A case of cutaneous larva migrans acquired from soiled toilet floors in urban kuala lumpur

CASE REPORT
A Case of Cutaneous Larva Migrans Acquired from Soiled
Toilet Floors in Urban Kuala Lumpur
N Z Robson, PhD, S Othman, PhD
Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia over the sole of the right foot. He was unable to sleep due to Despite being a common skin dermatosis in the tropics,
the intense itchiness. After four days, he noticed a reddish physicians in the tropics may miss the diagnosis of cutaneous
curly line over the inner side of his right foot. He consulted larva migrans for other pruritic skin manifestation. This is
a general practitioner who diagnosed the skin condition as especially in those who live in urban housing with no history
allergic reaction and prescribed some antihistamines and of travel. Cutaneous larva migrans, an intensely pruritic skin
calamine lotion, but the condition persisted. pathology is mainly contracted by people with history of
beach holiday or contact with moist soft sand which had
He presented to the author’s clinic seven days after the been contaminated with dog or cat faeces. This article
weekend trip. Physical examination revealed an afebrile reports a patient who presented with intensely itchy papular
patient who had several reddish, well circumscribed, 1cm spots over the dorsum of his foot after walking barefooted
papular spots over his right sole. A raised curly line (2-3 mm in an urban toilet soiled with cat faeces. The patient had
wide) was seen at the level of the medial malleolus of the initially seen an urban general practitioner who diagnosed
right foot. A diagnosis of cutaneous larva migrans was made the papular skin lesion as an allergic reaction, and prescribed
based on the clinical presentation. The patient was antihistamines. The patient subsequently developed
prescribed albendazole 200mg bd for three days and given a creeping skin lesions and was seen by the author who
ten day follow up. The patient reported less itching after two prescribed albendazole 400 mg twice daily for three days.
days of treatment. On follow up, the lesion had healed and The patient reported reduction in itching after two days of
the itchiness had subsided. This case report was written after albendazole treatment and a follow up at ten days revealed
obtaining informed consent from the patient.
a healed infection.
KEY WORDS:
DISCUSSION
Larva migrans, Ancylostoma braziliensis, Cutaneous larva Cutaneous larva migrans is commonly reported in travellers migrans, Creeping eruption, Hookworm returning from beach holidays in the tropics and sub-tropicsor from direct contact with moist soil contaminated withanimal faeces1,2. However, the first author is not aware of INTRODUCTION
reports involving cutaneous larva migrans acquired from Cutaneous larva migrans, a percutaneous penetration of urban housing or from toilet floors. The patient in this case larvae of some nematode parasites, is a common acquired report probably acquired the infection by direct contact dermatosis in the tropic and subtropics 1. The condition (barefoot) with cat faeces in the wet bathroom and toilet manifests as an intensely pruritic skin eruption, and secondary bacterial superinfection may occur due toscratching 2. It is usually reported by people returning from Cutaneous larva migrans is caused by hookworms that beach holiday or direct contact with moist sand 3. The usually infest cats, dogs and other animals1. The hookworms diagnosis may therefore be missed in those without similar responsible for cutaneous larva migran are: 1) Ancylostoma braziliensis (hookworm of wild cats and domestic dogs andcats), 2) Ancylostoma caninum (dog hookworm), 3) Uncinariastenocephala (dog hookworm), 4) Bunostomum phlebotomum CASE REPORT
(cattle hookworm) and 5) other rare causes include Necator Mr MH, a 40 year old male presented with itchiness over his americanus (human hookworm), Ancylostoma duodenale, and right foot and leg. His problem started after a weekend trip to Ancylostoma tubaeforme 3. The larvae excreted from the animal a relative’s house in urban city housing in Kuala Lumpur. The faeces initially feed on soil bacteria before becoming infective.
relative had cats as pets and let the cats soil the bathroom and The larvae penetrate the new host’s skin, and then shed their toilet floors. Mr MH gave a history of taking his shower natural cuticle. Once infected, the larvae migrate under the barefooted in the bathroom and toilet despite being aware of skin’s surface within a few days, thus creating the typical the presence of cat’s faeces on the floor. He denied any wormlike burrows visible under the skin. As humans are history of beach holiday. Upon returning from the weekend accidental hosts, the larvae are believed to lack the enzymes trip, the patient noticed an intense itchiness over the sole of required to penetrate the basement membrane to invade the his right foot. On the first evening, he noticed a few red spots dermis 2. Therefore human skin infestations are limited to the This article was accepted: 14 July 2008Corresponding Author: Noor Zurani Md Haris Robson, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603 KualaLumpur, Malaysia Email: noorzurani@um.edu.my skin. Lesions are commonly reported to be distributed on the usually based on the classical appearance of the eruption. A distal extremities, especially the dorsum of the foot, however small proportion of patients were observed to have peripheral lesions over the anogenital region, the buttocks, the knees eosinophilia and increased IgE levels 3.
and the hands have been reported 1,2. These manifest ascreeping eruptions which causes intense itchiness. Intense Although commonly reported in tropical and subtropical itchiness may result in secondary bacterial superinfection, regions, the skin manifestation has been reported in many which may require antibiotic therapy. However, the disease is non-endemic countries around the world. This is probably self limiting, as the larvae will eventually die in the epidermis due to the growing incidence of foreign travel. This case after several weeks or months as they are unable to complete report demonstrates that cutaneous larva migrans can be their lifecycles in the accidental human hosts 3. Untreated acquired in an urban setting, and that high level of suspicion uncomplicated lesions usually resolve within 4-8 weeks, but should be kept in pet owners and in those with contact with pharmacological treatment has been shown to shorten the domestic animal faeces who present with itchy skin lesions.
course of the disease. However, in very rare cases of When at the beach, people should be educated of the cutaneous larvae migrans (usually infections with large importance of wearing footwear (slippers/beach shoes), number of parasites), pneumonitis (Loeffler syndrome) may beaches should be kept free of cat or dog faeces and occur2. With pharmacotherapy, itchiness is reduced within sunbathers should be advised to lie on a towel to provide a 24-48 hours of starting treatment and skin lesions resolved barrier when sitting on the ground. At home, people should within seven days of the start of treatment. A few be advised to wear proper footwear in wet bathroom and antihelminthic agents (albendazole, mebendazole and toilets and not permit cats or dogs to soil bathroom or toilets.
thiabendazole) have been reported to be effective for treating As a preventive measure, this article also suggests that dog cutaneous larva migrans. Another antiparasitic medication, and cat owners regularly deworm their pets and ensure that ivermectin (a semisynthetic macrolytic lactone with broad their pets have regular veterinary check ups. spectrum action against nematodes) has also been reported tobe effective in treating cutaneous larva migrans 1.
REFERENCES
In this patient, the first physician made a diagnosis of allergic 1. Gillespie S. Cutaneous larva migrans. Curr Infect Dis Rep 2004; 6 (1): 50- reaction. This was probably based on the intense skin 2. Rao R, Prabhu S, Sripathi H. Cutaneous larva migrans of the genitalia.
itchiness. The diagnosis of cutaneous larva migrans was Indian J of Dermatol, Venereol & Leprol 2007; 73 (4): 270-1.
probably missed as the patient did not give a history of travel 3. Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J or beach holiday. Other differential diagnoses that could be considered are allergic contact dermatitis, photoallergicdermatitis and epidermal dermatophytosis. Diagnosis is

Source: http://eprints.um.edu.my/2703/1/A_Case_of_Cutaneous_Larva-Med_J_Malaysia-vol_63_(4)-October_2008.pdf