Cutaneous Larva Migrans (CLM) is the most common skin disease of tropical origincaused by hookworms larvae, occurring in international travelers. Typical manifestations consist of erythematous, serpiginous slightly elevated linear cutaneous lesions. We describe the case of an 8-year-oldboy, with CL Min fectionacquired duringtravel to Burkina-Faso, and successfully
Background:Skin diseases are a common occurrence in international travellers and representthethirdreasonforseekingmedicalattentioninreturningtravellers.Assomeskindiseases can have life-threatening complications, especially in children, it is important to discriminate whether the skin complaint represents a serious condition [1]. In these cases, history taking is very important and must include specific destination of travel and all possible exposures to in- sects and animals. CasePresentation:An 8-year-old boy came to our pediatric Emergency Room because of a skin lesion on the median left foot (Figure 1a, 1b). Physical examination showed an erythem- atous, non-itching, slightly elevated both tortuous and linear lesion, extended for 3 cm. On the foot plant, there were some round crusted lesions. The lesion was noted 5 days after the return from travel to Burkina Faso. Traumas, insect bites or animal contacts were excluded. The boy had a normal chest and abdominal physical examination, no fever, no lymph-adenomegaly, no neurologicalsigns.Apartfromthefootlesion,theskinexaminationwasunremarkable.Complete blood count (CBC) showed marked eosinophilia (13.0% of WBC corresponding to 1296/ L). Treatment with an antihistamine agent was started and we referred the patient to the nearby Tropical Infectious Disease Center for further assessments, where the diagnosis of Cutaneous Larva Migrans (CML) was confirmed and he was prescribed oral ivermectin. A follow-up visit wasplannedintheoutpatientclinicofourcenter;after15daystheboyshowedcompleteremission(Figure1c)andadecreasedeosinophilscount(8.1%ofWBCcorrespondingto740/ )was observed. Discussion:CLMisthemostcommonskindiseaseoftropicalorigincausedbyhookworms, mostcommonlyAncylostomavermemiense,Ancylostomacaninum,NecatorAmericanus,UncinariastenocephalaandStrongyloidesstenocephala.ItisendemicintheCaribbean,Centraland SouthAmerica,Africa,SoutheastAsia,andAustralia.Atemperaturebetween23°Cand30°C,the presenceofhumidsoil,andproperaerationfavorlarvalgrowth.Thedegreeofcontaminationand thedurationofcontactwiththesoilalsoinfluencetheoccurrenceofthedisease.Theadultworms
2. KeywordsChild; Cutaneouslarvamigrans; Diagnosis; Therapy; Epidemiology
liveintheintestineofdogsandcatsandtheireggsareshedthrough feces that contaminate the environment. Humans are accidental host where the parasite cannot complete its life cycle. The larvae penetratetheintactskinandtravelintheepidermis,butareunable tocrosstheskinbasalmembraneandtodevelopintoadults.Clinicalmanifestationsmainlydependonenvironmentalandbehavior- al factors such as walking barefoot in contaminated sand. The incubationperiodisgenerallyoffewdaysfollowedbytheappearance of itching erythematous tunnels, which can be linear or tortuous. Creepingeruptionusuallyappears1–5daysafterskinpenetration, buttheincubationperiodmaybe≥1month.InadultsCLMcan http://www.acmcasereports.com/ rarelybebilateralorpresentasfolliculitisorurticarialpapules.The speed of migration depends on the parasite species, being usually ofonecentimeterperday.Thenumbersoflarvaethatcaninfectthe areavaryfromonetohundreds(sotherearealsovariationsofthe lesiontopography).Theinfectionisgenerallyself-limiting,asthe larvae cannot progress further in the human skin [2, 3]. CLMinfectionisobservedintravelersreturningfromtropicallocationsandautochthonouscasesarerareinItaly.Thediagnosisis clinicalandbasedonthedetectionofthetypicalskinlesions.The feetandbuttocksarethemorefrequentlocalizations,butCLMcan alsoinfectthearms,hands,andtrunk[4].FaceandscalpsiteCLM lesionsareatypicalandveryrare,eveniftheyweredescribedina 5 years boy [5].The occurrence in infants is rare, due to their limited mobility, while children can be easier affected because they areusedtowalkbarefootonbeacheswhiletheywereonvacation andsandisoneofthemostfrequenthigh-riskenvironmentforthe infection acquisition [6]. CDC reported an outbreak of CML in a children'saquaticsportsdaycampinFloridainvolving22people. Erythema, pruritic rashes, serpiginous lesions, changing location rash or lesions were reported. Manifestations were noted on the buttocks, feet, legs, hands, groin, and abdomen and 9 of the patients had lesions in more than one location [7] . In our case the child returned from a travel in an endemic region, themotherreportedthatthechildhasplayedbarefootonthesand and the high number of peripheral eosinophils on CBC was compatible with parasitic infection. Thediagnosisisbasedonhistoryandclinicalexamination,biopsy is not recommended and laboratory exams, as peripheral hypereosinophilia,leucocytosis,hypergammaglobulinemiaandpositive serology, are useful to confirm diagnosis. Differentialdiagnosisthatshouldbeconsideredare:Dirofilariasis, Fascioliasis,Gnathostomiasis,hookworminfection,Paragonimiasis, Pediatric Toxocariasis, Scabies, Strongyloidiasis, Visceral Larva Migrans[3].AcuriousdifferentialdiagnosisisPilimigrans,avery rareconditionthatmimicCMLinfection,butitisduetoaforeign body penetration in the skin, in their case hair [8]. Evenifthediseaseisusuallybenignandcanbeself-limiting,complicationsmayoccur.Super-infectionwithStaphylococcusAureus and/or Streptococcus Pyogeneshas been reported, facilitated by scratching the area. This may cause edema making the parasite tunnels less visible. Moreover, allergic reactions to the parasite could worsen the erythema and the pruritus in the involved area [9].TheassociationofCMLwithLöffier’ssyndromeisparticularly
Conclusions:Intheeraofmodernmedicine,itisimportantto beawareofCLMinfectionthat,evenifrare,caneasilybeacquired byinternationaltravellingchildrenwhenplayingoncontaminated ground.Preventionbywearingslippersandclothesisimportantto avoidthisinfectionalongwithpoliciesforpetsdeworming.Evenif prognosisisgood,earlyrecognitionandtreatmenthelpinpreventingcomplication.ThesurveillanceofCLMinfection,importedor
References1. Cunha PR, Flora TB, Kroumpouzos G. Travelers’ tropical skin dis-eases: Challenges and interventions. Dermatol Ther. 2019; 32(4):e12665.
2. VeraldiS,ÇukaE,VairaF.Cutaneouslarvamigrans.In:Dermat olog- ical Cryosurgery and Cryotherapy. 2016; 11: 475- 477.
3. Muller ML.Pediatric CutaneousLarva Migrans.Medscape. 2015.
4. PaulIS,SinghB.Cutaneouslarvamigransinchildren:Acasese riesfrom Southern India. Indian J Paediatr Dermatology. 2017; 18: 36- 38.doi:10.4103/2319-7250.188454
5. DimitreLuzF.SilvaJDCVB.ABoyWithaFacialPruriticErup tion From Cutaneous Larva Migrans | Consultant360.
www.consul- tant360.com/articles/boy-facial-pruriticeruption-cutaneou.6. HeukelbachJ,FeldmeierH.Epidemiologicalandclinicalchar acter-istics of hookworm-related cutaneous larva migrans. Lancet InfectDis. 2008; 8: 302-309.
7. O’Connell E, Suarez J, Leguen F. Outbreak of cutaneous larva migransatachildren’scamp-Miami,Florida,2006.MorbMortalWklyRep. 2007; 56: 1285-1287.
8. KimJY,SilvermanRA.Migratinghair:Acaseconfusedwithcutane-ous larva migrans. Pediatr Dermatol. 2010; 27: 628-630.
9. Tianyi FL, Agbor VN, Kadia BM, Dimala CA. An unusual case ofextensive truncal cutaneous larva migrans in a Cameroonian baby:A case report. J Med Case Rep. 2018; 12: 270.
10. WangS,XuW,LiLF.CutaneousLarvaMigransAssociatedwithLöffler’sSyndromeina6-Year-OldBoy.PediatrInfectDisJ.2017;36:912- 914.
11. VeraldiS,AngileriL,ParducciBA,NazzaroG.Treatmentofhookworm-related cutaneous larva migrans with topical ivermectin. JDermatolog Treat. 2017; 28:263-263.
12. DelGiudiceP,HakimiS,VandenbosF,MaganaC,HubicheT.Autochthonous Cutaneous Larva Migrans in France and Europe. ActaDerm Venereol. 2019; 99:805-808.
Citation:Decembrino L. Cutaneous Larva Migrans: ACase Report in aTraveler Child. Annals of Clinical and Medical Case Reports 2020