Dermatology Online Journal

Cutaneous larva migrans: A bad souvenir from the vacation
Paulo Ricardo Criado MD PhD, Walter Belda Jr MD PhD, Cidia Vasconcellos MD PhD, Cristiana Silveira Silva MD
Dermatology Online Journal 18 (6): 11

Dermatology Department, Sao Paulo University, Sao Paulo, Brazil

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Abstract

Cutaneous larva migrans (CLM) is a common endemic disease in tropical and subtropical countries. This condition is caused by skin-penetrating larvae of nematodes, mainly of the hookworm Ancylostoma braziliense and other nematodes of the family Ancylostomidae. We report three cases of CLM acquired during vacations in different regions of Brazil.

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Introduction

Cutaneous larva migrans (CLM) is the most common tropically acquired dermatosis [1], first reported by Lee in 1874 [2]. This condition is frequently seen in the southern United States, Central and South America, and other subtropical areas but rarely in northern climates [3]. The larvae of the nematode Ancylostoma braziliense are most often the causative organisms [3]. During the months of summer vacation we generally see several patients referred to dermatological outpatient clinics related to CLM acquired in several locations. We describe three patients with CLM acquired in different regions of Brazilian territory during the vacation periods.

Case 1

Figure 1

A 31-year-old previously healthy woman presented to our outpatient clinic with pruritic cutaneous lesions, which had been progressing for 3 days, after a vacation at the southeast beaches of Brazil (Ubatuba City). The dermatological exam showed a cutaneous eruption composed of vesicles and papules disposed in a linear and serpiginous pattern on plantar regions of the left foot (Figure 1: 1A) and on the dorsal aspect of right foot (Figure 1: 1B). This peculiar serpiginous pattern and severe itching lead to the clinical diagnosis of CLM. In the face of extensive cutaneous involvement we introduced ivermectin (200 μg/kg single dose) orally. After 7 days the patient returned to our office and reported an alleviation of the pruritus. The physical exam demonstrated lesions displaying less erythema, but bullae persisted (Figure 1: 2A and 2B).

Case 2

Figure 2

A 12-year-old Caucasian girl presented to our private practice reporting severe itching on her left wrist. She recently returned from her summer vacation on Mato Grosso, where she swam in several rivers and walked upon beaches. The dermatological exam revealed a linear papulo-vesicle lesion disposed in a serpiginous pattern on the left wrist (Figure 2: 3A and 3B). Because of a single and localized lesion the patient was treated with topical thiabendazole.

Case 3

Figure 3

A 22-year-old woman was referred to our private practice because of an intense itching in her left foot. The patient reported that she had returned from her vacation at the beaches of Camboriu (Santa Catarina). She had been previously treated with Ketoconazole 2 percent cream by a general medical practitioner without benefit. On physical exam a linear, erythematous-papulo-vesicle on the plantar area was observed (Figure 3: 4A), which displayed a serpiginous pattern on the dorsum and side of the foot (Figure 3: 4B and 4C). The patient was treated with 200 mg of albendazole orally for 3 days.

Discussion

Cutaneous larva migrans is a frequent disease in tropical and subtropical countries. The disease is endemic in islands of the the Caribbean and Southeast Asia, Africa, South America, and the central and southeastern states of the United States [1]. The endemic nature of this disease is caused by poor sanitation and suitable environmental conditions [1]. The clinical appearance of this infestation is a serpiginous cutaneous eruption usually occurring on the skin of the feet, abdomen, buttocks, hands, and genitals [4]. The source of infection is dog and cat feces contaminated by hookworms (i.e., nematodes), most commonly Ancylostoma braziliense, whose larvae penetrate into the skin, resulting in a creeping eruption (i.e., larva migrans) [5]. Eruptions are a result of the skin’s hypersensitivity reaction to these worms and their by-products [4]. The most common cause is the larvae of Ancylostoma braziliense. Less common species include Ancylostoma caninum, Uncinaria stenocephala, and Bunostomum phlebotomum. In rare cases CLM is caused by human hookworms, such as Strongyloides stercoralis, Ancylostoma duodenale, and Necator americanus; exceptionally, insect larvae can produce a similar picture [1].

In animal hosts, the parasites enter the body through the skin, penetrate the dermis, and migrate through the lungs before reaching the intestines, where they mature into adult parasites. In accidental hosts, such as humans, they can enter the epidermis but cannot penetrate the dermis, so they migrate within the epidermis for a few weeks before dying [1].

Exact rates of incidence are unknown. However, one report showed that 6.7 percent of all patients visiting a travel-related disease clinic had CLM [5].

Patients with CLM might remember a stinging sensation upon initial penetration of the larvae [4]. A reddish papule or a nonspecific dermatitis can develop hours after penetration [4]. The passage of the larvae produces a 2 to 4 mm wide, erythematous, elevated, and serpentine track [4]. Vesicles and papules might be observed in conjunction with the linear track, as in our three patients. The rate of larval migration ranges from a few millimeters to a few centimeters per day (2-3 cm) [1, 4], depending on the species of larvae. The actual location of the larvae is typically 1 to 2 cm away from the erythematous track [4]. Multiple larvae can be active at the same time, with the formation of disorganized loops and tortuous tracks; multiple vesicles may appear [1] as demonstrated in our patient 1.

The diagnosis of CLM is based on physical examination in conjunction with the epidemiologic background [1, 5]. The relative ease of travel to endemic areas necessitates the consideration of CLM in the differential diagnosis of serpiginous pruritic lesions, even in non-endemic areas of the world. A skin biopsy is usually not helpful because the location of the larvae is uncertain and thus is not recommended as a diagnostic procedure [1]. In our patients the diagnosis was based on typical clinical features and the history of the present illness. Because there was no history of fever or pulmonary or intestinal difficulties, visceral involvement was excluded.

Although the condition is self-limiting and the larvae usually die within a couple of months, the intense pruritus and risk of infection often warrant treatment [5]. Moreover, patients might not want to wait for the natural healing process of the disease [5].

Although double-blind controlled studies are lacking, antihelmintics are considered to be the drugs of choice for CLM. These agents include ivermectin (200 μg/kg, single dose) [5], albendazole (400 mg/d for 3 days) [6], thiabendazole (25 to 50 mg/d for 2 to 5 days) [7], and mebendazole (200 mg twice daily for 4 days) [5]. Antihistamines and topical corticosteroids can be used in addition to antihelmintics for symptomatic relief of pruritus. Topical 10-15 percent thiabendazole ointment has shown good efficacy in a few small case series [8]. However, for the best results, patients should treat the lesions three times daily for at least 15 days [9]. Treatment of this condition with cryotherapy is rarely effective [10]. Oral antibiotics are only used if secondary skin bacterial infection or cellulitis is present.

Finally, clinicians should counsel patients prior to travel to tropical climates and beaches about the risk of CLM and advise them to seek medical attention if they develop a creeping eruption.

References

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2. Lee RJ. Case of creeping eruption. Trans Clin Soc London. 1874;8:44-5.

3. Edelglass JW, Douglass MC, Stiefler R, Tessler M. Cutaneous larva migrans in northern climates. A souvenir of your dream vacation. J Am Acad Dermatol. 1982 ;7(3):353-8. [PubMed]

4. Ghosh SK, Bandyopadhyay D. Dermacase: Can you identify this condition? Cutaneous larva migrans. Can Fam Physician. 2009;55(5):489, 491. [PubMed]

5. Jelinek T, Maiwald H, Nothdurft HD, Löscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis. 1994 Dec;19(6):1062-6. [PubMed]

6. Tomovic M, Skiljevic D, Zivanovic D, Tanasilovic S, Vesic S, Dakovic Z, et al. Two cases of probable endogenous extensive cutaneous larva migrans in Serbia. Acta Dermatovenerol Alp Panonica Adria. 2008;17(1):37-40. [PubMed]

7. Karthikeyan K, Thappa D. Cutaneous larva migrans. Indian J Dermatol Venereol Leprol. 2002;68(5):252-8.[PubMed]

8 Chatel G, Scolari C, Gulletta M, Casalini C, Carosi G. Efficacy and tolerability of thiabendazole in a lipophil vehicle for cutaneous larva migrans. Arch Dermatol. 2000;136(9):1174-5. [PubMed]

09. Patel S, Sethi A. Imported tropical diseases. Dermatol Ther 2009;22:538-49. [PubMed]

10. Karthikeyan K, Thappa DM, Jeevankumar B. Cutaneous larva migrans of the penis. Sex Transm Infect. 2003;79(6):500. [PubMed]

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