocytosis with polymorphonuclear predominance and a mild eosinophilia (15%). His ESR was 30 mm. Chest Xray was normal.

A biopsy done from the right upper back showed acanthosis and spongiosis of the epidermis with transepidermal leckocytic infiltration as well as areas of parakeratosis. The dermis showed markedly dilated blood vessels of the upper and mid corium and edema. PAS stain was negative for any larvae.

On clinical grounds and from the morphology of the serpiginous and linear lesions a provisional diagnosis of generalized cutaneous larva migrans was made and he was empirically started on albendazole 400 mg twice a day. Antihistamine tablets (terfenadine 60 mg) were given three times a day for symptomatic control of itching. A 10% suspension of albendazole in calamine lotion was given for local application twice daily. The patient dramatically improved objectively and subjectively. The erythema and itching subsided within 2 weeks and all traces of inflammation disappeared after 4 weeks. The residual pigmentation also cleared after 6 weeks (Figures 4,5).

Figure 4	Figure 5
Figures 4 & 5. Patient six weeks after treatment with 10% albendazole lotion

Summary

Cutaneous larva migrans is not an uncommon condition in the tropics and it can affect both children and adults. On an average we see about 3 to 5 patients in a year. The common sites affected are the exposed parts of the lower limbs, back, or the buttocks. Sitting, playing, or lying down on riverbanks, dunes of river sand collected for construction purposes, or even lawns in public gardens or popular picnic spots are ways that patients are exposed. The lesion is usually single and starts as a single small erythematous papule or papulovesicle, which grows by longitudinal extension in an irregular fashion resulting in a bizarre but distinct clinical picture. Occasionally more than three such lesions are seen in patients who had been sleeping on the floor under the influence of alcohol.

The diagnosis of cutaneous larva migrans is easy, but treatment was not, prior to the introduction of modern anthelmentics. Freezing the lesion with ethyl chloride spray, liquid nitrogen, or cryo probe were popular modes of therapy in the past. With the introduction of powerful systemic anthelmentics like albendazole a rapid and complete clinical cure is now possible.

References

1. Thomas A. Moore in Harrison's Principles of Internal Medicine on CDROM Edition 15 Part 7 section 16 - 212 :- Therapy for Parasitic Infections.

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