Cutaneous larva migrans acquired in Britain

Prevalence and Risk Factors of Hookworm-Related Cutaneous Larva Migrans (HrCLM) in a Resource-Poor Community in Manaus, Brazil

Background

Hookworm-related cutaneous larva migrans (HrCLM) is a neglected tropical skin disease associated with significant clinical pathology. Little knowledge exists about prevalence and risk factors of HrCLM in endemic regions.

Methodology/ Principal Findings

To understand the epidemiology of HrCLM in Amazonia, we conducted a cross-sectional study in a resource-poor township in Manaus, Brazil. HrCLM was diagnosed in 8.2% (95% CI, 6.3–10.1%) of the study population (N = 806) with a peak prevalence of 18.2% (95% CI, 9.3–27.1%) in children aged 10–14. Most of the tracks (62.4%) were located on the feet, and 10.6% were superinfected. HrCLM was associated independently with age under 15, male sex, presence of animal faeces on the compound, walking barefoot on sandy ground and poverty.

Conclusions/ Significance

HrCLM is common in resource-poor communities in Amazonia and is related to poverty. To reduce the disease burden caused by HrCLM, living conditions have to be improved.

Hookworm-related cutaneous larva migrans (HrCLM) is a parasitic skin disease caused by the penetration of animal hookworm larvae into the human skin. In this compartment the larvae cannot pass the basal membrane and reproduce, but migrate in the outer skin layer for several weeks, causing skin inflammation and intense itching. Thus, humans are a biological impasse. Although HrCLM is a common skin disease in tropical and subtropical regions, studies on prevalence and risk factors are scarce. We clinically examined the population of a resource-poor neighbourhood in Manaus, capital of Amazonas State, Brazil, and investigated HrCLM-associated risk factors. HrCLM was very common with an overall prevalence of 8.2%. Children in general, and boys in particular, were most frequently infected. We could confirm that walking barefoot on sandy ground is a significant risk factor, and we identified the presence of animal faeces on the compound as another important predictive factor. Clearly, HrCLM was associated with low income and poverty-related living conditions. The poorest of the poor were identified as the most vulnerable population group.

Hookworm-related cutaneous larva migrans acquired in the UK

Hookworm-related cutaneous larva migrans (HrCLM) is a skin disease caused by infection with the larvae of animal hookworms. With conditions for infection more favourable in tropical climates, HrCLM in the UK is classically diagnosed in the returning traveller. We present two cases of clinically diagnosed UK-acquired HrCLM from a district general hospital in the south of England. A 68-year-old woman presented with a pruritic serpiginous tract on the right hand. She was a keen gardener and had been handling compost. A 50-year-old man, a long distance runner, presented with a similar lesion on the dorsum of his foot. Both patients were treated with a single dose of albendazole. These cases may represent an emerging infection in the UK. In the absence of a suggestive travel history, early recognition followed by efficient access to therapy is vital for treating HrCLM transmitted in the UK.

Mini review: Hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans (HrCLM) is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis. Since these larvae cannot penetrate the basal membrane of human skin, they remain confined to the epidermis and are unable to develop and complete their lifecycle. By consequence, HrCLM is a self-limiting disease. However, if not treated promptly, the skin pathology may persist for months. HrCLM is endemic in many resource-poor communities in the developing world. In high-income countries, HrCLM occurs sporadically or in the form of small epidemics. Travelers account for the great majority of cases seen by health-care professionals in high-income countries. Transmission occurs when naked skin comes into contact with contaminated soil. Exposure may also occur indoors. Exceptionally, larvae may be transmitted through fomites. The first clinical sign is a small reddish papule. Thereafter, the characteristic serpiginous, slightly elevated, erythematous track becomes visible. Itching becomes more and more intense. Excoriations induced by scratching facilitate bacterial superinfection of the lesion. The diagnosis is essentially clinical. It is supported by a recent travel history and the possibility of exposure. The drug of choice is ivermectin in a single dose (200 μg per kg bodyweight). Repeated treatments with albendazole (400 mg daily) are a good alternative in countries where ivermectin is not available.

A case report of cutaneous larva migrans in Argentina

Cutaneous larva migrans (CLM) represents the most common tropically acquired dermatosis. CLM is caused by infection with hookworm larvae in tropical and sub-tropical areas, and people who have a history of foreign travel and of walking barefoot on sandy soil or beaches are at a high risk of getting infected with it. The diagnosis is usually made on the basis of the typical appearance of the lesion, intense itching and history of foreign travel. CLM is a common parasitic skin disease that can be easily prevented by wearing 'protective' footwear. A case of CLM is described in this article.

Mucocutaneous Splendore-Hoeppli phenomenon

Splendore-Hoeppli phenomenon (asteroid bodies) is the in vivo formation of intensely eosinophilic material (radiate, star-like, asteroid or club-shaped configurations) around microorganisms (fungi, bacteria and parasites) or biologically inert substances. This study presents a literature review concerning Splendore-Hoeppli reaction in the mucocutaneous diseases. It examines the histopathological features, nature and differential diagnosis of this reaction. It also discusses the mucocutaneous infections and the non-infective diseases associated with it. Available studies indicate that several mucocutaneous infections can generate Splendore-Hoeppli reaction. The fungal infections include sporotrichosis, pityrosporum folliculitis, zygomycosis, candidiasis, aspergillosis and blastomycosis. The bacterial infections include botryomycosis, nocardiosis and actinomycosis. The parasitic conditions include orbital pythiosis, strongyloidiasis, schistosomiasis and cutaneous larva migrans. In addition, Splendore-Hoeppli reaction may be seen with non-infective pathology such as hypereosinophilic syndrome and allergic conjunctival granulomas. The Splendore-Hoeppli reaction material comprises antigen-antibody complex, tissue debris and fibrin. Although the exact nature of this reaction is unknown, it is thought to be a localized immunological response to an antigen-antibody precipitate related to fungi, parasites, bacteria or inert materials. The characteristic formation of the peribacterial or perifungal Splendore-Hoeppli reaction probably prevents phagocytosis and intracellular killing of the insulting agent leading to chronicity of infection. To conclude, Splendore-Hoeppli reaction is a tell tale of a spectrum of infections and reactive conditions. The molecular pathways involved in the development of this reaction are open for future investigations.

Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans is caused by the migration of animal hookworm larvae in the human skin. The disease mainly occurs in resource-poor communities in the developing world, but it is also reported sporadically in high-income countries and in tourists who have visited the tropics. Diagnosis is made clinically in the presence of a linear serpiginous track moving forward in the skin, associated with itching and a history of exposure. Itching is typically very intense and can prevent patients from sleeping. Bacterial superinfection occurs as a result of scratching. Treatment is based on oral drugs (albendazole or ivermectin) or the topical application of tiabendazole. To control hookworm-related cutaneous larva migrans at the community level, regular treatment of dogs and cats with anthelmintic drugs is necessary, but this is seldom feasible in resource-poor settings. Animals should be banned from beaches and playgrounds. For protection at the individual level, unprotected skin should not come into contact with possibly contaminated soil.

Seasonal contamination of public squares and lawns by parasites with zoonotic potential in southern Brazil

The presence of helminths and protozoans in public squares and lawns of the city of Maringá, southern Brazil, during winter and summer was assessed in order to evaluate their seasonal fluctuations in relation to edaphic and climatic factors. Samples were collected from January 2003 through June 2004 in 90% (13) of all public squares covered by sand, and in 30% (4) of all lawns used as leisure areas. The samples were analysed quantitatively by modified centrifugal-flotation and sedimentation in water techniques, and qualitatively by a method based on positive larval thermo-hydrotropism. Meteorological data were recorded, and physical, chemical and structural characteristics of the soil were analysed. One hundred and thirty samples of sand from squares, 65 in summer and 65 in winter, and 40 samples of grass from lawns, 20 in each season, were collected. All samples from lawns, 62 (95.38%) from squares in winter and 45 (69.23%) in summer, contained protozoans and/or helminths. Eggs of Toxocara spp. were the most frequently observed parasites in both winter and summer in squares (P < 0.0001) and in lawns (P = 0.6142), being equally distributed among the different locations (P = 0.2038). Species diversity was lower in winter; fewer parasites were found in summer. This region, with a tropical climate and a mild winter dry season, has favourable edaphic and climatic conditions for soil contaminants to persist year-round. In addition, the high frequency of animals such as dogs and cats and the poor sanitary measures in force made it possible for zoonoses to be transmitted in the public spaces.

Cutaneous larva migrans in northern Germany

We report a 14-month-old female infant with typical cutaneous larva migrans, but without a history of travelling outside Germany. Cutaneous larva migrans is most commonly observed in and imported from tropical countries. Only a few cases have been described in northern Europe. This report serves as a reminder that under certain circumstances acquisition of this "tropical" parasite is possible even in non-tropical countries.

A Study in a Community in Brazil in Which Cutaneous Larva Migrans Is Endemic

BACKGROUND

Cutaneous larva migrans (CLM) is a common but neglected parasitic skin disease in impoverished communities of the developing world.

METHODS

To describe the clinical features and the morbidity associated with CLM, active-case finding was performed during rainy and dry seasons in a rural community in the state of Alagoas, Northeast Brazil.

RESULTS

A total of 62 individuals received a diagnosis for CLM, and among them there were a total of 75 larval tracks. The number of tracks per person ranged from 1 to 3. Children <9 years old were affected significantly more often than other age groups (P<.001). Children had their lesions mainly on the buttocks, genitals, and hands, whereas in older patients, the majority of lesions were located on the feet. Twenty-four percent of the 75 lesions were superinfected. Bacterial superinfection was more common among children. All but 1 patient complained about itching, and 84% of the 62 patients complained about sleep disturbances. Itching was classified as being severe by 61% of patients. Approximately 40% of the 62 patients had attempted to treat their creeping eruption previously. Larvae moved forward 2.7 mm per day. There was a significant correlation between the length of the track and the duration of infestation ( rho =.53; P<.0001).

CONCLUSIONS

CLM is a common parasitic skin disease in this rural community, with different topographic patterns of lesions in children and adults. CLM is associated with considerable morbidity. The length of the track can be used to estimate the duration of infestation.