JOURNAL READING 16 JULI 2019

CUTANEOUS LARVA MIGRANS

Karl Imanuel Leiwakabessy
2018-84-083

Pembimbing :
dr. Novriyani Masuku, Sp.KK, M.Kes

DEPARTEMEN ILMU KESEHATAN KULIT DAN KELAMIN

FAKULTAS KEDOKTERAN UNIVERSITAS PATTIMURA
RSUD DR M HAULUSSY
AMBON
2019
INTRODUCTION
Introduction

Cutaneous larva migrans is a zoonotic infestation caused by

penetration and migration in the epidermis of filariform larva of
different kinds of animal hookworms through contact with feces of
infected animals, mostly dogs and cats

Clinically, cutaneous larva migrans is characterized

by a pruritic erythematous migrating tortuous or
serpiginous, slightly raised track
Although some authors use
the term "cutaneous larva
migrans" and "creeping synonyms
eruption" interchangeably,

• Creeping • Sandworm
eruption disease

Beachworm
Ground itch
disease

Plumber’s itch Duck hunter’s itch

Linear
Dermatitis
Serpiginous
serpiginous
dermatitis

• Migrant linear • Creeping

dermatitis verminous
dermatitis
Introduction
Cutaneous larva migrans is one of the most
common skin diseases reported in travelers
returning from tropical regions

Misdiagnosis of course leads to inappropriate

or delayed treatment.

A review of the topic is therefore in order and

is the purpose of the present communication.
EPIDEMIOLOGY
Cutaneous Larva Migran

EPIDEMIOLOGY
Cutaneous larva migrans affects millions of people worldwide

The condition is common in individuals residing in tropical and

subtropical regions, especially in developing countries

in a rural community in Brazil, approximately 4.4% of the general

population and 15% of children have been found to be infested
Epidemiology

In one study, cutaneous larva migrans accounted for approximately 10% of dermatological
diagnoses in sick travelers returning from tropical regions

Prevalence is high in geographic regions with a warm and humid climate where
individuals tend to walk barefoot and come in contact with feces of dogs and cats

Cutaneous larva migrans is endemic in Central and South America, Mexico, Caribbean,
Africa, Southeast Asia, Medi- terranean regions, the southeastern parts of the United
States, and other tropical areas
epidemiology

Individuals whose hobbies and occupations bring them

There is no racial or sex predilection because the
disease depends on exposure. The condition is more
common in children than in adults
in contact with contaminated soil or sand are at risk for
cutaneous larva migrans;
These individuals include travelers, swimmers,
sunbathers, hunters, plumbers, miners, carpenters,
farmers, gardeners, fishermen, and pest exterminators.

Poor hygiene and poor sanitation are important

predisposing factors
Causative organisme
Causative organisme
Cutaneous larva migrans is caused by the filariform larvae of animal

The most common causative larva is Ancylostoma braziliense (6.5 mm

long and has a diameter of 0.5mm)

Other causative larvae are Uncinaria stenocephala (dog hookworm), Bunostomum phlebotomum (cattle
hookworm), and Ancylostoma ceylonicum (dog and cat hookworm)
Causative organisme

The adult hookworms infest the intestines of the definite host

animals  eggs are excreted in their feces and contaminate the
surrounding soil or sand.

The embryonated eggs hatch in the superficial layer of the soil

within two days

The released rhabditiform larvae feed on the bacteria in the soil

and/or feces

These larvae mature and molt twice in 5 to 10 days to become

fiariform larvae which are infective
Disease transmission
Disease transmission

Infected when the filariform larvae come into direct contact

and penetrate the stratum corneum.
• Human infection typically occurs after walking barefoot or with open-type
shoes or lying undressed on the sand/soil, especially sandy beaches,
contaminated by feces of infected dogs and cats

The larvae can also be found in sandpits, and loose soil at

construction sites, gardens, fields, or under houses
pathophysiology
pathophysiology
penetrate fissures, hair
follicles, sweat glands and
Secrete proteases and filariform larvae shed
hyaluronidase that they intact skin by digesting their cuticle
the keratin in the
epidermis

The larvae creep or

wander aimlessly within
the larvae remain
the epidermis in a the larvae start migration
confined to the
serpiginous route at a in approximately 7 days
epidermis.
rate of 2mm to 2cm per
day
Clinical manifestations
Clinical manifestation
A stinging or tingling
• 30 minutes
sensation

itchy reddish-brown papule •Few hours later

or nonspe- cific eruption at
the site of penetration

5 to 15 days
incubation period

erythematous, slightly raised,

tortuous, winding, serpiginous or, • After the incubation period
less often, linear track extending
from the reddish-brown papule

The pruritic serpiginous

track
Clinical manifestation
Papular and vesicular lesions may
be present in conjunction with the
track

Bullous cutaneous larva  quite

rare

The width of the track ranges from

1 to 4mm

The length may reach 20cm

Sites of predilection
include the ankles, feet,
legs, but- tocks, and thigh
diagnosis
diagnosis
• The diagnosis is mainly clinical, based on the history of travel to an
endemic area and exposure to contaminated soil/sand and the
characteristic serpiginous track. Unfortu- nately, the initial diagnosis is
correct in less than 50% of cases
Diagnostic studies
Diagnostic studies
• Dermoscopy shows translucent, brownish, structureless areas in a
segmental arrangement corresponding to the body of the larva and
red-dotted vessels corresponding to an empty burrow.
• Confocal scanning laser microscopy  detect the highly refractile
larva and a dark disruption in the normal honeycomb epidermis
corresponding to the burrow.
Diferential diagnosis
 DIFERENTIAL DIAGNOSIS
Larva currens (strongyloidiasis), caused
by Strongyloides stercoralis
Migratory (creeping) myiasis is caused by G. intestinalis presents  Superficial
larvae of the horse (Gasterophilus
intestinalis) and cattle (Hypoderma ovis
and Hypoderma lineatum) bot flies
SIGN PICT
Rapidly migrating urticarial or
maculopapular, pruritic, linear or
serpiginous, eruption.
The eruption usually starts in the
perineum and then spreads to the
buttocks and thighs
serpiginous track
H. ovis and H. lineatum  presents with
tender subcutaneous nodules in the
absence of a serpiginous track
 DIFERENTIAL DIAGNOSIS SIGN PICT

Loiasis, caused by the filarial nematode "eye worm" and Calabar swellings
Loa loa,
Is transmitted to humans through the
bites of deerflies of the genus Chrysops

Cercarial dermatitis (swimmer's itch) Pruritic maculopapular rash within hours

follows penetration of the human skin by to a day after exposure to water
cercariae of nonhuman schistosome contaminated with schistosomes
flukes released from infected snails.
 DIFERENTIAL DIAGNOSIS
Gnathostomiasis, also known as larva
migrans profundus,
Is caused by the infective third stage larva
of Gnathostoma species, notably G.
spinigerum and G. bispidum
Dirofilariasis is caused by the zoonotic
filarial worms of the Dirofilaria species,
notably D. repens and D. tenuis; the
natural hosts of which are dogs and wild
canines
SIGN PICT
Intermittent migratory cutaneous or
subcutaneous swellings or nodules
Mosquitoes feed on the infected animal,
the microfilariae are ingested with the
blood meal.
Humans acquire the infection via bites
from mosquitoes. The larva wanders in
the subcutaneous tissue and produces an
asymptomatic, non-migratory,
subcutaneous nodule.
Sites of predilection include the
extremities, head, and neck.
 DIFERENTIAL DIAGNOSIS
Dracunculiasis, also known as guinea-
worm disease,
Is caused by drinking water
contaminated with parasite- infected
water-fleas (Cyclops species) that have
ingested guinea-worm larvae
(Dracunculus medinensis).
Tungiasis is an ectoparasitic infestation
caused by the penetration of the gravid
female sand flea Tunga penetrans into
the skin
SIGN PICT
Subcutaneous dracunculiasis presents as
a painful papule, most commonly on the
lower extremities but may occur on the
genitalia and buttocks.
Worms may emerge from the papule.
Non-migratory papule or nodule with a
central black dot.
The lesion can be asymptomatic, painful,
or pruritic.
The majority of the lesions are located on
the feet.
 DIFERENTIAL DIAGNOSIS
Scabies is a skin infestation caused by
the parasite mite Sarcoptes scabiei var
hominis
Herpes zooster
SIGN PICT
Burrows (appear as serpiginous grayish,
whitish, reddish, or brownish lines
several millimeters long in the upper
epidermis ), an erythematous papular
eruption, and intense pruritus.
Sites of predilection include the
interdigital web spaces and flexor aspects
of wrists.
A painful, unilateral vesicular eruption in
a restricted dermatomal distribution.
Herpes zoster has a predilection for areas
supplied by the cervical and sacral
dermatomes in young children and the
lower tho- racic and upper lumbar
dermatomes in adults
 DIFERENTIAL DIAGNOSIS
Tinea corporis refers to a superficial
fungal infection of the skin most often
caused by Trichphyton rubrum, T.
tonsurans, and Microsporum canis
Contact dermatitis results from either
exposure to allergens (allergic contact
dermatitis) or irritants (irritant contact
dermatitis).
SIGN PICT
Sharply circumscribed, well-demarcated,
annular, erythematous plaque with a
raised leading edge and scaling.
The border can be papular, vesicular, or
pustular. The lesion spreads centrifugally
and clears centrally to form the
characteristic lesion commonly known as
“ring- worm”.
The lesion is eczematous and occurs only
in an area which has been in contact with
the irritant or allergen agent.
It does not have a serpiginous
appearance.
 DIFERENTIAL DIAGNOSIS SIGN PICT

Bacterial folliculitis Follicular, erythematous, maculopapules

and fol- licular pustules in a hair-bearing
area.

A hair shaft may be seen at the center of

the lesion.

The lesions may be painful, tender or

mildly pruritic.
complication
complications

Repeated scratching may lead to excoriation and secondary bacterial infection and
eczematization

In previously Sensitized individuals, erythema multiforme may occur. Pruritus may

cause sleep distrubance

Rarely  cutaneous larva migrans may be complicated by optic disease edema and
Löffler syndrome. Löffler syndrome is characterized by migratory pulmonary eosinophilic
infiltrates and peripheral blood eosinophilia. Affected patients may present with fever,
malaise, cough, substernal discomfort, and blood-tinged sputum containing Charcot-
Leyden crystals.
prognosis
prognosis
• The prognosis is excellent
• The disease is self- limited and usually resolves in weeks to months
even without treatment
management
management
ORAL ANTIHELMINTIC AGENTS
 Oral ivermectin

• Ivermectin (Stromectol, Mectizan, Revectina, Ivermec), a macrocyclic

lactone, is a semisynthetic avermectin derived from the bacterium
Streptomyces avermitilis
• The medication works by stimulating excessive release of
neurotransmitters in the peripheral nervous system and increasing the
permeability of cell membrane of the helminth, resulting in the
paralysis and death of the helminth.
• Oral ivermectin in a single dose of 12mg in adults (150 to 200mcg/kg in
children, maximum 12mg) is the treatment of choice for cutaneous
larva migrans
Oral ivermectin

• As follicular cutaneous larva migrans is more resistant to treatment,

adult patients should be treated with 12mg (150 to 200mcg/kg in
children; 12mg, maximum) of ivermectin twice a day for several days
• Side effects include anorexia, nausea, vomiting, ab- dominal pain,
constipation, dizziness, xerosis, burning skin, flushing, eye pain, red eye,
transient tachycardia, and hypotension.
• contraindicated during pregnancy, in children under 5 years of age or
less than 15kg, and in those with hepatic or renal disease
Oral albendazole
• Albendazole (Eskazole; Albenza, Andazol, Alworm, Noworm, Alben-G,
ABZ, Cidazole, Zentel) is methyl 5-(propylthio)-2-benzimidazole
carbamate.
• The medication works by causing degeneration in the intestinal cells
of the helminth by binding to the colchicine-sensitive cells of tubulin,
thereby preventing its polym- erization into microtubules. This in turn
leads to impaired uptake of glucose by the helminth, and ultimately,
to its death
• Dose of 10 to 15mg/kg (800 mg, maximum) divided into 2 doses for 3
to 5 days
Oral albendazole
• The medication should be taken with meals.
• Side effects include nausea, vomiting, abdominal pain, dizziness,
headache, reversible thinning of hair or hair loss, fever, rash,
increased intracra- nial pressure, bone marrow suppression, and
hepatic dys- function.
• contraindicated during pregnancy and in those with hematologic or
hepatic disease
Oral thiabendazole
• Thiabendazole (Mintezol) is a benzimidazole derivative with
antihelminthic property
• Thiabendazole works by inhibiting the helminth-specific
mitochondrial enzyme fumarate reductase, thereby inhibiting the
citric acid cycle, mitochondrial respiration and subse- quent
production of ATP, ultimately leading to the death of the helminth.
• Doses of 25 to 50mg/kg/day (2.5g/day, maximum) given twice daily
for 2 to 5 days
Oral thiabendazole
• The tablet formulation must be chewed before swallowing and taken
after meals.
• Side effects are common and include anorexia, nausea, vomiting,
abdominal cramps, diarrhea, blurred vision, dizziness, and headaches
• contraindicated during pregnancy
MANAGEMENT
TOPICAL ANTIHELMINTIC AGENTS
Topical albendazole
• Topical albendazole 10% in a lipophilic base applied under occlusion
three to four times a day for 5 to 10 days
• Side effects include irritant contact dermatitis and skin ulceration.
Topical thiabendazole
• Topical thiabendazole 10 to 15% in a lipophilic base applied under
occlusion three to four times a day for 5 to 10 days
• Side effects include irritant contact dermatitis and skin ulceration.
MANAGEMENT
CRYOTHERAPY
cryotheraphy
• cryotherapy with liquid nitrogen was at one time used for the
treatment of cutaneous larva migrans.
• In addition, the procedure is painful. As such, cryotherapy is no longer
routinely recommended for the treatment of cutaneous larva migrans
except for patients in whom oral antihelminthics are contraindicated
MANAGEMENT
FRACTIONAL CARBON DIOXIDE LASER
Fractional Carbon Dioxide Laser
• Single session of 1 to 4 passes of fractional carbon dioxide laser up to 1 to 2cm pe-
rimeter around the erythematous portion of the serpiginous track is effective in the
treatment of cutaneous larva migrans
• In one study, ten cases (eight patients) with cutaneous larva migrans were treated
with one session of carbon dioxide laser treatment and followed up daily for the
first week with photographic documentation and then weekly for the next 3 weeks
to complete a 4 week follow-up period.
• The first case received one to two passes of fractional CO2 laser, experienced
further larval migration for 2 to 3 days  no more progression was noted.
• seven cases, the authors increased the number of CO2 laser passes to 3 to 4
noted no further larval migration. At the end of the 4-week follow-up period, all
CO2 laser-treated areas were completely healed.
MANAGEMENT
Miscellaneous
miscellaneous
• Systemic antihistamines and topical corticosteroid may be considered
to provide symptomatic relief of itchiness
• Secondary bacterial infection may require treatment with appropriate
antibiotics.
PREVENTION
prevention In endemic areas

• deworming of dogs and cats • disposing the

and banning them from waste products of
beaches and playgrounds dogs and cats
properly

wearing proper
footwear while using towels,
walking on the on the beach
beach

Sandpits that
avoiding lying
children play
or sitting
with should be
directly on the
protected from
sand/soil.
dogs and cats
• Gloves should be worn when • Using mattresses
soil/sand is handled and deckchairs on
the beach
CURRent & future
developments
CURRent & future developments

Current methods for diagnosis of hookworm

infections primarily involve microscopic
examination of fecal samples, either directly in
fecal smears or following concentration of ova

These microscopic methods are time- consuming,

are unpleasant, require specialized equipment,
and can have low specificity having have to rely
heavily on the skill and expertise of the operator.
CURRent & future developments
• The drugs currently used against hookworms have limitations as
they are contraindicated during pregnancy, in very young children,
and in those with certain systemic diseases, making new drugs
highly desirable.
Eickhoff et al  treatment of infectious disease including Cutaneous larva
migrans
• pyrazolo-triazine derivatives

Spangenberg  treatment of parasitic disease including cutaneous larva

migrans
• azepanyl derivatives

Levine et al  treating or amelioroting skin lesions as may result from

cutaneous larva migrans
• herbal bioactive (ambucus nigra, Centella asiatica or Echinacea purpurea)
CURRent & future developments

Ji et al  Treating pruritus
• superoxide dismuate (SOD) mimetic (The invention can be given
orally, parenterally, or topically)

Kaspar and speaker  treating pain and/or itch

• mTOR pathway inhibitor (The mTOR inhibitor in this invention is
rapamycin (Sirolimus) or an analogue thereof. Rapamycin is a
macrocyclic lactone produced by the organism Streptomyces
hydroscopicus )
conclusion
conclusion
Cutaneous larva migrans is a zoonotic infestation caused by penetration and migration in the
epidermis of filariform larva of different kinds of animal hookworms through contact with feces
of infected animals, mostly dogs and cats.

It is characterized by a pruritic erythematous migrating tortuous or serpiginous, slightly raised

track.

Compared with oral antihelminthics, topical treatment over the affected area is less effective
since the larva is mobile and the exact location of the larva is not precisely known.
Unfortunately, the two available oral antihelminthics (ivermectin and albendazole) are
contraindicated during pregnancy and should be avoided in breastfeeding mothers.
THANKYOU 