Cutaneous larva migrans with folliculitis: a new clinical presentation of this infestation

Hookworm Folliculitis: Report of Two Cases of Cutaneous Larva Migrans With Histologically Identified Follicular Involvement

ABSTRACT

Cutaneous larva migrans (CLM) is an ectoparasitic infestation predominantly caused by nematodes, specifically Ancylostoma braziliense and Ancylostoma caninum, found in tropical and subtropical regions. Although follicular involvement by the parasite is a rare manifestation, with approximately 20 cases reported in the English literature, its pathogenesis remains underexplored. The present study reports 2 cases of CLM presenting with follicular involvement in patients with pruritic lesions following travel to subtropical areas. The first of them is a 32-year-old woman who developed an abdominal skin lesion subsequent to a trip to Thailand and the second is a 28-year-old woman who exhibited a knee lesion after a volunteer mission in Senegal. Histologic examination revealed characteristic features of CLM, such as nematode larvae traversing the hair follicle. The hookworm larvae were observed creating tunnels within the external root sheath. In addition, they were interfacing with the vitreous layer, sparing the perifollicular connective tissue sheath and the Henle layer, and approaching the vicinity of the hair bulb. The application of skin ultrasound to guide the biopsy facilitated the visualization and identification of the parasite within the follicle in the latter case. This study not only underscores follicular involvement in CLM but also provides insights into its anatomopathological presentation and spread through the hair follicle.

K, Baral A, Shrestha R, Shrestha R. Cutaneous larva migrans in a child: a case report and review of literature

Introduction

Cutaneous larva migrans (CLM) is a dermatitis caused by the invasion and migration of parasitic larvae of hookworms, primarily affecting tropical and subtropical regions. This report presents a case of CLM in a Nepali child and provides an overview of the literature on this condition.

Case report

A 4-year-old boy from a rural area in Nepal presented with a pruritic skin lesion on his left foot, initially misdiagnosed as fungal infection. The lesion gradually expanded, forming a serpiginous erythema, and became intensely pruritic. The patient's family had poor socioeconomic conditions, and the child frequently walked barefoot in an area with many domestic and stray dogs. Diagnosis was confirmed clinically, and treatment with oral albendazole and antihistamines resulted in complete resolution of symptoms.

Discussion

CLM is a neglected zoonotic disease, with an underestimated burden in developing countries due to underreporting and misdiagnosis. The larvae of Ancylostoma spp. are common culprits, causing a localized inflammatory reaction as they migrate through the skin. Diagnosis is mainly clinical and routine investigations usually reveal no abnormality. Complications may include secondary bacterial infections, allergies, and rare migration to internal organs. Treatment options include albendazole or ivermectin, with preventive measures emphasizing hygiene, footwear use, and pet deworming.

Conclusion

CLM is a neglected disease that primarily affects marginalized communities in tropical regions. Raising awareness among healthcare providers, conducting observational studies, and developing treatment guidelines, especially for children, are essential steps to address this public health concern. Preventive efforts, such as promoting hygiene and footwear use, should be encouraged to reduce CLM incidence.

Immune response induced by major environmental pollutants through altering neutrophils in zebrafish larvae

Environmental pollutants may cause adverse effects on the immune system of aquatic organisms. However, the cellular effects of pollutants on fish immune system are largely unknown. Here, we exploited the transgenic zebrafish Tg(lysC:DsRed2) larva as a preliminary screening system to evaluate the potential inflammatory effects of environmental pollutants. Tg(lysC:DsRED2) larvae aged 7-day-postfertilization (7 dpf) were treated with selected environmental chemicals for 24 h (24 h) and the number of neutrophils were quantified using both image analysis and fluorescence activated cell sorting (FACS). We found that the numbers of neutrophils in the Tg(lysC:DsRED2) larvae were significantly increased by most of the organic chemicals tested, including E2 (17β-estradiol), BPA (Bisphenol-A), NDEA (N-nitrosodiethylamine), 4-NP (4-Nitrophenol) and Lindane (γ-hexachlorocyclohexane). Neutrophil numbers were also increased by all the metals tested (Na2HAsO4· 7H2O, Pb(NO3)2, HgCl₂, CdCl2, CuSO₄·5H₂O, ZnSO4, and K2Cr2O7). The only exception was TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin), which significantly reduced the number of neutrophils after exposure. Additionally, the transcription of genes (lyz, mpo, tnfα and il8) related to fish immune system were significantly modulated upon exposure to some of the selected chemicals such as E2, TCDD, Cu and Cd. This study revealed that representatives of major categories of environmental pollutants could cause an acute inflammatory response in zebrafish larvae as shown by alterations in the neutrophils, which may imply a common immunotoxicity mechanism for most environmental pollutants. This study has also demonstrated that Tg(lyz:DsRed2) transgenic zebrafish is an excellent tool for screening environmental chemicals with potential inflammatory effects through FACS-facilitated neutrophil counting.

Follicular cutaneous larva migrans: a report of three cases and review of the literature

BACKGROUND

Hookworm-related cutaneous larva migrans (CLM) is characterized clinically by erythematous and slightly raised tracks, located especially on the feet. These tracks may be single or multiple, linear or serpiginous, more or less ramified and intertwined. The length is variable (up to many cm); the width ranges from 1 mm to 4 mm. Tracks are often accompanied by severe pruritus.

METHODS

Three adult Caucasian patients recently returned from trips to Malaysia and Thailand, presented with follicular CLM. The disease was characterized clinically by follicular, erythematous, small papules that were sometimes topped with vesicles or pustules, located on the buttocks. Pruritus was severe.

RESULTS

Histopathological examinations revealed a perifollicular infiltrate predominantly consisting of lymphocytes and eosinophils. All patients were successfully treated with oral albendazole (400 mg/day for seven days). In the first patient, two courses were necessary.

CONCLUSIONS

Dermatologists should be aware of the existence of this rare and atypical, although emerging, clinical presentation of hookworm-related CLM.

Cutaneous larva migrans syndrome: a case report

Cutaneous larva migrans (CML) is a frequent parasitic infestation caused by migration of animal hookworm larvae into the human epidermis. This skin disease is common in warmer climates among people, who have contact with contaminated soil. Clinical manifestation of CML is an itchy, erythematous, linear tract, which appears days to even months after exposure to infested sand or soil. Diagnosis is established on the clinical presentation. We describe a case of CML acquired during a holiday in Brazil.

Mini review: Hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans (HrCLM) is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis. Since these larvae cannot penetrate the basal membrane of human skin, they remain confined to the epidermis and are unable to develop and complete their lifecycle. By consequence, HrCLM is a self-limiting disease. However, if not treated promptly, the skin pathology may persist for months. HrCLM is endemic in many resource-poor communities in the developing world. In high-income countries, HrCLM occurs sporadically or in the form of small epidemics. Travelers account for the great majority of cases seen by health-care professionals in high-income countries. Transmission occurs when naked skin comes into contact with contaminated soil. Exposure may also occur indoors. Exceptionally, larvae may be transmitted through fomites. The first clinical sign is a small reddish papule. Thereafter, the characteristic serpiginous, slightly elevated, erythematous track becomes visible. Itching becomes more and more intense. Excoriations induced by scratching facilitate bacterial superinfection of the lesion. The diagnosis is essentially clinical. It is supported by a recent travel history and the possibility of exposure. The drug of choice is ivermectin in a single dose (200 μg per kg bodyweight). Repeated treatments with albendazole (400 mg daily) are a good alternative in countries where ivermectin is not available.

Mucocutaneous Splendore-Hoeppli phenomenon

Splendore-Hoeppli phenomenon (asteroid bodies) is the in vivo formation of intensely eosinophilic material (radiate, star-like, asteroid or club-shaped configurations) around microorganisms (fungi, bacteria and parasites) or biologically inert substances. This study presents a literature review concerning Splendore-Hoeppli reaction in the mucocutaneous diseases. It examines the histopathological features, nature and differential diagnosis of this reaction. It also discusses the mucocutaneous infections and the non-infective diseases associated with it. Available studies indicate that several mucocutaneous infections can generate Splendore-Hoeppli reaction. The fungal infections include sporotrichosis, pityrosporum folliculitis, zygomycosis, candidiasis, aspergillosis and blastomycosis. The bacterial infections include botryomycosis, nocardiosis and actinomycosis. The parasitic conditions include orbital pythiosis, strongyloidiasis, schistosomiasis and cutaneous larva migrans. In addition, Splendore-Hoeppli reaction may be seen with non-infective pathology such as hypereosinophilic syndrome and allergic conjunctival granulomas. The Splendore-Hoeppli reaction material comprises antigen-antibody complex, tissue debris and fibrin. Although the exact nature of this reaction is unknown, it is thought to be a localized immunological response to an antigen-antibody precipitate related to fungi, parasites, bacteria or inert materials. The characteristic formation of the peribacterial or perifungal Splendore-Hoeppli reaction probably prevents phagocytosis and intracellular killing of the insulting agent leading to chronicity of infection. To conclude, Splendore-Hoeppli reaction is a tell tale of a spectrum of infections and reactive conditions. The molecular pathways involved in the development of this reaction are open for future investigations.

Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans

Hookworm-related cutaneous larva migrans is caused by the migration of animal hookworm larvae in the human skin. The disease mainly occurs in resource-poor communities in the developing world, but it is also reported sporadically in high-income countries and in tourists who have visited the tropics. Diagnosis is made clinically in the presence of a linear serpiginous track moving forward in the skin, associated with itching and a history of exposure. Itching is typically very intense and can prevent patients from sleeping. Bacterial superinfection occurs as a result of scratching. Treatment is based on oral drugs (albendazole or ivermectin) or the topical application of tiabendazole. To control hookworm-related cutaneous larva migrans at the community level, regular treatment of dogs and cats with anthelmintic drugs is necessary, but this is seldom feasible in resource-poor settings. Animals should be banned from beaches and playgrounds. For protection at the individual level, unprotected skin should not come into contact with possibly contaminated soil.

Imaging of cutaneous larva migrans by optical coherence tomography

BACKGROUND

Cutaneous larva migrans is a parasitic skin eruption caused by migration of larvae of various nematodes. Diagnosis of cutaneous larva migrans is currently based on the clinical signs of the creeping eruption. We are investigating a new diagnostic technology called optical coherence tomography (OCT) , which is potentially able to visualize structures in the skin with an 8 microm resolution. This technology could therefore potentially allow rapid, non-invasive, in vivo diagnosis of infestations.

METHOD

Clinical cases of cutaneous larva migrans (n=3) were studied. All patients had a characteristic itching, serpinginous eruption typical of cutaneous larva migrans. The parasites were acquired on beach holidays in Thailand and Malaysia. All skin lesions were imaged by an OCT system developed at Risoe National Laboratory, Denmark.

RESULT

Two out of three patients showed a round to oval structure (diameter 0.3-0.5mm) in the epidermis, Thus distinct OCT morphology in skin areas affected by cutaneous larva migrans was demonstrated. The larvae were not visualized in any of the patients.

CONCLUSION

This study demonstrates that OCT a novel optical imaging technology, can image the larva tunnel in the skin with adequate spatial resolution, but not the larvae itself. OCT has a potential in imaging of skin infestations.