Cutaneous Larva Migrans, an Occupational Disease

ANNALS OF CLINICAL AND LABORATORY SCIENCE, Vol. 7, No. 5 Copyright © 1977, Institute for Clinical Science Cutaneous Larva Migrans, an Occupational Disease IRENE E. ROECKEL, M.D. and EUGENE T. LYONS, Ph.D. Central Kentucky Blood Center, Lexington, KY 40508 and College of Agriculture, Department of Veterinary Science, University of Kentucky, Lexington, KY 40506 ABSTRACT Creeping skin eruption is known to follow exposure to canine and feline hookworm larvae found in contaminated soil encountered in humid, tropical and subtropical regions. A little known hazard of similar infections exists among veterinarians and laboratory workers exposed to Strongyloides larvae from horses located in temperate climates. The evolving clinical picture is described in detail. Continued exposure may lead to a state of hypersensitiv ity to the parasitic protein resulting in severe hyperimmune reactions. The invasiveness of Strongyloides larvae through intact skin and the pathologic changes associated with infection were demonstrated in a rabbit. Introduction frequently reported following exposure to larvae of canine and feline hookworm, Creeping eruption or cutaneous larva less commonly due to larvae of human and migrans is a condition in man resulting nonhuman species of Strongyloides.1 from skin invasion by filariform larvae of a Experimentally, filariform larvae of number of species of nematodes. Not Strongyloides myopotami from the nutria much space is devoted in the literature to and Strongyloides procyonis of the rac cases of cutaneous larva migrans, al coon resulted in creeping eruption in a though this condition is prevalent in some human volunteer.3 Accidental exposure, regions with warm, humid, tropical or resulting in skin penetration of the hands subtropical climates, including the south of laboratory workers by larvae of Stron ern United States and South, East and gyloides ransomi of swine and Stron West Africa and Ceylon.7 In the United gyloides papillosus from sheep, goats, and States, cases of creeping eruption are most cattle and Strongyloides westeri from horses, has also been reported.6 Because The investigations reported in this paper (No. cases are so infrequently seen, only a few 77-4-106) are published with the approval of the D i rector of the Kentucky Agricultural Experiment Sta physicians are familiar with the clinical tion. picture and know the nematodes respon 4 0 5 4 0 6 ROECKEL AND LYONS sible for creeping eruption. Accidental patient permitted skin biopsy of a lesion exposure to free-living third-stage larvae for diagnostic purposes. All three patients of S. westeri was observed in three pa remain symptom free as long as there is tients and forms the basis for this report. no contact with the parasite. The exposure resulted from the individu als working with the parasites in the labo Case Reports ratory. In addition, free-living third-stage larvae of S. westeri were used to repro Case 1. This 58-year-old white Caucasian male had about 17 years ofexperience working with fecal duce skin lesions in a rabbit. cultures containing free-living third-stage larvae of S. papillosus and S. westeri. He wore no gloves while working with the larvae. O n September 24, Aetiologic Agent 1966, a large, but undetermined number of S. wes teri larvae from a 30 ml syringe filled with water The adult parasite, S. westeri, is a tiny containing 2.25 m illion larvae, splashed on his 8 to 9 mm long nematode found in the forehead, leading to a striking edema with spon small intestines of young horses. The life taneous recovery after 360 hrs. The details are tabu lated in table I. He continued to work with fecal cycle has been elucidated.4,5 Infection cultures containing larvae of both species of Stron- occurs predominantly from parasitic gyloides for seven more years, wearing rubber third-stage larvae passed through the gloves, and remained free of symptoms. milk of mares to their foals, and these Case 2. This 29-year-old, red-haired individual stages mature in a minimum of about with light complexion had approximately 1 2 years experience with fecal cultures of larvae of both S. eight days. The adult worms lay eggs papillosus and S. westeri. This included cleaning which pass in the embryonated state in stalls as well as handling cultures. He wore no the feces of foals. Larvae hatch from the gloves while working. On October 6 , 1970, a mas sive accidental exposure on the right arm, wrist and eggs on the ground and develop, directly area of antecubital fossa, to probably several or indirectly, to free-living third-stage thousand free-living third-stage larvae of S. westeri, larvae, capable of skin penetration, that from a sample containing 6 .0 million larvae, led to the illness reported here. During the observation enter foals and mature or enter tissues of period, at least two additional exposures to the lar horses, possibly all ages, and become in vae occurred over a 60-day period. hibited as parasitic third stages. Shortly The patient became progressively sensitized and he experienced recurring edematous swelling of his after parturition, the parasitic third-stage hands and arms for several days after working with larvae begin passing in the milk of mares fecal cultures. Edema was pronounced on the right to foals where the parasite matures and hand and right forearm between 18 and 234 hrs, peaking between 42 and 138 hrs, after the initial the life cycle is completed. massive exposure. In addition, erythema was evi dent in two areas of known exposure, on the right wrist and in area of antecubital fossa, between 18 Diagnosis and 618 hrs (figure 4). At 234 and 1,362 hrs after the initial known exposure to the right arm, the left Diagnosis in the three reported cases hand was exposed to probably a small number of were made after known accidental expo free-living third-stage larvae. This resulted in sure to free-living third-stage larvae (fig edema of the left hand within 24 hours after each ure 1) of S. westeri resulting in the dif exposure, lasting for 384 and 48 hours, respectively. Two years following the first accidental massive ex ficult clinical pictures to be reported. All posure, he changed jobs and no longer experienced three subjects, while doing research, had reactions until when he one day milked a mare. As previously noted, mares’ milk may contain parasitic previous contact for several years with third-stage larvae ofS. westeri which could possibly free-living third-stage larvae of S. papil- cause recurrence of the allergic reaction. losus from sheep and cattle and S. westeri Case. 3. This 45-year-old white male had about from horses. The number of exposures 15 years of experience with larvae of S. papillosus prior to the illnesses reported in this and S. westeri, most contact being with the latter. The exposure was to parasitic third-stage larvae in paper remain unknown, but oppor milk and free-living third-stage larvae in fecal cul tunities to exposure were frequent. One tures. On September 3,1976, an accidental exposure, CUTANEOUS LARVA MIGRANS 407 probably on right middle finger, to free-living third- 24 hrs after exposure, spreading caudally as well as stage larvae of S. westeri led to the illness described laterally. Note a possible second exposure at 180 hrs in table II. A somewhat different clinical course was after the first one. seen than in the first two cases experienced. The Creeping eruptions occurred 324 hrs postexpo allergic reaction seen on the right hand (figure 5) and sure, moving mainly from right to left under the right detailed in table II consisted mostly of edema within pectoral muscle (figure 3), between both pectorals, FIGURE 1. Free-living third-stage larva of Strongyloides westeri (Total length is about 500 fx). F i g u r e 2. Creeping eruption on right side F i g u r e 3. Creeping eruption under right of neck (Case No. 3). pectoral area (Case No. 3). F i g u r e 4. Erythema on right wrist and in F i g u r e 5. Edema of right hand; left hand area of antecubital fossa (Case No. 2). normal (Case No. 3). 40 8 ROECKEL AND LYONS TABLE I Clinical Picture in Case 1 Following Accidental Exposure to Forehead of Several Thousand F ree-living Third-stage Larvae o f S. westeri on September 24, 1966 Time ________ Edema_____ _______________________________ Erythema Postexposure ____________Top of Head___________ (Hours) Right Orbit Nose Forehead Anterior Middle Posterior Rear of Head 0 0 0 -- - -- 24 0 0 -- - -- 48 2 0 + ---- 72 3 3 + + + - - 96 4 3 + + + + - 120 4 4 + + + + + 144 3 3 + + + + + 168 2 2 + + + + + 192 to 288 1 1 + + + + + 312 0 0 - -- -- 360 1 0 -- - -- 364 0 0 - - - -- Edema graded from 0 to 4. Erythema marked - = absent; + = present. on the right side of the neck (figure 2 ), over the top of injected through 16-gauge needle into rear hip mus the right shoulder and on the lower right shoulder, as cles. On May 14, 1971, 0.5 milliliter of the same detailed in table II. mixture was injected into hip muscles, prior to appli Blood eosinophiles rose from 6 percent at 96 hrs to cation o f600,000 live larvae on the shaved abdomi a peak of 18 percent at 504 hrs postexposure. The 6 nal area. The area at the site of the application be percent level returned by 912 hours after exposure. came red. On May 21, 1971, 0.5 milliliter of frozen One site of the allergic dermatitis, on the right larvae with Freund’s adjuvant was injected again just forearm, was biopsied, showing areas of epidermal prior to application of 300,000 live larvae on shaved thickening overlying the most intense inflammatory abdomen.

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