traveler's parasitic skin infections

1. Common Skin Infections in Travelers
Group 3 Members
1- Epidemiology - Ahmed Yousef Mohamed 118
2- Bacterial skin infection - Ayman Hassan Hamed
302
3- HrCLM - Bashayer Michel Farag 349
4- Leishmaniasis - Ahmed Mohamed Mohamed Aly
105
5- Myiasis- Al shaimaa ahmed 211
6- Tungiasis- Alaa Gamal Soliman 258
7- Scabies - Dalia hassan attia 411
8-Arboviral infection - Amira Fetiany 243

2.  In Nepal, three studies showed that dermatoses were the third to the fourth
most frequent presenting illness among tourists
 in the Maldives and Fiji, dermatoses were the most frequent presenting
illnesses in tourists, with sunburns, superficial injuries (including those due to
contact with marine creatures), and skin infections documented most often
 South African tick typhus, or African tick-bite fever (Rickettsia africae) is the
most frequent cause of fever and rash in southern Africa. Transmitted by ticks
 In an international study concerning 17,353 returning travelers, dermatologic
disorders were the third most common cause of health problems after systemic
febrile illness and acute diarrhea. The most common causes of dermatologic
problems were insect bites (with or without secondary infection), cutaneous
larva migrans, allergic reactions, and skin abscesses.
“GeoSentinel Surveillance Network”

3. SKIN LESION
PERCENTAGE OF ALL DERMATOLOGIC
DIAGNOSES (N = 4,742)
Cutaneous larvae migrans 9.8
Insect bite 8.2
Skin abscess 7.7
Superinfected insect bite 6.8
Allergic rash 5.5
Rash, unknown origin 5.5
Dog bite 4.3
Superficial fungal infection 4.0
Dengue 3.4
Leishmaniasis 3.3
Myiasis 2.7
Spotted-fever group rickettsiae 1.5
Scabies 1.5

4. 1-According to the presence of fever: with e.g cellulitis,
lymphangitis, bacteremia, toxin-mediated. Without e.g Most of
minor skin infection
2-According to the causative agent : e.g viral , bacterial , fungal ,
parasitic .
3-According to the dermatologic gross pathology :
Ulcers , papules , nodules , rash..etc
4-According to the spread of infection :
Localized (or) systemic with skin involvement

5.  Insect bites probably act as a frequent portal of entry of bacterial
skin infections in travelers.
 Lesions usually appear while the patient is still abroad but are
also a leading cause of consultation in returning travelers.
 The clinical spectrum ranges from impetigo and ecthyma to
erysipelas, abscess, and necrotizing cellulitis.

6.  Bacterial analysis and susceptibility testing should be widely
recommended considering the risk of antibiotic resistance and the
possibility of highly pathogenic S aureus strains , Streptococcus
pyogenes and also Gram‐negative bacilli such as Vibrio vulnificus
( swimming or seafood ) .
Treatment :
Penicillinase‐resistant penicillins.
first‐generation cephalosporins, clindamycin, or vancomycin for
patients with life‐threatening penicillin allergies.

7.  Is the most frequent travel‐associated skin disease of tropical
origin.
 Caused by : the penetration of the skin by cat or dog nematode
larvae usually while landing or walking on contaminated lake e.g
ancylostoma braziliense .

8. Signs and symptoms
- The striking symptom: is pruritus localized at
the site of the eruption .
- most frequent and characteristic sign: is
“creeping dermatitis,”
- Two other major clinical signs: are edema and
vesiculobullous lesions along the course of the
larva.
- Hookworm folliculitis
- Local complications are : secondary bacterial
infection
Without any treatment, the eruption usually
lasts between 2 and 8 weeks.

9. Diagnosis:
usually a clinical diagnosis based on the typical clinical presentation in
the context of recent travel to a tropical country and beach exposure.
Treatment:
thiabendazole ointment remains the first‐choice treatment.
First‐line treatments: Oral ivermectin and albendazole are the
Taken in a single dose.
In the case of hookworm folliculitis: Treatment may necessitate
repeated courses of oral anthelmintic agents.
** When oral ivermectin and albendazole are contraindicated (eg,
very young children): then the application of a 10% albendazole
ointment, twice a day for 10 days, is a safe and effective alternative
treatment.

10.  Localized cutaneous leishmaniasis (LCL) occurs in tropical and
warm temperate countries and is transmitted by sandflies.
 Old World : Leishmania major and Leishmania tropica )
(sub‐Saharan and North Africa, the Mediterranean basin, and the
Middle East) .
 New World LCL : Leishmania braziliensis and Leishmania
mexicana (Amazon Forest of South America) .
- The lesion may be papule, nodule, ulcer, and nodular
lymphangitis .
- Usual features of LCL include the anatomic location on exposed
skin (face, arms, and legs), absence of pain, chronicity (more than
15 d duration), and failure of antibiotics (which are often
prescribed, given that it often looks like pyoderma).
Clinical picture

11. - direct examination of a slit‐skin smear with Giemsa stain .
- culture with identification of subsequent species.
- Skin biopsy from the edge of the ulcer may reveal the
characteristic amastigotes within macrophages but is less sensitive
than culture.
- PCR
Treatment
PCR guided treatment
-antimony sodium gluconate (pentostam) Injected
intralesionally
- Amphotericin B

12.  Myiasis is defined as the infestation of human tissues by larvae or maggots of
flies usually occurring in tropical and subtropical areas e.g Central America,
South America, Africa, and the Caribbean Islands.
 The most common form of human myiasis reported in travelers is furuncular
myiasis, which is often caused by Cordylobia anthropophaga and Dermatobia
hominis
Signs and symptoms:
The cutaneous lesion is a
furuncle‐like lesion with a central
punctum through which
serosanguineous or purulent fluid
discharges. Importantly, the patient
complains of a crawling sensation
within the lesion, and movements of
the larvae may be seen within the
central punctum.

13.  Careful skin covering , window screens and mosquito nets
in endemic areas .
 insect repellant .
 In tropical areas, iron any clothes that were put on the line
to dry.
Treatment:
• The larvae need to be surgically removed by
a medical professional either by extraction
or lateral expression .
• Myiasis wounds should be disinfected in
addition to the provision of tetanus
prophylaxis and antibiotic treatment for
secondary bacterial infections

14. •Tungiasis is caused by penetration of the gravid female sand flea
Tunga penetrans that burrows into the skin of its host, usually on the
feet to feed on blood while producing and extruding eggs
Distribution:
Tunga penetrans is distributed in tropical and
subtropical regions of the world.
specially In South America, tungiasis has
been reported from Columbia to Argentina.

15. Symptoms:
 itching .
 Irritation.
 Inflammation and ulceration .
 difficulty in walking.
Signs:
The acute cutaneous lesion is a papule with a
central black dot at the site of penetration that
develops into a wart‐like nodule through which eggs
of the flea are expelled. There is a limited number
of nodules (most commonly one), which are usually
located on the feet (subungual, soles, tips or toes,
and web spaces) and lower extremities.

16.  Diagnosis:
Identification is made by the finding of adult fleas and
their eggs in lesions.
 Treatment:
 Complete sterile excision .
 Administration of tetanus prophylaxis, and oral
antibiotics if there are signs of secondary bacterial
infection.33

17.  Human scabies is caused by an infestation of the skin by the
human itch mite (Sarcoptes scabiei var. hominis).
 The adult female scabies mites burrow into the upper layer of
the skin (epidermis) where they live and deposit their eggs.
 scabies is passed by direct skin-to-skin contact with a infected
person.
 Humans are the source of infection ; animals do not spread
human scabies
Scabies

18.  The most common symptoms of scabies, itching and a skin
rash which are caused by allergic reaction to the proteins
and feces of the parasite.
* Severe itching (pruritus), especially at night.

19. Itching and rash may affect much of the body or be limited
to common sites such as:
 interdigital web spaces, flexor surfaces of the wrists, the
elbows, the axillae, the buttocks and genitalia, and on the
breasts of women. Other skin changes are secondary to
pruritus and include excoriation, lichenification, and 2ry
bacterial infection .

20.  the diagnosis of scabies should be confirmed by identifying
the mite or mite eggs or fecal matter (scybala). This can be
done by carefully removing the mite from the end of its
burrow using the tip of a needle or by obtaining a skin
scraping to examine under a microscope for mites, eggs, or
mite fecal matter

21. one or more of the following may be used
 Permethrin cream 5 %.
 Crotamiton lotion 10% and Crotamiton cream
10%.
 Sulfur ointment (5%-10%)
 Lindane lotion 1% .
 Ivermectin
 Bedding and clothing must be laundered or
removed from contact for at least 3 days. Personal
and household contacts must also be treated

22. • The arboviruses spread mainly through insect bites.
• The most common insect that spreads arboviruses is the mosquito
( Aedes aegypti ).
• They are also transmitted through :
• blood transfusion ,organ transplant ,sexual contact ,pregnancy
and childbirth from mother to child
Transmission
. Dengue is widely reported in tropical and subtropical countries,
and dengue hemorrhagic fever is reported in travelers returning
from Southeast Asia, South Pacific Islands, Caribbean, and Latin
America.

23.  The most frequent arboviral infections that give rise to a
cutaneous eruption in travelers are caused by dengue and
chikungunya viruses.
 Typical presentation of classic dengue fever includes the sudden
onset of fever, headache, retroorbital pain, fatigue, arthralgia ,
myalgia and an exanthem that usually appears when the fever
decreases. The exanthema is typically macular or maculopapular,
confluent with the sparing of small islands of normal skin. Other
dermatologic signs include pruritus, flushed facies, and
hemorrhagic manifestations such as petechiae and purpuraN.B : Manifestations of chickungunya virus is
similar to that of dengue fever so they must be
differentiated through PCR techniques because
they have different complications :
Dengue fever …. Shock and GIT Hge
Chikungunya ….. Long-lasting arthralgia

24.  CBC : thrombocytopenia, leukopenia, lymphopenia, low
hematocrit may indicate hemorrhagic dengue fever
 serology or PCR.
 evidence of plasma leakage (eg, pleural effusion, ascites, or
hypoproteinemia).
Treatment
- treatment of the acute phase is only symptomatic (eg,
antipyretic agents such as paracetamol and bed rest).
- Rehydration ( ORS or IV )
- Blood transfusion when needed

25. - Rickettsioses are zoonotic bacterial infections transmitted to
humans by arthropods :
- African tick bite fever (ATBF) :
ATBF is currently the leading rickettsiosis reported in
travelers. ATBF is endemic in large parts of rural sub‐Saharan
Africa and the eastern Caribbean.
- causative agent:
- It is caused by Rickettsia africae and transmitted by cattle ticks of
the Amblyomma genus
Rickettsioses

26. - Regardless of the causative agent, most patients usually
present with a benign febrile illness accompanied by:
Headache, myalgia, and cutaneous eruptions (diffuse skin
rash and sometimes a cutaneous eschar, the portal of
entry).
- ATBF is usually a mild disease, and typical clinical
presentation usually includes one or several inoculation
eschars with a maculopapular or vesicular cutaneous
rash accompanied by fever, headache, and neck myalgia .

27.  Diagnosis:
An early diagnosis may be possible using PCR testing
of skin biopsies performed on the eschar .
 Treatment:
- Doxycycline is recommended whenever a case of
rickettsiosis is suspected allowing for rapid recovery and
prevention of complications.
- The usual dosage of doxycycline is 200 mg/d.
- Symptoms usually resolve within 24 to 48 hours after the
onset of treatment, which may also help with the diagnosis
of rickettsiosis.

28. Reference :
Journal of Travel Medicine, Volume 15,
Issue 4, 1 July 2008