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West Indian Medical Journal

Print version ISSN 0043-3144

West Indian med. j. vol.55 no.3 Mona June 2006

http://dx.doi.org/10.1590/S0043-31442006000300016 

CONTINUING MÉDICAL EDUCATION

 

Image and diagnosis

 

 

Contributed by EW WilliamsI; JF LindoII; S FrenchI; A ChambersIII; J Williams-JohnsonI

IDepartments of Surgery, Radiology, Anaesthesia and Intensive Care, Emergency Medicine Division, The University of the West Indies, Kingston 7, Jamaica, West Indies
I IDepartment of Microbiology, The University of the West Indies, Kingston 7, Jamaica, West Indies
IIIDepartment of Medicine, Section of Dermatology, The University of the West Indies, Kingston 7, Jamaica, West Indies

Correspondence

 

 

Clinical Data

This 50-year-old diabetic Caucasian male tourist presented with a two-day history of a pruritic eruption on the skin of his left leg and thigh. He had reported being on the beach several times prior to his presentation. Significant examination findings were confined to his skin. There were multiple erythematous serpiginous tracts on his left leg and left thigh (Figure). The rest of his examination was unremarkable. He was only on oral medication for diabetes mellitus.

 

 

What is the diagnosis?

 


 

Answer to image and diagnosis

 

Diagnosis

Cutaneous Larva Migrans (CLM)

Comment

Cutaneous Larva Migrans (creeping eruptions) is often a self-limiting, erythematous serpiginous pruritic rash as seen in the photograph. It is caused by the burrowing larvae of the dog and cat hookworms, Ancylostoma caninum and Ancylostoma braziliensis. The larvae hatch from eggs, which are passed in dog and cat faeces and mature into the third stage (filariform) in the soil. Humans become infected after skin contact with soil contaminated with these larvae. The larvae form tortuous tracts through the dermal-epidermal junction and advance several centimetres per day. Once in the skin, the larvae are unable to penetrate the stratum germinativum of their unnatural human host and migrate laterally, causing a localized non-specific dermatitis (1).

Cutaneous larva migrans occur in a sporadic manner and is often not encountered by physicians. As the cases are often self-limiting and the lesions may not be visually obvious in dark skinned persons, the number of cases may be under-diagnosed in the Jamaican population. The initial diagnosis made by clinicians is inaccurate in 55% of cases; erroneous diagnoses include ant bites, scabies and linear lichen planus (2). Diagnosis (as in this case) is made on the basis of the characteristic clinical features. Laboratory testing has no role since eosinophilia occurs in a minority of cases (1). Cutaneous larva migrans is especially prevalent among children and in regions with warm humid climate including the southern United States of America (3). Epi-demiologic information for the Caribbean is scant. Several cases of CLM have been reported among European and American tourists while on holiday in Jamaica (2, 4).

At present, there are intervention programmes in the Caribbean to remove cats and dogs from public beaches in light of the adverse health effects and the impact this may have on the tourist industry (4).

Symptoms can be alleviated by thiabendazole administered orally (25 mg/kg twice daily). Physicians in industrialized areas as well as in tourist resort regions should be fully aware of this condition which can be mis-diagnosed if there is not a high index of suspicion.

 

REFERENCES

1. Gillespie S H. Migrating Worms. In: Gillespie S H, Pearson R D, eds. Principles and Practice of Clinical Parasitology. Chichester: Wiley, 2001: 535–51

2. Jelinek T, Maiwald H, Nothdurft HD, Loscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis 1994; 19: 1062–6.

3. Harrison’s Principles of Internal Medicine 14th edition: McGraw-Hill, New York, 1207.

4. French S, Lindo J. Severe cutaneous larva migrans in a traveler to Jamaica, West Indies. J Travel Med 2003; 10: 249–50.

 

 

Correspondence:
Dr EW Williams
Emergency Medicine Division, Department of Surgery, Radiology, Anaesthesia and Intensive Care, The University of the West Indies
Kingston 7, Jamaica, West Indies
E-mail: verz3us@yahoo.com