Skin Diseases in Returned Travelers

Skin diseases in returned travelers

Pr. Eric CAUMES Dept Maladies Infectieuses et Tropicales Hop Pitié- Salpêtrière Paris Sorbonne University (ex ESCMID eLibraryPierre & Marie Curie) © by author Potential links of Interests

• In the past 5 years, I (or my department) have received honoraria from BMS, Baxter, Galen, Codexial and Takeda, for lectures on STDs and participation in advisory boards (TBE vaccine, KS management, permethrin, and dengue vaccine).

• Editor in Chief of the Journal of Travel Medicine (submission wellcome) ESCMID eLibrary © by author ESCMID eLibrary © by author What is the part of tropical diseases amongst skin diseases in returned travelers seen in travel units? • 1/ > 50% • 2/ 35-50% • 3/ 20-35% • 4/ 5-20% ESCMID• 5/ < 5% eLibrary

5769 © by author Tropical skin diseases in returning travelers : less and less common 60

30 Tropical 20

0 1995 2007 2008 2014 1995- Caumes E. Clin Inf Dis 1995; 20:542-548 2007- Ansart S. Am J Trop Med Hyg 2007; 76:184-186 2008 ESCMID- GeoSentinel. Int J Inf Dis 2008eLibrary i:10.1016/j.ijd.2007.12.008 2015- Stevens MS et al. CMAJ open 2015; 0.9778/cmajo.20140082 © by author What is/are the leading skin disease(s) diagnosed in returning travelers seen in travel units?

• 1/ cutaneous larva migrans • 2/ skin and soft tissue infections • 3/ sexually transmitted diseases • 4/ insect bites and stings • 5/ESCMID skin related animal eLibrary exposures

5768 © by author Skin diseases in 8.227 ill travelers (19%), GeoSentinel, 2007-2011

Rabies 18% 16% PEP 14% 12% 10% 8% Derm 6% 4% 2% Sentinel 0% ESCMIDSSTI Insecte prurit eLibraryAnimal LMCa Leder K et al. Ann Intern Med 2013; 158: 456-468 © by author Dermatoses Canadian Travellers, 2009-2012 • 1076 dermatoses/6639 consultations (16%) • 5/6 Canadian Sites; 6 possible purpose for travel • Sex: 41% M; 58%F; age (IQR): 39.7 y (26-52) • Travel duration (IQR): 15 d (7-31d) • Outpatient: 1049 (97%) • Carribean: 242 (22%); Latin America: 197 (18%) • Tropical Infections (16.4%): HrCLM (9.8%); LCL (3.3%); myiasis (1.7%); leprosy (1.4%)

Stevens ESCMID MS et al. CMAJ open eLibrary 2015; 10.9778/cmajo.20140082 © by author What is the leading animal to which travelers are exposed?

• 1/ Bat • 2/ Dog • 3/ Cat • 4/ Monkey • 5/ESCMID Tiger eLibrary

5770 © by author Skin problems in 1076 travellers Canada

200 Sentinel 180 160 Insect bites (19%) 140 SSTI (14%) 120 HrCLM (9.8%) 100 Rash ukn (7.1%) 80 Prurit ukn (6%) 60 Animal (5.2%) 40 20 0 Stevens ESCMID MJ et al. monkey (25),eLibrary dog (18), other (10: bat CMAJ open 2015 6, cat 3, tiger, stingray & leech 1) © by author Skin diseases in returned travelers (post travel and ID/travel unit biases)

• Epidemiological overview • Skin and soft tissue Infections • Hookworm related CLM, creeping dermatitis • Arthropodes exposure, pruritic dermatoses ESCMID eLibrary © by author What is the leading clinical form of SSTI in returned travelers?

• 1/ cellulitis • 2/ abscess • 3/ impetigo • 4/ furuncle ESCMID• 5/ folliculitis eLibrary 5771 © by author SSTI in 48 travelers, 1991 - 1993 • Impetigo : 19 (39%) - S aureus (40%) [12 (63%) arthropod] - S.a + S.p (20%) - S.pyogenes (20%) - negative (20%) • Erysipela : 9 (18%) • Ecthyma : 8 (16%) • Abscess: 4 (8%) • Furoncle : 4 (8%) • Intertrigo : 2 (4%) • Folliculitis : 1 (2%) • NecrotizingESCMID cellulitis : 1 (2%) eLibrary Caumes et al. Clin Inf Dis 1995;20:542-548 © by author SSTI: from presentation to treatment Clinical form

Microbial agent

ESCMIDPresumptive eLibrary treatment © by author SSTI in 60 travelers, 01/2006 - 08/2007

Forms N (%) % culture + MS Sa GAS (Sp) Sa + Sp

Impetigo 21 (35%) 76% 31% 38% 31%

Abscess 14 (23%) 57% 100% 0 0

Ecthyma 11 (19%) 91% 10% 60% 30%

Cellulitis 11 (19%) 0 NA NA NA Folliculitis ESCMID3 (5%) 33% eLibrary100% 0 0 Hochedez P et al. Am J Trop Med Hyg 2009; 80: 431-4 © by author M, 37 yo D3 after bite 1. Furuncle 2.Folliculitis 3.Impetigo 4.Prurigo 5. ESCMIDAnthrax eLibrary

5772 © by author M, 43 yo, D2 after return 1.Furuncle; 2.Anthrax; 3.Impetigo; 4.Abscess; 5.Cellulitis

ESCMID eLibrary

5773 © by author M, 32 yo D3 after bite 1. Furuncle 2.Ecthyma 3.Impetigo 4.Anthrax 5. CellulitisESCMID eLibrary

5774 © by author M, 37 yo D3 > return 1. Furuncle 2.Anthrax 3.Impetigo 4.Cellulitis Traveling5. ESCMIDAbscess eLibrary MRSA 5775 © by author Abscess management « Ubi pus, Ibi evacuata »

Still true since Hippocrate

ESCMIDAm J Med 1876; eLibrary 6: 226 © by author F, 35 yo, D1 > Ivory Coast D3 > onset 1. Furuncle 2.Folliculitis

3.Impetigo D 1 : arthropod bite 4.Cellulitis D 4 : lesion onset ESCMID eLibraryD 6 : return; 5.Abscess D 7 : 1st consultation 5776 © by author M, 41 yo D3 > onset 1. Furuncle 2.Abscess 3.Impetigo 4.Cellulitis 5.Anthrax Cutaneous lesion appeared 6 ESCMID dayseLibrary after N°1 went back

5777 © by author Mrs fistulized abscess Mr cellulitis

ESCMID eLibrary © by author Mr Abscess & Mrs fistulized abscess

ESCMID eLibrary © by author What is the bacteria most likely involved in the SSTI of both couples? • 1/ Streptococcus pyogenes • 2/ Staphylococcus aureus PVL + • 3/ Streptococcus agalactiae • 4/ Staphylococcus aureus PVL - ESCMID• 5/ Staphylococcus eLibrary epidermidis

5778 © by author Import and spread of PVL+ S.aureus in travelers with SSTI • 38 travelers with S.aureus + SSTI vs 124 control with other trav-dis; genotyping • S.aureus SSTI were associated with travel duration and location (Africa: OR =4.2) • Pts with PVL+ S.aureus SSTI were also colonized in the nares (73% vs 25%) • SSTI due to PVL+ S.aureus were more likely to be complicated, have reduced antibiotic susceptibility and ESCMID lead to 2ry spread (5eLibrary clusters) Zanger P et al. Clin Inf Dis 2012; 54: 483-92 © by author S.aureus related SSTI in travelers

• Transmission in the household then in the community • Antibiotic resistance • Recurrences • Portage

Zhou YP, et al. J Travel Med. 2014; 21: 272-81 Zanger ESCMID P (editorial). J Travel MedeLibrary 2014; 21: 225-7 © by author Palais ESCMID des Papes eLibrary Avignon, France © by author ESCMID eLibrary © by author All these five patients presented with creeping dermatitis, where is the patient with loiasis ? • 1/ Center • 2/ Upper right • 3/ Upper left • 4/ Lower right • 5/ESCMID Lower left eLibrary

5781 © by author CreepingCreeping eruptioneruption and CLM

Related to the Related to the Not related to migration of migration of parasitic parasite’s parasite : disease : lichen larvae (incl CLM): scabies, striatus, dracunculiasis, thrombophlebitis, animal pili migrans,… hookworm, loiasis, myiasis gnathostomiasis, ESCMID eLibraryCaumes E. Lancet Infect Dis larva currens 2004; 4: 659-660 © by author What is the most common cause of creeping dermatitis in returned travelers? • 1/ Loiasis (nematode) • 2/ Gnathostomiasis (nematode’s larvae) • 3/ Hookworm related CLM (nematode’s larvae) • 4/ Pyemotes ventricosus (arthropod) • 5/ LarvaESCMID currens (strongyloidiasis)(nematode) eLibrary

5782 © by author 70 pts with creeping dermatitis, 2008-2012 Disease Number of cases (%) HrCLM including 66 (94%) including Hookworm folliculitis 7 HF /66 (11%) Gnathostomiasis 2 (3%) Loiasis 1 (1.5%) Creeping (dog) hair 1 (1.5%)

Migratory myiasis, 0 dirofilariasis, larva currens, Pyemotes ESCMIDventricosus, scabies eLibrary Van Haecke C et al. Br J Dermatol 2014; 170: 1166-1169 © by author ESCMID eLibraryBoracay, Philippines © by author What is the disease causing creeping dermatitis with such a parasitic cycle? • 1/ Loiasis • 2/ Gnathostomiasis • 3/ Hookworm related CLM • 4/ Pyemotes ventricosus • 5/ESCMID Larva currens (strongyloidiasis) eLibrary

5783 © by author ESCMID eLibrary © by author ESCMID eLibrary © by author ESCMID eLibrary © by author Folliculitis (HrCLM)

ESCMID eLibrary © by author ESCMID eLibrary © by author Diagnosis of HrCLM relies on

1. Epidemiological data : typical exposure 2. Clinical appearance : creeping dermatitis (but also pruritic folliculitis) 3. Course of the disease : appearance less than one month after return, chronic 4. Biopsy of local lesion useless (except in folliculitis) 5. Stool examination : no interest except in ……dogsESCMID eLibrary © by author Hr Cut larva migrans in travellers

Ref (1) (2) (3) Patients 60 67 64 Nationality Canada France France After return 45 % 51 % 55 % Lagtime 5d (0-30) 8d (0-28) 16d (1-120)

(1) Davies et al. Arch Dermatol 1993;129:588-591 ESCMID(2) Caumes eLibrary et al. Clin Infect Dis 1995;20:542 -548 (3) Bouchaud et al. Clin Infect Dis 2000;31:493-498 © by author Identification of Ancylostoma braziliense in HrCLM (Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5)

Living hookworm larva recovered from a skin scraping of folliculitis Lesion ESCMID(optical micro, x10) eLibrary Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5 © by author You can treat HrCLM patient with… • 1/ Ivermectine single or double dose according to clinical presentation • 2/ Albendazole 400 mg/d, 5 days • 3/ Albendazole 800 mg/d, 3 days • 4/ Albendazole 10% ointment • 5/ESCMID Praziquantel eLibrary 5784 © by author Albendazole in HrCLM

Ref N= Dosage Cure rate Coulaud, 1987 18 400 mg/d x 5 d 100%

Veraldi, 2011 78 400 mg/d x 7d 100% Kaba, 2012 77 200-400 mg/d x 3 d 89%

Ref N= Dosage Cure rate Jones, 1990 2 800 mg/d x 3 d 100% Williams, ESCMID 1989 4 800eLibrary mg/d x 3 d 100% © by author HrCLM : efficacy of a single dose ivermectin varies with the clinical presentation.

• 62 travellers (35 F, 27 M, mean age 35) with HrCLM treated with 200 g/kg dose of ivermectin, single dose. • All pts had creeping dermatitis and 6 patients (10%) also had hookworm folliculitis (HF). • Overall CR = 59/62 pts (95%). CR = 98% in the 56 pts presenting with only creeping dermatitis and 66% in the 6 patients also presenting with HF

Vanhaecke ESCMID C et al. J Eur Acad Dermatol eLibrary Venereol 2014; 28: 655 -657 © by author ESCMID eLibrary © by author Topical albendazole in CLM : 2 pts

• 2 children, 10 kgs, 2 years old • Return from Senegal, Dominican Republic • 1 cutaneous lesion/pt • ivermectin and albendazole contra indicated • thiabendazole no more marketed • albendazole ointment 10% (3 tablets, i.e. 1200 mg, mixed with 12 gr crotamiton) twice a day during 10 days ESCMID eLibrary Caumes E ; Clin Inf Dis 2004; 38: 1647-1648 © by author A traveler wants to know how to avoid HrCLM on his next vacation. Your advice to him is :

1. Use insect repellent 2. Sleep under bednets 3. Protect skin against direct sand/soil exposure 4. ESCMIDMake dogs wearing eLibrary sun glasses 5. Make dogs clean their shit 5785 © by author Beppu, Japan

ESCMID eLibrary © by author ESCMID eLibrary © by author Larva currens Strongyloidiasis ESCMID eLibrary © by author Creeping Dermatitis Loiasis

Pruritus

Localized Generalized

Arthropod related sine materia with skin exposure lesions ESCMID eLibrary © by author What is the main cause of generalized pruritus in a returned traveler? • 1/ Ciguatera • 2/ HIV infection • 3/ Onchocerciasis • 4/ Scabies • 5/ESCMID Marine dermatitis eLibrary

5786 © by author Generalized pruritus in travelers (onset during travel) • Scabies • Skin dryness (aged African migrants VFRs) • HIV infection, • Filariasis (onchocerciasis, loiasis), invasive phase of helminthic disease, African trypanosomiasis • Ciguatera • Cercarial ESCMID dermatitis, eLibraryMarine dermatitis © by author What are the main itchy body areas in a returned traveler w scabies ? • 1/ Genitalia • 2/ Breast • 3/ Hands • 4/ Head • 5/ESCMID Back eLibrary

5787 © by author ESCMID eLibrary © by author Courtesy Antoine Mahé ESCMID eLibrary © by author ESCMID eLibrary © by author Scabies = 1st cause of pruritus • Occurs within one month after exposure (1st episode) and within a few days (history of previous scabies) • Generalized itching, worsen at night, sparing head • Specific findings : 5 to 10 mm burrows, vesiculopustules and papulonodular genital lesions. Classic distribution : interdigital web spaces, flexor surfaces of the wrists, elbows, axillae, buttocks, genitalia ESCMID and breast. eLibrary © by author Itching in the marital bed is scabies …..before ……….. bedbugs ESCMID eLibrary © by author Common scabies = treatment

• Varies according to the country • Topical: either permethrin OR benzyl benzoate • Oral : ivermectin • To be repeated : – D 2 for BB, – D 7 for permethrin, – D 7 for ivermectin • Also include persons sharing the same household (sex/bed partners, children) and environment (clothes, bedsheets,…)ESCMID eLibrary © by author Imported Tropical skin infections • Seen according to the place of exposure : HrCLM, LCL, tungiasis, myiasis, • Uncommon : tuberculosis, leprosy, gnathostomiasis, loiasis, • Rare : M.ulcerans infection (Buruli ulcer), anthrax, C.diphteriae, onchocerciasis, lymphatic filariasis, cutaneous forms of schistosomiasis, trypanosomiasis ESCMID and amebiasis.eLibrary © by author Cutaneous diseases in returned travellers • Acquisition: arthropods bites • SSTI are the most common • Tropical diseases: less and less common • Dg of skin disease oriented by epidemiologal data (visited country, time return/appearance, at-risk exposure), and clinical signs • Dg ESCMID confirmed by specific eLibrary tests © by author Thank you for your attention and kind invitation