An Indigenous Case of Cutaneous Larva Migrans Conrad Benedetto, DO,* Irini Youssef, BS,** Paul Shitabata, MD,*** Navid Nami, DO****

*Dermatology Resident, 1st year, Western University of Health Sciences, Pomona, CA **Medical Student, 3rd year, State University of New York Downstate Medical Center - College of Medicine, Brooklyn, NY ***Director of Dermatopathology, Harbor-UCLA Medical Center, Torrance, CA ****Program Director, Dermatology Residency, Western University of Health Sciences, Pomona, CA

Disclosures: None Correspondence: Conrad Benedetto, DO; [email protected]

Abstract Cutaneous larva migrans (CLM) is an infection caused predominantly by the Ancylostoma hookworm, most commonly found in tropical and subtropical areas. The hookworm is acquired through skin contact with soil contaminated by larvae-infested dog or cat feces. Although most U.S. cases are described in patients with a travel history, a few cases of indigenous infections have been reported in patients who cohabitate with canines and felines, whose intestines may be inhabited by the nematode. Once shed into sand or soil, the ova of Ancylostoma larvae require a warm and humid climate to develop into infective filariform larvae. We describe a patient with no travel history who presented to our Southern California clinic with symptoms of CLM.

5 Introduction Discussion filariform stage. Upon direct contact, the larvae Cutaneous larva migrans (CLM) was first described Cutaneous larva migrans is primarily a clinical penetrate skin, most commonly of the feet, legs, by Lee in 1874 as a “creeping eruption.”1 The classic diagnosis, most often presenting in those who buttocks or back. Due to their inability to produce clinical feature of the disease is a serpiginous or have traveled to tropical countries. In the United the collagenase enzyme essential to invade the linear, erythematous, elevated tract that migrates in States, most indigenous cases are from coastal basement membrane of the epidermis, the larvae an irregular pattern. In 1926, Kirby-Smith et al. were states, including Texas and New Jersey, with the remain limited to the epidermis. Humans serve the first to recover nematode larvae from biopsies of highest incidence in Florida.3 It is caused by as dead-end hosts for the larvae. As the larvae patients with creeping eruptions.2 CLM is caused the tropical hookworms Ancylostoma braziliense, migrate through the skin, the host inflammatory by the tropical hookworms Ancylostoma braziliense, Ancylostoma caninum, and Uncinaria stenocephala, response produces an intense pruritic and Ancylostoma caninum, and Uncinaria stenocephala, which inhabitant the intestines of domestic serpiginous, threadlike reaction that marks the which inhabit the intestines of domestic animals, animals like dogs and cats.4 About 20,000 eggs including dogs and cats. CLM is acquired via direct may be produced per female Ancylostoma. Within contact with soil or sand contaminated with larvae 56 hours to 66 hours after being shed in the of the causative organisms. The disease is endemic feces of dogs and felines, the eggs undergo two in developing regions, particularly in tropical areas rhabditiform molts to develop into their infective like Central and South America, India, and Africa. Cases seen in the United States are almost always associated with recent travel to endemic regions. We describe a native case of CLM, diagnosed in a patient with no recent history of travel outside the United States. Case Report A 59-year-old man with a past medical history of diabetes mellitus type 2 and hypertension presented with a pruritic eruption on the hands and feet of several weeks’ duration. He denied recent travel prior to the onset of the lesions, and no other members of his household were affected. He admitted to having a cat in his home, and reported the cat was healthy. Figure 1. Erythematous papules and serpiginous Figure 3. H&E at 10x magnification showing raised tracts on the medial aspect of the right foot. parasitic burrows. Physical examination revealed multiple erythematous papules and serpiginous raised tracts on the patient’s feet and hands (Figure 1). Low-power histopathologic examination of a lesion on the right medial foot revealed acral skin with intraepidermal vesicles consistent with parasitic burrows (Figure 2). On higher power, variously sized burrows were noted (Figure 3). On highest power (Figure 4), the burrows were observed to contain collections of neutrophils and eosinophils. Additional features seen histologically with CLM are spongiosis, a lymphohistiocytic dermal infiltrate with eosinophils, and, occasionally, collections of eosinophils within the epidermis and hair follicles. It is unusual for parasites to be seen in the biopsy specimen. Based on the clinical presentation, a diagnosis of cutaneous larva migrans (CLM) was established. He was treated with a one-time dose of 12 mg oral ivermectin, and the eruption had resolved by his two-week Figure 2. H&E at 4x magnification showing Figure 4. H&E at 40x magnification showing follow-up appointment. intraepidermal parasitic burrows. neutrophils and eosinophils in one of the burrows.

Page 29 AN INDIGENOUS CASE OF CUTANEOUS LARVA MIGRANS larvae’s tracts, typically 2 mm to 4 mm wide and While CLM is a self-limited disease, with humans 3,6 References 15 cm to 20 cm long. Hookworm folliculitis is a as the dead-end hosts, the associated eruption can 1. Lee RJ. Case of creeping eruption. Trans Clin less common presentation of the disease marked be distressing to the patient and may last several Soc Lond. 1874;8:44-5. by papules and vesicles resembling folliculitis.7 months. Treatment results in shortening the course of the disease. Treatment options include a 2. Kirby-Smith JL. Creeping Eruption. Arch Ancylostoma ova and larvae require moist, warm single, 400 mg dose of albendazole in adults and Dermatol. 1926 Jan;13(2):137. soil to mature. In the United States, sporadic children older than two years of age, or 400 mg/ indigenous cases of cutaneous larva migrans have day to 800 mg/day (10 mg/kg/day to 15 mg/kg/ 3. Meinking TL, Burkhart CN, Burkhart CG. been described and are commonly associated with day in children) for three to five days; a single, 12 Changing paradigms in parasitic infections: unusual climatic conditions, such as protracted mg dose of ivermectin (150 mcg/kg in children); 8 common dermatological helminthic infections periods of humid weather or rainfall. When or thiabendazole 10% to 15% solution or ointment and cutaneous myiasis. Clin Dermatol. individuals live in close contact with their pets, applied topically three times daily for at least 15 9 2003;21(5):407–16. infections can also occur in the winter season. In days. states with hot climates, such as in the southern 4. Tekely E, Szostakiewicz B, Wawrzycki B, United States, hookworm-related cutaneous larva Conclusion Kądziela-Wypyska G, Juszkiewicz-Borowiec migrans occurs sporadically or in small epidemics. CLM is one of the most frequent helminthic M, Pietrzak A, et al. Cutaneous larva migrans In 1966, Fuller described a small outbreak of infections diagnosed in travelers returning from syndrome. Adv Dermatol Allergol. 2013;2:119–21. cutaneous larva migrans in nine workmen who areas where the Ancylostoma hookworm is endemic, worked in a 3-foot-high crawl space under a new including the Caribbean, Southeast Asia, Central 5. Fuller CE. A Common Source Outbreak of 5 hospital in Florida. The soil in the crawlspace America and Africa. Autochthonous cases of CLM Cutaneous Larva Migrans. Public Health Rep was “light, moist, sandy loam, completely shaded are rare, and the few reported cases describe human (1896-1970). 1966;81(2):186. by the concrete floor of the building…with little skin contacting infected soil, which was likely ventilation,” coupled with a temperature of 86° F, contaminated with feline or canine feces and then 6. Quashie NB, Tsegah E. An unusual recurrence close to the mean August temperature. exposed to the humidity and warmth that allow the of pruritic creeping eruption after treatment of ova to develop into infective larvae. Despite the rare cutaneous larva migrans in an adult Ghanaian A study conducted between 2007 and 2011 looked occurrence of CLM in the United States, doctors male: a case report with a brief review of literature. at 30 GeoSentinel sites and more than 42,000 must keep the differential in mind when examining Pan Afr Med J. 2015;21:285. travelers who returned to the United States with patients exhibiting CLM-like symptoms and an illness. The researchers found that 19.5% of the cutaneous lesions, even without a history of recent 7. Malvy D, Ezzedine K, Pistone T, Receveur 11 conditions were dermatologic. Eight percent travel. These patients should be educated about MC, Longy‐Boursier M. Extensive Cutaneous were hookworm-related cutaneous larva migrans, wearing protective clothing, including shoes, when Larva Migrans With Folliculitis Mimicking with the highest prevalence of the condition in outside. Their pets should also be screened and Multimetameric Herpes Zoster Presentation in an those returning from Caribbean destinations, treated for intestinal worms. Adult Traveler Returning From Thailand. J Travel followed by Southeast Asia and Central America. Med. 2006 Jan;13(4):244–7. Just 1.6% of patients (675 persons) had traveled only within the United States, supporting the 8. Heukelbach JCB, Feldmeier H. Epidemiological rarity of acquiring cutaneous larvae migrans from and clinical characteristics of hookworm-related North American soil. Several hypotheses have cutaneous larva migrans. Lancet Infect Dis. been proposed to explain the isolated epidemics 2008;8(5):302–9. of domestic cutaneous larva migrans. One study in Florida between 1998 and 2000 found that 9. Patterson CRS, Kersey PJW. Cutaneous larva 20 (33%) of 60 feral cats were infected with migrans acquired in England. Clin Exp Dermatol. A. braziliense.12 There is also genetic evidence 2003;28(6):671–2. that Puma concolor, which was introduced into southern Florida between 1956 and 1966 from 10. TW Boland, Agger WA. Cutaneous larva Central and South America, carried several migrans. Recent experience in the La Crosse area. Ancylostoma species.13 The introduction of foreign Wis Med J. 1980;79(2):32–4. animals from tropical countries into the United States may spearhead the growing prevalence of 11. Leder K. GeoSentinel Surveillance of Illness in autochthonous cutaneous larvae migrans cases. Returned Travelers, 2007–2011. Ann Intern Med. 2013;158(6):456. The differential diagnosis for CLM includes, but is not limited to, tinea pedis, human scabies, 12. Anderson TC, Foster GW, Forrester DJ. ancylostomiasis, migratory myiasis, and larva Hookworms of feral cats in Florida. Vet Parasitol. currens. Larva currens is caused by Strongyloides 2003;115(1):19–24. stercoralis and distinguished by its single or multiple, pruritic tracks on the buttocks, 13. O’Brien SJ, Roelke ME, Yuhki N, Richards abdomen, or upper thigh regions that advance KW, Johnson WE, Franklin WL, Anderson much faster than CLM. Migratory myiasis is AE, Bass OL Jr, Belden RC, Martenson JS. a self-limited, cutaneous eruption caused by Genetic introgression within the Florida panther larvae from the adult flies Hypoderma bovis or Felis concolor coryi. Natl Geogr Res. 1990 Gasterophilus intestinalis, characterized by the Jan;6(4):485-94. painful subcutaneous nodules that develop as 14. Brenner MA, Patel MB. Cutaneous they migrate at 1 cm/hour. They eventually larva migrans: the creeping eruption. Cutis. die within the tissue or exit via furuncle-like 2003Aug;72(2):111-5. lesions. Ancylostomiasis is caused by Ancylostoma duodenale and Necator americanus, the dissemination of which leads to iron deficiency anemia, GI and pulmonary symptoms, and malnutrition. Human scabies, caused by Sarcoptes scabiei, is characterized by erythematous papules and linear burrows in hand creases, finger webs, axillae and genitalia. Tinea pedis, a dermatophyte infection, causes a circular, erythematous plaque with a scaling border and central clearing.14

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