326 Hookworm-Related Cutaneous Larva Migrans Patrick Hochedez , MD , and Eric Caumes , MD Département des Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, Paris, France DOI: 10.1111/j.1708-8305.2007.00148.x Downloaded from https://academic.oup.com/jtm/article/14/5/326/1808671 by guest on 27 September 2021 utaneous larva migrans (CLM) is the most fre- Risk factors for developing HrCLM have specifi - Cquent travel-associated skin disease of tropical cally been investigated in one outbreak in Canadian origin. 1,2 This dermatosis fi rst described as CLM by tourists: less frequent use of protective footwear Lee in 1874 was later attributed to the subcutane- while walking on the beach was signifi cantly associ- ous migration of Ancylostoma larvae by White and ated with a higher risk of developing the disease, Dove in 1929. 3,4 Since then, this skin disease has also with a risk ratio of 4. Moreover, affected patients been called creeping eruption, creeping verminous were somewhat younger than unaffected travelers dermatitis, sand worm eruption, or plumber ’ s itch, (36.9 vs 41.2 yr, p = 0.014). There was no correla- which adds to the confusion. It has been suggested tion between the reported amount of time spent on to name this disease hookworm-related cutaneous the beach and the risk of developing CLM. Consid- larva migrans (HrCLM).5 ering animals in the neighborhood, 90% of the Although frequent, this tropical dermatosis is travelers in that study reported seeing cats on the not suffi ciently well known by Western physicians, beach and around the hotel area, and only 1.5% and this can delay diagnosis and effective treatment. noticed dogs. 12 Indeed, misdiagnosis or inappropriate treatment affects 22% to 58% of the travelers with CLM. 6 – 8 In Geographical distribution one case report, the time lag between the onset of disease and the diagnosis was 22 months. 9 Published cases in Western countries mainly con- Five large (>40 patients each) published studies cern tourists returning from tropical areas. 6 – 8 The of imported cases of CLM in returning travelers hookworms responsible for CLM are distributed have greatly helped improve knowledge of this dis- worldwide, but infection is more frequent in the ease. 2,6 – 8,10 This is particularly true as regards its tropical and subtropical countries of Southeast Asia, natural history and response to treatment in short- Africa, South America, Caribbean, and the south- term travelers without possibility of recontamination. eastern part of the United States. 8 In a prospective We reviewed the epidemiological, clinical, and analysis of parasitic infections in Canadian travelers therapeutic data drawn from studies of CLM in and immigrants, CLM was one of the leading causes travelers. The aim of this review was to contribute of infections and was primarily acquired in beach to a better defi nition and description of the disease destinations such as Jamaica, Barbados, Brazil, known as HrCLM. Thailand, and Mexico.11 HrCLM is rare in temper- ate countries, but a few autochthonous cases have been reported from Europe, North America, and Epidemiological data New Zealand. 13 – 18 HrCLM is common in the HrCLM is one of the leading causes of dermato- economically deprived communities of some areas logic disorders observed in ill returned travelers. 1,2,11 in Brazil, but the clinicoepidemiologic pattern is different from that observed in travelers. 19,20 Corresponding Author: Eric Caumes, MD, Départe- Pathophysiology ment des Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, 45-83 Bld de l ’ hôpital, F-75013 Paris, HrCLM is caused by the penetration of the skin by France. E-mail: [email protected] cat, dog, or other mammal nematode larvae. The © 2007 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine, Volume 14, Issue 5, 2007, 326–333 Hookworm -Related Cutaneous Larva Migrans 327 main culprit species are Ancylostoma braziliense and The most frequent and characteristic sign of Ancylostoma caninum , but other animal hookworms HrCLM is “ creeping dermatitis, ” a clinical sign like Uncinaria stenocephala and Bunostomum phleboto- defi ned as an erythematous, linear, or serpiginous mum are possible agents of HrCLM. 6,8,10,21 The track that is approximately 3 mm wide and may be up adult hookworms live in animal intestines, and their to 15 to 20 mm in length. 27 The creeping track, as- eggs are spread on the soil during defecation. Egg sociated with the larva migration, may extend a few hatching and larva survival are facilitated by moist millimeters to a few centimeters daily. 8 The mean grounds like beaches. After two molts in the soil, number of lesions per person varies from 1 to 3. 2,7,8 larvae become infectious and acquire the ability to Two other major clinical signs are edema and ve- penetrate the host skin. 8,13 The infection is usually siculobullous lesions along the course of the larva. acquired via contact with soil or sand contaminated Local swelling is reported in 6% to 17% of patients Downloaded from https://academic.oup.com/jtm/article/14/5/326/1808671 by guest on 27 September 2021 with feces of infected cats or dogs, which explains and vesiculobullous lesions in 4% to 40%. 2,8,10,12 why bare feet are the predominant site of penetra- Potentially, all unprotected parts of the skin in tion by the parasite larvae. In contrast to cats and contact with contaminated soil may be involved. dogs, humans are incidental hosts, and the larvae However, the most frequent anatomic locations of are unable to complete their natural cycle; thus, HrCLM lesions are the feet in more than 50% of they are not able to deeply penetrate the human skin individuals, followed by the buttocks and thighs. 2,6,8,12 and consequently migrate within it for weeks. 8 Other sites may include the elbow, breast, legs, and During skin penetration, the secretion of hyaluron- face. 7,8 idase by hookworm larvae facilitates passage Without any treatment, the eruption usually through the epidermis and dermis. 22 Usually, the lasts between 2 and 8 weeks, but it may be longer. In typical eruption develops within a few days, and one case report, an active disease was reported for the larva itself is usually located 1 to 2 cm ahead of almost 2 years. 9 the eruption. 6 Without appropriate treatment, the Hookworm folliculitis is a particular form of larva dies and is resorbed within weeks or months HrCLM. The largest series included seven travelers of invasion. 23 Most of the time, the infection is and consisted of numerous (20 – 100) follicular, ery- restricted to the skin, but migration to the lung has thematous, and pruritic papules and pustules, located been reported and is responsible for pulmonary mainly on the buttocks and associated with numerous eosinophilic infi ltrate. 24,25 relatively short tracks, generally arising from follicu- lar lesions 28 . Hookworm larvae can be histologically found trapped in the sebaceous follicular canal. 28,29 Clinical presentation The clinical features of HrCLM have been accu- Complications rately described in fi ve large series of travelers ad- mitted to tropical medicine clinics 2,6 – 8,10 and in two Local complications are led by secondary bacterial outbreaks ( Table 1 ). 12,26 The incubation period of infection of the involved skin area (impetiginiza- HrCLM is usually a few days and rarely goes be- tion). It occurs in up to 8% of cases. 7,8 yond 1 month. Cutaneous lesions appeared after Systemic complications are uncommon and return in 51% to 55% of the travelers, and the mean mainly involve the lungs, consisting of cases of eo- time of onset after return ranged from 5 to 16 sinophilic pneumonitis associated with CLM. 25,30 – 32 days. 2,7,8 In a German study, the time of onset ranged Although the pathogenesis is not completely un- from 16 weeks before return to 28 weeks after re- derstood, the Ancylostoma larva has been identifi ed turn (mean: 1.5 d after return). In the two above- in the sputum in one case report. 24 mentioned outbreaks of CLM, the median time One case of visceral larva migrans caused by from the start of the trip to the development of the A caninum has been reported, 33 together with one eruption ranged from 10 to 15 days. 12,26 However, larval invasion of skeletal muscles in a man who also some extremely long incubation periods have been had pulmonary symptoms. 34 One case of erythema reported, lasting for 4 to 7 months. 6,7 multiforme in which HrCLM was considered as one The striking symptom of HrCLM is pruritus lo- of the triggering events has also been reported. 35 calized at the site of the eruption. It is reported in 98% to 100% of patients. 7,8 After effective treat- Diagnosis ment, the pruritus has been shown to disappear much sooner than the eruption (on average 7.2 d HrCLM is usually a clinical diagnosis based on the earlier). 12 typical clinical presentation in the context of recent J Travel Med 2007; 14: 326–333 J TravelMed2007; 14:326–333 328 Table 1 Main clinical features of cutaneous larva migrans in eight series (>15 patients) of travelers returning from endemic countries Date 1993 1994 1995 2000 2001 2000 2001 1st author Davies 8 Jelinek 6 Caumes 2 Bouchaud 7 Blackwell10 Tremblay12 Green 26 Study type Retrospective Retrospective Prospective study Prospective study Retrospective Outbreak, Outbreak case study case study of travel- case study retrospective associated (questionnaire- dermatitis based study) Study site Canada Germany France France England Canada England Population Canadian (97%), German (100%)