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Creeping eruption due to Spirurina type X larva
Case Report
Creeping eruption due to Spirurina type X larva Teruhiko Makino, Naoya Mori, Hiromu Sugiyama, Megumi Mizawa, Yuri Seki, Ko Kagoyama, Tadamichi Shimizu Lancet 2014; 384: 2082 Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan (T Makino MD, N Mori MD, M Mizawa MD, Y Seki MD, K Kagoyama MD, T Shimizu MD), and Department of Parasitology, National Institute of Infectious Diseases, Shinjuku, Japan (H Sugiyama PhD) Correspondence to: Dr Teruhiko Makino, Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan [email protected]
A
A 42-year-old Japanese man presented to our hospital in March, 2014, with a 2 day history of an erythematous eruption on his abdomen. He had eaten small raw squid (hotaruika or firefly squid, Watasenia scintillans; figure) a week before, and 2 days later developed severe abdominal pain. An oesophagogastroduodenoscopy at the time showed no abnormalities and the abdominal pain improved within a few days, but he developed an itchy abdominal rash 9 days after eating the raw squid. Physical examination showed a linear oedematous rash with small vesicles and crusts in the centre of his abdomen about 6 cm in length (figure). Blood tests showed eosinophilia (22·7%; normal 0·2–8·9%), white blood cells (10·7 × 10⁹/L; 4·3–9·4 × 10⁹/L), and raised serum IgE (1·98 mg/L; <0·41 mg/L). Because we suspected a creeping eruption caused by parasitic larvae such as gnathostomiasis, sparganosis mansoni, or larval spiruriniasis, we excised the lesion completely. Histological examination showed intraepidermal blistering and infiltration of inflammatory cells throughout the dermis, mainly infiltrating eosinophils and lymphocytes, especially around the vessels and cutaneous appendages. In the deep dermis we saw a parasitic larva about 80 μm wide with an oesophageal gland and lateral cords seen in cross-section. The cuticle was about 2 μm thick and had no spines and the somatic musculature was of the polymyarian–coelomyarian type. The patient’s serum reacted with a type X larva but healthy control serum did not. We diagnosed a creeping eruption due to the larva of Spirurina type X. The patient had no further symptoms during 3 months’ follow-up. Spirurina are classified into types I to XIII. Only type X larvae have been identified as pathogenic to humans.1 The type X larva is 5·43–9·80 mm long and 74–110 μm B
1 cm
Figure: Creeping eruption due to Spirurina type X larva (A) Watasenia scintillans, the firefly squid, is one of the intermediate hosts of Spirurina type X larva. (B) Erythematous lesion on the patient’s abdomen.
2082
wide.1 The intermediate hosts are small squid and fish, such as W scintillans, Todarodes pacificus (Japanese flying squid), Arctoscopus japonicus (sailfin sandfish), and Gadus macrocephalus (Pacific cod).2 A recent molecular study identified the type X larva as Crassicauda giliakiana. The final hosts of the nematode are marine mammals such as Berardius bairdii (Baird’s beaked whale).3 The type X larva is thought to survive for only a short time in the human body, because humans are an inappropriate host for their growth. Clinically, the patient first notices abdominal pain several days after eating raw squid or fish, which can sometimes progress to acute ileus,4 caused by enteritis or mesenteritis due to invasion of the type X larva into the intestinal wall or abdominal cavity. The type X larva then migrates to the nearest cutaneous tissue to the intestine.2 1–4 weeks later, a creeping eruption develops on the abdomen. Ocular involvement has also been reported.5 Treatment is surgical excision of the skin lesion to remove the larva, but the rash usually resolves within 2 months even if no treatment is done. There is no evidence that anthelmintic agents are effective for type X larvae. Approximately 50 cases with creeping eruptions due to type X larva have been reported in Japan, probably because the Japanese have a long tradition of eating raw squid and fish. We speculate that this condition will be encountered in other countries in the near future because of the increasing consumption of raw squid and fish as sushi or sashimi. Contributors TM and TS cared for the patient. NM and KK did the histological examination. HS did the immunohistochemistry examination and HS, MM, and YS identified the larva. All authors contributed to writing the report. Written consent to publish was obtained. References 1 Hasegawa H. Larval nematodes of the superfamily Spiruroidea—a description, identification and examination of their pathogenicity. Acta Med Biol 1978; 26: 79–116. 2 Otaki N, Fukushima K, Takuno T, Ando K, Kagei N. Two cases of creeping diseases due to spirurina larva with a review of recorded cases. Jpn J Clin Dermatol 1995; 44: 88–94. 3 Sugiyama H, Morishima Y, Arakawa K, Kishiro T, Kawanaka M. Recent advances in the studies on larval spirurin nematode. Jpn Soc Syst Parasitol Circ 2007; 25: 4–7. 4 Miyake T, Ikoma H, Hoshima M, Yamane E, Hasegawa H, Arizono N. Case of acute ileus caused by a spirurina larva. Pathol Int 2004; 54: 730–33. 5 Chuang CK, Nakajima Y, Sato S, Kagei N, Araki K. A case of spirurid larva infection in the anterior chamber of the human eye. Int J Parasitol 1993; 23: 647–49.
www.thelancet.com Vol 384 December 6, 2014
Creeping eruption due to Spirurina type X larva Teruhiko Makino, Naoya Mori, Hiromu Sugiyama, Megumi Mizawa, Yuri Seki, Ko Kagoyama, Tadamichi Shimizu Lancet 2014; 384: 2082 Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan (T Makino MD, N Mori MD, M Mizawa MD, Y Seki MD, K Kagoyama MD, T Shimizu MD), and Department of Parasitology, National Institute of Infectious Diseases, Shinjuku, Japan (H Sugiyama PhD) Correspondence to: Dr Teruhiko Makino, Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan [email protected]
A
A 42-year-old Japanese man presented to our hospital in March, 2014, with a 2 day history of an erythematous eruption on his abdomen. He had eaten small raw squid (hotaruika or firefly squid, Watasenia scintillans; figure) a week before, and 2 days later developed severe abdominal pain. An oesophagogastroduodenoscopy at the time showed no abnormalities and the abdominal pain improved within a few days, but he developed an itchy abdominal rash 9 days after eating the raw squid. Physical examination showed a linear oedematous rash with small vesicles and crusts in the centre of his abdomen about 6 cm in length (figure). Blood tests showed eosinophilia (22·7%; normal 0·2–8·9%), white blood cells (10·7 × 10⁹/L; 4·3–9·4 × 10⁹/L), and raised serum IgE (1·98 mg/L; <0·41 mg/L). Because we suspected a creeping eruption caused by parasitic larvae such as gnathostomiasis, sparganosis mansoni, or larval spiruriniasis, we excised the lesion completely. Histological examination showed intraepidermal blistering and infiltration of inflammatory cells throughout the dermis, mainly infiltrating eosinophils and lymphocytes, especially around the vessels and cutaneous appendages. In the deep dermis we saw a parasitic larva about 80 μm wide with an oesophageal gland and lateral cords seen in cross-section. The cuticle was about 2 μm thick and had no spines and the somatic musculature was of the polymyarian–coelomyarian type. The patient’s serum reacted with a type X larva but healthy control serum did not. We diagnosed a creeping eruption due to the larva of Spirurina type X. The patient had no further symptoms during 3 months’ follow-up. Spirurina are classified into types I to XIII. Only type X larvae have been identified as pathogenic to humans.1 The type X larva is 5·43–9·80 mm long and 74–110 μm B
1 cm
Figure: Creeping eruption due to Spirurina type X larva (A) Watasenia scintillans, the firefly squid, is one of the intermediate hosts of Spirurina type X larva. (B) Erythematous lesion on the patient’s abdomen.
2082
wide.1 The intermediate hosts are small squid and fish, such as W scintillans, Todarodes pacificus (Japanese flying squid), Arctoscopus japonicus (sailfin sandfish), and Gadus macrocephalus (Pacific cod).2 A recent molecular study identified the type X larva as Crassicauda giliakiana. The final hosts of the nematode are marine mammals such as Berardius bairdii (Baird’s beaked whale).3 The type X larva is thought to survive for only a short time in the human body, because humans are an inappropriate host for their growth. Clinically, the patient first notices abdominal pain several days after eating raw squid or fish, which can sometimes progress to acute ileus,4 caused by enteritis or mesenteritis due to invasion of the type X larva into the intestinal wall or abdominal cavity. The type X larva then migrates to the nearest cutaneous tissue to the intestine.2 1–4 weeks later, a creeping eruption develops on the abdomen. Ocular involvement has also been reported.5 Treatment is surgical excision of the skin lesion to remove the larva, but the rash usually resolves within 2 months even if no treatment is done. There is no evidence that anthelmintic agents are effective for type X larvae. Approximately 50 cases with creeping eruptions due to type X larva have been reported in Japan, probably because the Japanese have a long tradition of eating raw squid and fish. We speculate that this condition will be encountered in other countries in the near future because of the increasing consumption of raw squid and fish as sushi or sashimi. Contributors TM and TS cared for the patient. NM and KK did the histological examination. HS did the immunohistochemistry examination and HS, MM, and YS identified the larva. All authors contributed to writing the report. Written consent to publish was obtained. References 1 Hasegawa H. Larval nematodes of the superfamily Spiruroidea—a description, identification and examination of their pathogenicity. Acta Med Biol 1978; 26: 79–116. 2 Otaki N, Fukushima K, Takuno T, Ando K, Kagei N. Two cases of creeping diseases due to spirurina larva with a review of recorded cases. Jpn J Clin Dermatol 1995; 44: 88–94. 3 Sugiyama H, Morishima Y, Arakawa K, Kishiro T, Kawanaka M. Recent advances in the studies on larval spirurin nematode. Jpn Soc Syst Parasitol Circ 2007; 25: 4–7. 4 Miyake T, Ikoma H, Hoshima M, Yamane E, Hasegawa H, Arizono N. Case of acute ileus caused by a spirurina larva. Pathol Int 2004; 54: 730–33. 5 Chuang CK, Nakajima Y, Sato S, Kagei N, Araki K. A case of spirurid larva infection in the anterior chamber of the human eye. Int J Parasitol 1993; 23: 647–49.
www.thelancet.com Vol 384 December 6, 2014