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Cutaneous Larva Migrans

CLM

Cutaneous larva migrans (CLM) is a hookworm infection, which manifests as cutaneous eruption. It is caused by skin penetration of parasitic larvae due to direct skin contact with contaminated soil.


Presentation

CLM is a skin infection with features including pruritus, erythematous lesions, edematous erythematous papules, vesicles filled with serous fluid, prickling at the site of exposure and purulent discharge. The larvae migrate through the skin with a rate of 2 to 3 mm per day. The papules caused by the infection are usually 2 to 3 mm wide and they have a pink color. However, the color of old papules and lesions is pale. These features are usually seen on body areas that are exposed to the contaminated soil, such as the feet, the hands, the buttocks and the back. The symptoms usually resolve within a few weeks. However, in rare cases they could last for up to one year. Usually there is a history of direct skin contact with contaminated soil like sunbathing or barefoot walking on the beach [10]. 

Systemic complications are rare in CLM. However, Löffler syndrome is one of the complications that could rarely happen, which involves signs of peripheral blood esinophilia, patchy migratory pulmonary infiltrates, and elevated levels of immunoglobulin E.

Veterinarian
  • Guidelines for veterinarians: prevention of zoonotic transmission of ascarids and hookworms of dogs and cats. Available at http:// www.cdc.gov/ncidod/dpd/parasites/ascaris/prevention.pdf.[imic.or.jp]
Severe Pain
  • It was connected with severe pain, burning and erythema of adjacent skin. Symptoms appeared at least three times, approximately once a month, always in the evening or night and lasted from several minutes to several days.[ncbi.nlm.nih.gov]
Larva Migrans
  • 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.[ncbi.nlm.nih.gov]
  • OBJECTIVES: The purpose of this study is to present the 'chronic' or 'persistent' form of hookworm-related cutaneous larva migrans.[ncbi.nlm.nih.gov]
  • Cutaneous larva migrans is an endemic disease with predilection for poor and vulnerable persons.[ncbi.nlm.nih.gov]
  • 2001-2012, DermAtlas Image Name: Larva_Migrans_1_090828 File Type: jpg Diagnosis: CUTANEOUS LARVA MIGRANS Category: infections and infestations / linear eruptions Body Site: abdomen Age: 60 years Contributor: Lanka Padmavathy, PhD Description: 20 cm long[web.archive.org]
  • 2001-2010, DermAtlas Image Name: Larva_Migrans_1_090828 File Type: jpg Diagnosis: CUTANEOUS LARVA MIGRANS Category: infections and infestations / linear eruptions Body Site: abdomen Age: 60 years Contributor: Lanka Padmavathy, PhD Description: 20 cm long[web.archive.org]
Pruritus
  • Tracks are often accompanied by severe pruritus. Three adult Caucasian patients recently returned from trips to Malaysia and Thailand, presented with follicular CLM.[ncbi.nlm.nih.gov]
  • The disappearance of pruritus was reported after 2-3 days and skin lesions after 5-7 days of therapy.[ncbi.nlm.nih.gov]
  • All patients complained of pruritus. General physical examination and laboratory and instrumental examinations were normal or negative.[ncbi.nlm.nih.gov]
  • BACKGROUND: Cutaneous larva migrans (CLM), a zoonotic helminthiasis imported to Canada by travelers to the tropics, causes morbidity due to severe, intractable pruritus.[ncbi.nlm.nih.gov]
  • Even though the disease resolves spontaneously, the significant duration of the disease along with severity of pruritus make treatment unavoidable.[ncbi.nlm.nih.gov]
Cutaneous Manifestation
  • Cutaneous Manifestations of Selected Parasitic Infections in Western Pacific and Southeast Asian Regions. Curr Infect Dis Rep 18: 30, 1-7, 2016; 6. Meotti CD.[degruyter.com]
  • manifestations of intestinal helminthic infections, Dermatol Clin, 1989 , vol. 7 (pg. 275 - 90 ) 4 Hookworm folliculitis, Arch Dermatol, 1991 , vol. 127 (pg. 547 - 9 ) 5 The natural course of creeping eruption and treatment with thiabendazole, Arch Dermatol[doi.org]
  • Cutaneous manifestations of intestinal helminthic infections. Dermatol Clin. 1989 Apr. 7(2):275-90. [Medline]. Craythorne EE, Wong S, Jones RM, du Vivier AW. A characteristic rash. BMJ. 2009 May 20. 338:b1451. [Medline].[emedicine.com]
Excoriation
  • 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.[ncbi.nlm.nih.gov]
Neglect
  • BACKGROUND: Hookworm-related cutaneous larva migrans (HrCLM) is a neglected tropical skin disease associated with significant clinical pathology. Little knowledge exists about prevalence and risk factors of HrCLM in endemic regions.[ncbi.nlm.nih.gov]
  • Cutaneous larva migrans is a neglected zoonotic helminthic disease which is paradoxically underreported in low-income and middle-income countries from where a majority of the cases emanate.[ncbi.nlm.nih.gov]
  • INTRODUCTION: Hookworm-related cutaneous larva migrans (HrCLM) is a neglected parasitic skin disease commonly found in resource-poor communities in tropical countries.[ncbi.nlm.nih.gov]
  • BACKGROUND: Hookworm-related cutaneous larva migrans (CLM) is a common but neglected tropical skin disease caused by the migration of animal hookworm larvae in the epidermis.[ncbi.nlm.nih.gov]
  • BACKGROUND: Cutaneous larva migrans (CLM) is a common but neglected parasitic skin disease in impoverished communities of the developing world.[ncbi.nlm.nih.gov]

Workup

Personal and travel history are important in making the diagnosis of CLM, especially if there is history of sunbathing, barefoot walking on the beach, or recent travel to a tropical area. In addition to history, the clinical appearance is important in reaching the diagnosis of CLM. Larvae may be seen in a skin biopsy taken from the infected skin, which confirms the diagnosis [11].

Staphylococcus Aureus
  • In the second patient, a superinfection due to Staphylococcus aureus was recorded. The appearance in Brittany of a reservoir of nematodes capable of causing hookworm-related cutaneous larva migrans is hypothesized.[ncbi.nlm.nih.gov]
Tissue Nematode
  • Despommier, Tissue Nematodes, Principles and Practice of Pediatric Infectious Diseases, 10.1016/B978-0-323-40181-4.00277-2, (1381-1388.e2), (2018).[doi.org]

Treatment

CLM is a benign self-limited infection, which resolves within a few weeks. However, treatment is required to decrease the symptoms and the risk of developing secondary bacterial infections. The drug of choice used for the treatment of CLM is topical thiabendazole 15% for five days [12] [13] [14]. Oral thiabendazole is rarely used and may only be considered in the case of widespread lesions [6].

Other antihelminthic drugs may be employed for the treatment of CLM include ivermectin with a daily dose of 200 mcg/kg for 1 or 2 days (ivermectin is contraindicated in children under the age of five years) [1], and albendazole with a daily dose of 400 mg for 3 to 7 days [12].

If secondary bacterial infections occur, antibiotics should be used to treat the bacterial infection. With effective treatment, the pruritus will decrease within a couple of days and the lesions will resolve within a week.

Prognosis

CLM has excellent prognosis as it is a benign self-limited infection of the skin, and usually resolves in a few weeks (up to one year in very rare cases). However, one of its complications is Löffler syndrome, which is also a self-limited pulmonary reaction, characterized by eosinophilia and patchy pulmonary infiltrates.

Etiology

Different species of Ancylostoma may cause CLM. However, Ancylostoma braziliense is the most common one [3], which is usually found in the Caribbean, Central and South America, and the south of the United States [4]. Eggs of Ancylostoma braziliense pass from cats and dogs feces into the moist warm soil, where the larvae hatch. These larvae penetrate the skin of people, especially when walking barefoot, or not taking caution in contaminated areas [5] [6].

Other hookworms that cause CLM may be found in other places around the world, such as Ancylostoma caninum in Australia, and Uncinaria stenocephala in Europe. Soil contaminated with the hookworm larvae is usually due to cats and dogs feces; however, other hookworms that cause infection may be passed to the soil through other animals, such as Bunostomum phlebotomum, which is a cattle hookworm.

Epidemiology

CLM is the second most common helminthic infection in developed countries. Infection depends mainly on the exposure to soil contaminated with larvae, and that is why there is no difference in the incidence depending on gender, race, or age. However, children get infected more than adults, mainly because they walk barefoot more than adults and they may not take caution.

Based on geographic areas, CLM is commonly found in tropical and subtropical areas like Central and South America, Southeast Asia, and the central and south of the United States [7]. However, CLM cases were diagnosed in places other than these tropical areas, mainly as a result of travel and tourism [8].

Sex distribution
Age distribution

Pathophysiology

The cycle starts with hookworm eggs passed to the warm moist soil through cats or dogs feces. The larvae hatch in the soil and are then transmitted to people by penetrating the skin of body areas that are usually in contact with the contaminated soil, such as feet, legs, hands, buttocks, and the back.

The hookworm ova develop into larvae while in the ground. Transmission of the larvae from soil to humans occurs when there is direct contact with the unprotected skin of humans. The larvae penetrate the unprotected skin and cause the infection.

Humans are considered accidental hosts for the parasite, and the larvae are not able to penetrate into the basal membrane as they lack the required collagenase enzymes. This keeps the infection limited to the skin with formation of a characteristic rash called creeping eruptions [9]. However, in their natural hosts (cats and dogs), the larvae are able to migrate to other organs in the body, such as the lungs or the intestine, through the lymphatic and venous systems.

Prevention

CLM is not a dangerous condition, and it is self-limited. However, it is always better to prevent it from happening in the first place. Prevention of CLM involves avoidance of contact with soil contaminated with animal feces, for example by wearing shoes and using mattresses or chairs when sitting on the beach.

Due to tourism and the ease of travel, tourists travelling to tropical areas might get infected. Good education and guidance should be given in order to decrease the risk of getting the infection.

Summary

Cutaneous larva migrans (CLM) is a benign self-limited skin infection caused by skin penetration of larvae from soil contaminated with hookworm larvae. CLM is common in the tropical and subtropical areas [1]. Ancylostoma braziliense is the most common hookworm responsible for the development of the infection. It is commonly found in Central and South America as well as the south part of the United States.

The manifestations of CLM include cutaneous eruptions, which are erythematous, serpiginous, and pruritic [1] [2]. Patients who develop the infection usually have history of recent travel to a tropical area, sunbathing, or walking barefoot on the beach, where the soil may be contaminated with animal feces. Personal and travel history as well as the clinical appearance are important in the diagnosis of CLM. If diagnosed, the treatment may involve drugs, including ivermectin, albendazole and tiabendazole.

CLM is a benign infection, and usually does not require treatment. However, treatment is used to decrease symptoms and risk of developing secondary bacterial infections. Antibiotics may be needed, if secondary bacterial infections occur. Cutaneous larva migrans usually resolves within a few weeks, and has excellent prognosis with a very rare risk of developing other complications, such as Löffler syndrome.

Even though CLM is a benign self-limited infection, health education, especially for tourists and travelers to tropical areas, is important to decrease the risk of the infection.

Patient Information

Cutaneous larva migrans (CLM) is a skin infection caused by parasitic hookworms, mainly hookworms from the Ancylostoma species. The most common hookworm that causes CLM is Ancylostoma braziliense, which is common in tropical and subtropical areas like Central and South America, and the south areas of the United States.

Cats and dogs are the most common animals that pass hookworm eggs to the soil and contaminate it; however, other animals like cattle, may also pass hookworm eggs. The eggs passed from animals to soil develop into larvae before they are transmitted to humans. Larvae of the parasite penetrate the skin and cause the infection when people have direct contact with soil contaminated with the larvae from cats and dogs feces.

The larvae cause a benign self-limited skin infection, which is manifested by papules and vesicles seen on body areas that are exposed to the contaminated soil, such as the feet, the hands, the buttocks, and the back. Other systemic symptoms and signs are rare and the infection is usually limited to the skin.

Personal and travel history are very important in reaching the diagnosis of CLM. And the doctor will ask about recent travels to tropical areas, or if you had a recent sunbath or walked on the beach with bare feet. The doctor will also look for skin features and manifestations in the infected areas.

CLM is a benign and self-limited condition, which resolves within a few weeks. However, treatment is required to decrease the symptoms and discomfort, and to prevent secondary bacterial infections. Treatment includes antihelminthic drugs, such as thiabendazole, ivermectin, or albendazole for a few days. Antibiotics may be use if a secondary bacterial infection develops.

The outcome of CLM is excellent, and it resolves within a few weeks (in rare cases it could last for up to one year). Systemic complications are very rare to happen in CLM. Health education, especially to tourists and travelers to tropical areas, is very important to prevent the infection through raising awareness about the condition and how it is important to avoid direct contact with contaminated soil by wearing shoes on the beach or sitting on mattresses and chairs.

References

Article

  1. Heukelbach J, Feldmeier H. Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans. Lancet Infect Dis. May 2008; 8(5): 302-9. doi: 10.1016/S1473-3099(08)70098-7.
  2. Nash TE. Visceral larva migrans and other unusual helmintic infections. In: Mandell GL, Bennet JE, Dolin R, editors. Principles and practices of infectious disease. 6th Ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2005: 3295–6.
  3. Bowman DD, Montgomery SP, Zajac AM, et al. Hookworms of dogs and cats as agents of cutaneous larva migrans. Trends Parasitol. April 2010; 26(4): 162-7.
  4. Schuster A, Lesshafft H, Talhari S, et al. Life quality impairment caused by hookworm-related cutaneous larva migrans in resource-poor communities in Manaus, Brazil. PLoS Negl Trop Dis. November 2011; 5(11): e1355.
  5. Tan JS. Human zoonotic infections transmitted by dogs and cats. Arch Intern Med. September 22, 1997; 157(17): 1933-43.
  6. Richey TK, Gentry RH, Fitzpatrick JE, et al. Persistent cutaneous larva migrans due to Ancylostoma species. South Med J. June 1996; 89(6): 609-11.
  7. Caumes E, Carrière J, Guermonprez G, et al. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Clin Infect Dis. March 1995; 20(3): 542-8.
  8. Patel S, Sethi A. Imported tropical diseases. Dermatol Ther. November-December 2009; 22(6): 538-49. doi: 10.1111/j.1529-8019.2009.01275.x.
  9. Feldmeier H, Schuster A. Mini review: Hookworm-related cutaneous larva migrans. Eur J Clin Microbiol Infect Dis. June 2012; 31(6): 915-8.
  10. Archer M. Late presentation of cutaneous larva migrans: a case report. Cases J. August 12, 2009; 2: 7553.
  11. Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med.  September-October 2007; 14(5): 326-33.
  12. Jelinek T, Maiwald H, Nothdurft HD, et al. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis. December 1994; 19(6): 1062-6.
  13. Rodilla F, Colomina J, Magraner J. Current treatment recommendations for cutaneous larva migrans. Ann Pharmacother. May 1994; 28(5): 672-3.
  14. Van den Enden E, Stevens A, Van Gompel A. Treatment of cutaneous larva migrans. N Engl J Med. October 22, 1998; 339(17): 1246-7.

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Last updated: 2019-07-11 20:46