The bug beneath the bathing suit: A case report and discussion of seabather’s eruption versus cutaneous larva migrans Andrew Jensen, BS,* Marcus Goodman, DO, FAOCD** *Medical Student, 4th year, Philadelphia College of Osteopathic Medicine - Georgia Campus, Suwanee, GA **Dermatology Residency Program Director, PCOM/North Fulton Hospital Medical Campus, Roswell, GA Abstract Seabather’s eruption is an important differential diagnosis when a patient who has recently swum in a subtropical ocean presents with a pruritic rash in the distribution of their swimwear. Treatment with systemic corticosteroids is indicated in severe cases and can successfully reduce symptoms. Oral steroid therapy in general has proven to be an effective treatment for many acute and chronic diseases but has long been associated with increased risk for infections. In this report, we present an atypical case of cutaneous larva migrans and discuss its clinical unmasking after systemic steroid treatment was given for an initial diagnosis of seabather’s eruption. Introduction Case Report Figure 2 Seabather’s eruption is a benign, superficial A 52-year-old female presented to her reaction to toxins from marine-animal larvae. dermatologist complaining of an itchy rash on It is the most common marine-related problem her groin and upper leg for one week. The patient in the waters south of the United States.1 stated she recently traveled to Mexico, where she It was reported in Florida as early as 1903 spent several days on the beach and swimming in as a “rash which set up an intense itching” the ocean. Physical exam revealed erythematous, shortly after bathing in ocean water.2 In 1949, edematous papules on her lower abdomen and Sams postulated the eruption was caused by groin, assuming a location directly beneath her “some living, microorganism, in the nature of swimsuit (Figure 1). A biopsy was collected, nematocysts from some form of coelenterate and the patient was discharged with a topical which is free floating.”3 Substantiating Sams’ corticosteroid and antihistamine regimen. initial claim, the thimble jellyfish, Linuche Figure 3 unguiculata, is now thought to be the cause of Figure 1 seabather’s eruption in the southeastern United States, Mexico and the Caribbean.4 The skin reaction occurs when jellyfish stinging cells called nematocysts get trapped underneath swimwear and inject venom there, causing an immune response and succeeding rash. The condition is often exacerbated with persistent use of the contaminated swimwear, causing friction on nematocysts, or when the swimmer later bathes in fresh water, inducing osmotic irritation and Figure 4 subsequent envenomation.5 Less than 24 hours after the initial visit, the Seabather’s eruption is diagnosed clinically as a patient called the office complaining she constant, pruritic and erythematous rash, papular, could not tolerate the constant itch. She was macular or urticarial, most commonly located prescribed a methylprednisolone dose pack and underneath swimwear. Differential diagnoses was encouraged to follow up with the office in include animal schistosomiasis (swimmer’s four to five days or earlier if symptoms worsen. itch), scabies, insect bites, varicella zoster, Biopsy results were received (Figures 2 and 3) and contact dermatitis, folliculitis and almost any revealed a “papular urticaria/arthropod assault” marine-origin dermatosis. A skin biopsy is not consistent with an initial clinical diagnosis of required for diagnosis of seabather’s eruption seabather’s eruption. but most commonly shows a superficial and deep Five days after the initial visit, the patient perivascular and interstitial infiltrate consisting returned for follow-up stating the rash was Discussion of lymphocytes, neutrophils, and eosinophils.6 spreading. Physical exam showed a worsening of Corticosteroids and immune function The syndrome is not considered contagious and symptoms with urticarial papules and serpiginous Corticosteroids play a critical role in treating is self-limiting, usually lasting an average of three plaques radiating from the initial site (Figure 4). common diseases like rheumatoid arthritis, to seven days. Treatment of seabather’s eruption The patient was diagnosed with cutaneous larva chronic obstructive pulmonary disease and a host consists mainly of supportive therapy with topical migrans. She was instructed to discontinue the of mild-to-severe inflammatory disorders. Since corticosteroids and antihistamines, with systemic oral steroid and was given a single dose of 12 mg their advent in the late 1940s, both short- and steroid use reserved for severe cases. oral ivermectin. One week after treatment, the long-term use of oral corticosteroid therapy has patient’s rash was resolved. Page 38 THE BUG BENEATH THE BATHING SUIT: A CASE REPORT AND DISCUSSION OF SEABATHER’S ERUPTION VERSUS CUTANEOUS LARVA MIGRANS been associated with increased risk of infections.7 Skin biopsy is not recommended for diagnosis of 9. Klein NC, Go CH, Cunha BA. Infections The mechanism of action of these biologically CLM, as larvae advance ahead of the visible tracks, associated with Steroid Use. Infect Dis Clin of active steroid hormones is spread across the usually resulting in a negative biopsy. Eosinophilia North Am. 2001 Jun;15(2):423-4. entire immunological-response spectrum. is present in only 30% of cases, proving this test 12 10. Cronin L, Cook DJ, Carlet J. Corticosteroid Lionakis reported that glucocorticoids affect to be inadequate as a diagnostic study. First- treatment for sepsis: A critical reappraisal and virtually every cell type involved in immunity line treatments of CLM include oral ivermectin 8 meta-analysis of the literature. Crit Care Med. and inflammation. Klein observed that a single and albendazole. Caumes reported that a single 1995 Aug;23(8):1430-9. dose of corticosteroids caused neutrophilic 12 mg oral dose of ivermectin achieved a cure leukocytosis, monocytopenia, and eosinopenia rate of 81% to 100%, and a single 400 mg oral 11. Caumes E. Treatment of cutaneous larva within four to six hours of dosing.9 These and dose of albendazole achieved a cure rate of 46% migrans. Clin Infect Dis. 2000 May;30(5):811-4. 11 other reports have shown that steroid therapy is to 100%. Oral steroids are generally avoided in 12. Jackson A, Heukelbach J, Calheiros CM, associated with decreased migration of neutrophils parasitic or other occult infections due to their Soares VL, Harms G, Feldmeier H. A study to target tissues, a reduction of inflammatory immunosuppressing effects. in a community in Brazil in which cutaneous cytokines, and an inhibition of hydrogen peroxide larva migrans is endemic. Clin Infect Dis. 2006 8-10 production in lysosomes. Together, these Conclusion Jul;43(2):13-8. inhibitions decrease microorganism killing and As discussed in this case report, we submit 13. Hochedez P, Caumes E. Hookworm-related subsequent infection elimination. that our patient had an atypical presentation of cutaneous larva migrans most likely from lying cutaneous larva migrans. J Travel Med. 2007 Cutaneous larva migrans on a sandy beach contaminated with dog feces. Oct;14(5):326-33. Cutaneous larva migrans (CLM), or creeping With the original erythematous, papular rash 14. Heukelbach J, Feldmeier H. Epidemiological eruption, is the most common skin disease among appearing directly beneath the patient’s swimwear and clinical characteristics of hookworm-related travelers returning from tropical destinations.11 and the absence of any cutaneous tracks, cutaneous larva migrans. Lancet Infect Dis. 2008 CLM is caused by a penetrating parasite, most seabather’s eruption was initially diagnosed. Not May;8(5):302-9. commonly the Ancylostoma braziliense, which until treatment of a severely pruritic eruption flourishes in the gastrointestinal tracts of cats and with an oral steroid regimen did identifiable dogs. Commonly found along tropical beaches serpiginous and linear tracks appear, warranting Correspondence: Marcus Goodman, DO; where animal feces gets deposited, parasite larvae a modification of the clinical diagnosis and [email protected] can remain viable and infectious for months in 12 treatment. Once therapy was changed to an a warm and humid environment. With 95% of indicated treatment of cutaneous larva migrans, patients with CLM reporting recent exposure to the patient’s symptoms resolved. a beach, prevention is focused on limiting contact with feces-contaminated sand or soil.1 The best References suggested community prevention of CLM 1. Habif TP. Clinical Dermatology. 5th ed. has been to ban dogs from beaches, a difficult Amsterdam: Elsevier Academic Press; 2010. 625, task especially in developing countries. More 628-30 p. individual forms of prevention include wearing 2. Russell MT, Tomchik RS. Seabather’s eruption, shoes while walking, and lying on a mattress or or ‘sea lice’: new findings and clinical implications. sand washed with the ocean tide when touring a J Emerg Nurs. 1993 Jun;19(3):197-201. beach frequented by dogs. 3. Sams WM. Seabather’s eruption. Arch Derm. In a human host, larvae migration is confined 1949 Aug;60(2):227-37. within the epidermis, causing the classic presentation of incessantly pruritic, erythematous, 4. Burnett JW, Kumar S, Malecki JM. The edematous, serpiginous tracks.13 The irregular antibody response in seabather’s eruption. track pattern advances at an average rate of 2.7 Toxicon. 1995 Jan;33(1):99-104. millimeters per day and can often be used to 5. Ubillos SS, Vuong D, Sinnott JT, Sakalosky 12 estimate infection duration. CLM is diagnosed PE. Seabather’s Eruption. South Med J. 1995 clinically by recognition of these raised, red- Nov;88(11):1163-5. purple, linear or serpiginous tracks, which usually 6. Wong DE, Meinking TL, Rosen LB, Taplin occur along the feet. Other common sites of D, Hogan DJ, Burnett JW. Seabather’s eruption. involvement include the buttocks, thighs, elbows, Clinical, histologic, and immunologic features. J back and face. Am Acad Dermatol. 1994 Mar;30(3):399-406. For many clinicians, the disease may mimic 7. Dixon WG, Abrahamowicz M, Beauchamp scabies, schistosomiasis, tinea corporis, ME, et al. Immediate and delayed impact of oral or contact dermatitis.