Dermatology and the recently returned traveler: infectious diseases with dermatologic manifestations

Human myiasis cases originating and reported in africa for the last two decades (1998-2018): A review

The article reviews literature on myiasis in Africa and cases that originated in Africa over the last two decades (1998-2018). The relevant literature was obtained by using several databases (Science-Direct, JSTOR, Google Scholar, Ebscohost and PubMed). We searched for the following words or their combination myiasis, maggots, fly species responsible for myiasis found in Africa, and the different types of myiasis. References in several articles provided links to other relevant works. Only papers written in English were reviewed. In total, we reviewed 51 articles which covered a total of 849 myiasis cases. The review encompasses geographical distribution of the disease, dipteran species responsible, predisposing factors, sex of the patient, type of myiasis and treatment. Myiasis is found in most parts of the African continent, however only 18 articles reported myiasis cases in Africa during the period under review. The rest of the articles report cases from the rest of the world but acquired by travellers when visiting Africa. Cordylobia anthropophaga (Blanchard) was responsible for 93.28% of all the reported cases in this review. The low number of articles on human myiasis reported in Africa may be due to underreporting by physicians or most cases are not diagnosed. Therefore, the actual prevalence of myiasis in Africa is currently unknown.

A creeping holiday souvenir: about a misleading case of hookworm folliculitis†

Hookworm-related cutaneous larva migrans occurs in endemic areas but also amongst travelers. Although this disease usually presents as a single pruritic raised erythematous track, misleading clinical presentations are not uncommon. This particularly extensive, follicular presentation of larva migrans should warn clinicians about atypical forms of this emerging tropical disease.

Men’s Perception of Raped Women: Test of the Sexually Transmitted Disease Hypothesis and the Cuckoldry Hypothesis

Rape is a recurrent adaptive problem of female humans and females of a number of non-human animals. Rape has various physiological and reproductive costs to the victim. The costs of rape are furthermore exaggerated by social rejection and blaming of a victim, particularly by men. The negative perception of raped women by men has received little attention from an evolutionary perspective. Across two independent studies, we investigated whether the risk of sexually transmitted diseases (the STD hypothesis, Hypothesis 1) or paternity uncertainty (the cuckoldry hypothesis, Hypothesis 2) influence the negative perception of raped women by men. Raped women received lower attractiveness score than non-raped women, especially in long-term mate attractiveness score. The perceived attractiveness of raped women was not influenced by the presence of experimentally manipulated STD cues on faces of putative rapists. Women raped by three men received lower attractiveness score than women raped by one man. These results provide stronger support for the cuckoldry hypothesis (Hypothesis 2) than for the STD hypothesis (Hypothesis 1). Single men perceived raped women as more attractive than men in a committed relationship (Hypothesis 3), suggesting that the mating opportunities mediate men’s perception of victims of rape. Overall, our results suggest that the risk of cuckoldry underlie the negative perception of victims of rape by men rather than the fear of disease transmission.

Human wound myiasis caused by Phormia regina and Sarcophaga haemorrhoidalis in Minia Governorate, Egypt

Myiasis is the parasitic infestation of human by the larvae (maggots) of dipterous fly that grow within the host while feeding on its tissue. Cutaneous myiasis is the most considerably encountered clinical form. Moreover, wound (traumatic) myiasis is the main clinical manifestation of cutaneous myiasis. In this research, we aimed to study the type of infesting larvae that are responsible for wound myiasis in the patients in Minia city, Egypt. Three cases of wound myiasis have been noticed among 280 patients with wounds at different parts of bodies. Two of them were diabetic patients. The third one had a history of hypertension with right side hemiplegia 2 years ago. All of them were elderly. The larvae removed from cases 1 and 3 were identified macroscopically and microscopically as the third-stage larvae of Sarcophaga haemorrhoidalis. The larvae removed from case 2 were the third-stage larvae of Phormia regina, which is very rare worldwide. In addition to the open and obsolete wound, diabetes mellitus and low socio-economic circumstances were shown to be attributed as important predisposing risk factors that led to the occurrence of myiasis in these patients.

Clinical features and etiology of adult patients with Fever and rash

BACKGROUND

Patients with fever and rash often pose an urgent diagnostic and therapeutic dilemma for the clinician. The nonspecificity of many fever and rash syndromes mandates a systemic approach to diagnosis.

OBJECTIVE

We aimed to determine the etiology of fever and rash in 100 adult patients followed-up as in- or outpatients prospectively.

METHODS

All the patients, who presented with rash and fever, were followed-up prospectively and their clinical and laboratory studies were evaluated.

RESULTS

The median age was 35 years (14~79 years); 45 were female and 55 were male. Patients were divided into 3 groups according to the etiology: infectious (50%), noninfectious (40%) and undiagnosed (10%). The most common type of rash was maculopapular, and the most common 5 causes were measles, cutaneous drug reactions, varicella, adult-onset Still's disease (ASD) and rickettsial disease. Viral diseases among infectious causes and cutaneous drug reactions, among the noninfectious causes, were determined as the main diseases. The mortality rate was 5% and the reasons of mortality were as follows: toxic epidermal necrolysis (2 patients), ASD (1), staphylococcal toxic shock syndrome (1) and graft-versus-host disease (1).

CONCLUSION

Adult patients with fever and rash had a wide differential diagnosis. The most common type of rash was determined as maculopapular, and the most frequent five diseases were measles, drug reactions, chickenpox, ASD and rickettsial infection. Viral diseases among infectious causes and drug reactions among noninfectious causes were determined as the leading etiologies.

Myiasis

Myiasis is defined as the infestation of live vertebrates (humans and/or animals) with dipterous larvae. In mammals (including humans), dipterous larvae can feed on the host's living or dead tissue, liquid body substance, or ingested food and cause a broad range of infestations depending on the body location and the relationship of the larvae with the host. In this review, we deeply discuss myiasis as a worldwide infestation with different agents and with its broad scenario of clinical manifestations as well as diagnosis techniques and treatment.

Skin disorders among travellers returning from tropical and non-tropical countries consulting a travel medicine clinic

OBJECTIVE

To evaluate the causes and risks for imported skin disorders among travellers.

METHODS

Data of 34,162 travellers returning from tropical and non-tropical countries and presenting at the outpatient travel medicine clinic of the University of Munich, Germany, between 1999 and 2009 were analyzed for this study. Of these, 12.2% were diagnosed with skin disorders.

RESULTS

Main destinations visited were Asia (40%), Africa (27%) and Latin America (21%). Tourism in the form of adventure travel/backpacking (47%) and package holidays (23%) was the most common purpose of travel. The leading causes of skin disorders were arthropodal (23%), bacterial (22%), helminthic (11%), protozoan (6%), viral (6%), allergic (5%) and fungal (4%). The 10 most frequently diagnosed specific skin diseases associated with specific destinations were insect bites (17%, Southern Europe), cutaneous larva migrans (8%, Asia and Latin America), cutaneous leishmaniasis (2.4%, Mediterranean Region/Middle East), dengue fever (1.5%, Asia), rickettsioses (1.3%, Southern Africa), myiasis (0.8%, Central America), filarioses (0.7%, Africa), tick bites (0.6%, Central/Eastern Europe), schistosomiasis (0.6%, Africa) and tungiasis (0.6%, Africa). Travellers in sub-Saharan Africa had the highest relative risk of acquiring skin disorders.

CONCLUSION

As more than 20% of all skin disorders among returned travellers were caused by arthropods and about 50% by infectious pathogens, pre-travel consultations should include specific prophylaxis and consider the most important risk factor for the travel destination.

Exotic human myiasis

Human myiasis may be caused by several species of dipterous larvae. It is widespread in the tropics and subtropics particularly in Africa and the Americas and can occur in other parts of the world although less frequently. Larval infestation mostly affects the skin but can also involve wounds, bones, intestines and body cavities. Diagnosis is mainly clinical. The rule of treatment is to remove the larvae and treat any associated infection. Frequent international travel, immigration and rising global trade increase the likelihood of imported infestations. It is therefore vital that physicians in non-endemic areas are aware of clinical symptoms, exposure and presentation of this condition, as early recognition would prevent any costly, inappropriate treatments or complications. We report a case of imported human myiasis and present a literature review of human myiasis.

Identification of subcutaneous myiasis using bedside emergency physician performed ultrasound

BACKGROUND

Subcutaneous myiasis, a maggot infiltration of human tissue, is common in tropical countries. However, physicians in the United States may be unlikely to consider this etiology of dermatologic abnormalities even when a travel history suggests the diagnosis should be included in the differential.

CASE REPORT

We report the case of a patient who returned from Sierra Leone with an infestation of a maggot of Cordylobia anthropophaga (tumbu fly) that was diagnosed and appropriately treated based on ultrasound findings.

CONCLUSION

As international travel increases, clinicians should maintain a high level of suspicion for tumbu fly infestation in returned travelers from endemic areas. The increasing use of ultrasound in the Emergency Department for evaluation of skin and soft tissue infections may aid the physician in making the diagnosis of subcutaneous myiasis.

Enhancement by tumor necrosis factor alpha of dengue virus-induced endothelial cell production of reactive nitrogen and oxygen species is key to hemorrhage development

Hemorrhage is a severe manifestation of dengue disease. Virus strain and host immune response have been implicated as the risk factors for hemorrhage development. To delineate the complex interplay between the virus and the host, we established a dengue hemorrhage model in immune-competent mice. Mice inoculated intradermally with dengue virus develop hemorrhage within 3 days. In the present study, we showed by the presence of NS1 antigen and viral nuclei acid that dengue virus actively infects the endothelium at 12 h and 24 h after inoculation. Temporal studies showed that beginning at day 2, there was macrophage infiltration into the vicinity of the endothelium, increased tumor necrosis factor alpha (TNF-alpha) production, and endothelial cell apoptosis in the tissues. In the meantime, endothelial cells in the hemorrhage tissues expressed inducible nitric oxide synthase (iNOS) and nitrotyrosine. In vitro studies showed that primary mouse and human endothelial cells were productively infected by dengue virus. Infection by dengue virus induced endothelial cell production of reactive nitrogen and oxygen species and apoptotic cell death, which was greatly enhanced by TNF-alpha. N(G)-nitro-L-arginine methyl ester and N-acetyl cysteine reversed the effects of dengue virus and TNF-alpha on endothelial cells. Importantly, hemorrhage development and the severity of hemorrhage were greatly reduced in mice lacking iNOS or p47(phox) or treatment with oxidase inhibitor, pointing to the critical roles of reactive nitrogen and oxygen species in dengue hemorrhage.

Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network

BACKGROUND

Skin disorders are common in travelers. Knowledge of the relative frequency of post-travel-related skin disorders, including their geographic and demographic risk factors, will allow for effective pre-travel counseling, as well as improved post-travel diagnosis and therapeutic intervention.

METHODS

We performed a retrospective study using anonymous patient demographic, clinical, and travel-related data from the GeoSentinel Surveillance Network clinics from January 1997 through February 2006. The characteristics of these travelers and their itineraries were analyzed using SAS 9.0 statistical software.

RESULTS

A skin-related diagnosis was reported for 4594 patients (18% of all patients seen in a GeoSentinel clinic after travel). The most common skin-related diagnoses were cutaneous larva migrans (CLM), insect bites including superinfected bites, skin abscess, and allergic reaction (38% of all diagnoses). Arthropod-related skin diseases accounted for 31% of all skin diagnoses. Ill travelers who visited countries in the Caribbean experienced the highest proportionate morbidity due to dermatologic conditions. Pediatric travelers had significantly more dog bites and CLM and fewer insect bites compared with their adult counterparts; geriatric travelers had proportionately more spotted fever and cellulitis.

CONCLUSIONS

Clinicians seeing patients post-travel should be alert to classic travel-related skin diseases such as CLM as well as more mundane entities such as pyodermas and allergic reactions. To prevent and manage skin-related morbidity during travel, international travelers should avoid direct contact with sand, soil, and animals and carry a travel kit including insect repellent, topical antifungals, and corticosteroids and, in the case of extended and/or remote travel, an oral antibiotic with ample coverage for pyogenic organisms.

Imported tropical infectious ulcers in travelers

Skin ulcers are a commonly encountered problem at departments of tropical dermatology in the Western world. Furthermore, the general dermatologist is likely to be consulted more often for imported chronic skin ulcers because of the ever-increasing travel to and from tropical countries. The most common cause of chronic ulceration throughout the world is probably pyoderma. However, in some parts of the world, cutaneous leishmaniasis is one of the most prevalent causes. Mycobacterium ulcerans is an important cause of chronic ulcers in West Africa. Bacterial infections include pyoderma, mycobacterial infections, diphtheria, and anthrax. Pyoderma is caused by Staphylococcus aureus and/or beta-hemolytic streptococci group A. This condition is a common cause of ulcerative skin lesions in tropical countries and is often encountered as a secondary infection in travelers. The diagnosis is often made on clinical grounds. Antibacterial treatment for pyoderma should preferably be based on culture outcome. Floxacillin is generally active against S. aureus and beta-hemolytic streptococci. Infection with Mycobacterium ulcerans, M. marinum, and M. tuberculosis may cause ulcers. Buruli ulcers, which are caused by M. ulcerans, are endemic in foci in West Africa and have been reported as an imported disease in the Western world. Treatment is generally surgical, although a combination of rifampin (rifampicin) and streptomycin may be effective in the early stage. M. marinum causes occasional ulcerating lesions in humans. Treatment regimens consist of combinations containing clarithromycin, rifampin, or ethambutol. Cutaneous tuberculosis is rare in travelers but may be encountered in immigrants from developing countries. Treatment is with multiple drug regimens consisting of isoniazid, ethambutol, pyrazinamide, and rifampin. Cutaneous diphtheria is still endemic in many tropical countries. Cutaneous diphtheria ulcers are nonspecific and erythromycin and penicillin are both effective antibacterials. Antitoxin should be administered intramuscularly in suspected cases. Anthrax is caused by spore-forming Bacillus anthracis. This infection is still endemic in many tropical countries. Eschar formation, which sloughs and leaves behind a shallow ulcer at the site of inoculation, characterizes cutaneous anthrax. Penicillin and doxycycline are effective antibacterials. Cutaneous leishmaniasis is caused by different species belonging to the genus Leishmania. The disorder is one of the ten most frequent causes of skin diseases in travelers returning from (sub)tropical countries. The clinical picture is diverse, ranging from a painless papule or nodule to an ulcer with or without a scab. Treatment depends on the clinical manifestations and the species involved.Sporotrichosis, chromo(blasto)mycosis, and mycetoma are the most common mycoses that may be accompanied by ulceration. Infections are restricted to certain regions and often result from direct penetration of the fungus into the skin. Anti-mycotic treatment depends on the microorganism involved. The most common causes of infectious skin ulceration encountered in patients from tropical countries who present at a department of tropical dermatology are reviewed in this article.

Cutaneous leishmaniasis in the returning traveler

Infection with protozoan parasites of the genus Leishmania leads to a wide variety of clinical disease syndromes called leishmaniasis, or more appropriately the leishmaniases. The three major clinical syndromes are cutaneous leishmaniasis, mucosal leishmaniasis, and visceral leishmaniasis. All three of these syndromes have been documented in returning travelers. This article focuses on cutaneous leishmaniasis with some comment on mucosal leishmaniasis.

New and re-emerging cutaneous infectious diseases in Latin America and other geographic areas

Due to environmental factors and inadequate public health measures in many developing countries, new tropical infections, as well as infections that were previously isolated to remote locales, are becoming more prevalent in several areas of Latin America. This article discusses some tropical infections and infestations with predominantly cutaneous manifestations. Previously uncommon diseases such as gnathostomiasis, mycobacteria ulcerans infection, paederus dermatitis, Balamuthia mandrillaris infection, and human T-lymphotrophic virus 1 dermatitis are increasingly being reported. Well-known tropical infections such as bartonellosis, leishmaniasis, chromomycosis, larva migrans, and larva currens are also becoming more prevalent. On the other hand, the incidence of Hansen's disease, the quintessential tropical infection, is dwindling all over the globe thanks to a highly effective eradication campaign launched by the World Health Organization. Because of increased immigration and tourist travel, the number of cases of these diseases in the United States may escalate.

Tungiasis: more than an exotic nuisance

Tungiasis is a parasitic and zoonotic skin disease caused by the sand flea Tunga penetrans-also called the jigger flea, which burrows into human skin, usually on the feet. The ectoparasitosis occurs in many economically depressed communities in the Caribbean, South America and Africa, and affects sporadically travellers to endemic areas. Usually, only one or two lesions are found in travellers, whereas the local populations commonly harbour dozens, sometimes even hundreds of lesions, associated with severe morbidity. We review case reports of tungiasis in returned travellers in terms of history, epidemiological and clinical aspects, and the importance of the ectoparasitosis for travel medicine is discussed. It is concluded that tungiasis is more than merely an exotic nuisance, since it is an important health problem in endemic areas. Untrained dermatologists can diagnose and treat tungiasis properly; fleas should be extracted as early as possible to avoid secondary infections.

Skin diseases of travelers

The astute clinician must consider common ailments that occur independently of travel and diagnoses resulting from exotic exposures. Most causes of travel-related skin conditions can be sorted by obtaining a careful history of the patients' pretravel medical conditions and preparations for the journey, and their activities and possible exposures during the trip. Skin disorders also may be grouped by description of the lesions, thereby directing the clinician's diagnostic efforts.

Skin problems in the traveler

Skin lesions are common in travelers and include a mix of mundane dermatologic problems and rare diseases acquired only in remote or tropical regions. The morphology, distribution, and progression of the lesions are useful in assessing possible causes. Early in the evaluation it is important to determine whether the patient might have a process that is rapidly progressive, treatable, or transmissible. In addition to routine laboratory studies, biopsy and serologic tests are often necessary to confirm a specific diagnosis.