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Cutaneous larva migrans
Clinical Picture
Cutaneous larva migrans Kerri S Purdy, Richard G Langley, Amanda N Webb, Noreen Walsh, David Haldane Lancet 2011; 377: 1948 Published Online May 20, 2011 DOI:10.1016/S01406736(10)61149-X Division of Dermatology, (K S Purdy MD, R G Langley MD); Department of Medicine, (A N Webb BScH), Division of Anatomical Pathology, (N Walsh FRCPath), and Division of Infectious Diseases, Department of Pathology and Laboratory Medicine (D Haldane MB FRCPC), Dalhousie University, Halifax, Canada Correspondence to: Dr Richard G Langley, 4–195 Dickson Building, QE11 Health Sciences Center, 5820 University Avenue, Halifax, NS, B3H 1V7, Canada [email protected]
In November, 2009, a 38-year-old man presented with an itchy serpiginous eruption on the plantar aspect of his right foot that had developed after a trip to Mexico (figure A). He reported walking barefoot in the sand where cats and cat faeces were present. Physical examination showed an erythematous serpiginous eruption on the sole of his right foot. A clinical diagnosis of cutaneous larva migrans was made. Cutaneous larva migrans is most often caused by the larvae of the animal hookworm Ancyclostoma braziliense, which is able to penetrate and migrate through the epidermis of a host by releasing degradative enzymes. Usually, a clinical diagnosis is made, on the basis of typical clinical features, and empirical treatment with topical (thiobendazole) or oral (thiobenzadole, albendazole, ivermectin) anthelmintics are intitated. Histopathological confirmation and A
removal of the larvae are not usually attempted because the migrating larvae are difficult to locate. We used a high-resolution bedside instrument, a reflectance confocal microscope (Viva Scope 1500, Lucid, Henrietta, NY, USA) currently employed in experimental and clinical dermatology, to effectively locate the larvae. Imaging showed a dark disruption in the normal honeycomb pattern of the epidermis corresponding to the larval burrow, and a highly refractile oval larva (figure B). We identified the larvae and did a 4 mm punch biopsy extraction. The intact hookworm larva was successfully revealed within the epidermis and was richly eosinophilic on routine histology (figure C). Our patient’s symptoms resolved after removal of the larvae; however, he also requested treatment with thiobendazole.
B
C
100 μm
Figure: Cutaneous larva migrans (A) Serpiginous eruption of plantar aspect of right foot. (B) Reflectance confocal microscope imaging showing highly refractile oval larva (arrow). (C) Histological examination of punch biopsy extraction showing richly eosinophilic intact hookworm larva (arrow) within the epidermis.
1948
www.thelancet.com Vol 377 June 4, 2011
Cutaneous larva migrans Kerri S Purdy, Richard G Langley, Amanda N Webb, Noreen Walsh, David Haldane Lancet 2011; 377: 1948 Published Online May 20, 2011 DOI:10.1016/S01406736(10)61149-X Division of Dermatology, (K S Purdy MD, R G Langley MD); Department of Medicine, (A N Webb BScH), Division of Anatomical Pathology, (N Walsh FRCPath), and Division of Infectious Diseases, Department of Pathology and Laboratory Medicine (D Haldane MB FRCPC), Dalhousie University, Halifax, Canada Correspondence to: Dr Richard G Langley, 4–195 Dickson Building, QE11 Health Sciences Center, 5820 University Avenue, Halifax, NS, B3H 1V7, Canada [email protected]
In November, 2009, a 38-year-old man presented with an itchy serpiginous eruption on the plantar aspect of his right foot that had developed after a trip to Mexico (figure A). He reported walking barefoot in the sand where cats and cat faeces were present. Physical examination showed an erythematous serpiginous eruption on the sole of his right foot. A clinical diagnosis of cutaneous larva migrans was made. Cutaneous larva migrans is most often caused by the larvae of the animal hookworm Ancyclostoma braziliense, which is able to penetrate and migrate through the epidermis of a host by releasing degradative enzymes. Usually, a clinical diagnosis is made, on the basis of typical clinical features, and empirical treatment with topical (thiobendazole) or oral (thiobenzadole, albendazole, ivermectin) anthelmintics are intitated. Histopathological confirmation and A
removal of the larvae are not usually attempted because the migrating larvae are difficult to locate. We used a high-resolution bedside instrument, a reflectance confocal microscope (Viva Scope 1500, Lucid, Henrietta, NY, USA) currently employed in experimental and clinical dermatology, to effectively locate the larvae. Imaging showed a dark disruption in the normal honeycomb pattern of the epidermis corresponding to the larval burrow, and a highly refractile oval larva (figure B). We identified the larvae and did a 4 mm punch biopsy extraction. The intact hookworm larva was successfully revealed within the epidermis and was richly eosinophilic on routine histology (figure C). Our patient’s symptoms resolved after removal of the larvae; however, he also requested treatment with thiobendazole.
B
C
100 μm
Figure: Cutaneous larva migrans (A) Serpiginous eruption of plantar aspect of right foot. (B) Reflectance confocal microscope imaging showing highly refractile oval larva (arrow). (C) Histological examination of punch biopsy extraction showing richly eosinophilic intact hookworm larva (arrow) within the epidermis.
1948
www.thelancet.com Vol 377 June 4, 2011