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Annals of Clinical and Medical
Case Reports
Case Report
Cutaneous Larva Migrans: A Case Report in a Traveler Child
Decembrino L1, *
, Michetti G1
,Licardi G1
, Grecchi C2
, Pantaleo D1
, Grignani M1
, Colombo R4
, Capodieci C1
and Mazzucchelli I3
1
Department of Pediatrics and Neonatology, Civil Hospital Vigevano - ASST Pavia, Vigevano, Italy
2
Department of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo,Pavia, Italy
3
Department of Internal Medicine and Therapeutics, Rheumatology Unit, University of Pavia and Fondazione IRCCS Policlinico San
Matteo; Pavia, Italy
4
Service de Pedaitrie, Hopital du Jura, 2800-Deleèmont, Switzerland
Volume 3 Issue 3- 2020
Received Date: 16 Feb 2020
Accepted Date: 10 Mar 2020
Published Date: 16 Mar 2020
2. Key words
Child; Cutaneous larva migrans;
Diagnosis; Therapy; Epidemiology
1. Abstract
Cutaneous Larva Migrans (CLM) is the most common skin disease of tropical origincaused by
hookworms larvae, occurring in international travelers. Typical manifestations consist of er-
ythematous, serpiginous slightly elevated linear cutaneous lesions. We describe the case of an
8-year-old boy, with CLM infection acquired during travel to Burkina-Faso, and successfully
treated with Ivermectin. Epidemiology, clinicaldiagnosis and therapeutic are debated.
1.1. Background: Skin diseases are a common occurrence in international travellers and repre-
sent the third reason for seeking medical attention in returning travellers. As some skin diseases
can have life-threatening complications, especially in children, it is important to discriminate
whether the skin complaint represents a serious condition [1]. In these cases, history taking is
very important and must include specific destination of travel and all possible exposures to in-
sects and animals.
1.2. Case Presentation: An 8-year-old boy came to our pediatric Emergency Room because of
a skin lesion on the median left foot (Figure 1a, 1b). Physical examination showed an erythem-
atous, non-itching, slightly elevated both tortuous and linear lesion, extended for 3 cm. On the
foot plant, there were some round crusted lesions. The lesion was noted 5 days after the return
from travel to Burkina Faso. Traumas, insect bites or animal contacts were excluded. The boy
had a normal chest and abdominal physical examination, no fever, no lymph-adenomegaly, no
neurological signs. Apart from the foot lesion, the skin examination was unremarkable. Complete
blood count (CBC) showed marked eosinophilia (13.0% of WBC corresponding to 1296/L).
Treatment with an antihistamine agent was started and we referred the patient to the nearby
Tropical Infectious Disease Center for further assessments, where the diagnosis of Cutaneous
Larva Migrans (CML) was confirmed and he was prescribed oral ivermectin. A follow-up visit
was planned in the outpatient clinic of our center; after 15 days the boy showed complete remis-
sion (Figure 1c) and a decreased eosinophils count (8.1% of WBC corresponding to 740/ ) was
observed.
1. 3. Discussion: CLM is the most common skin disease of tropical origin caused by hookworms,
most commonly Ancylostoma vermemiense, Ancylostoma caninum, Necator Americanus, Unci-
naria stenocephala and Strongyloides stenocephala. It is endemic in the Caribbean, Central and
South America, Africa, Southeast Asia, and Australia. A temperature between 23°C and 30°C, the
presence of humid soil, and proper aeration favor larval growth. The degree of contamination and
the duration of contact with the soil also influence the occurrence of the disease. The adult worms
*Corresponding Author (s): Lidia Decembrino, Department of Pediatrics and Neonatology, Civil
Hospital Vigevano (PV) 27029, Italy, Tele: +39 3492121800, E-mail: lidia_decembrino@asst-pa-
via.it
http://www.acmcasereport.com/
Citation: Decembrino L, Cutaneous Larva Migrans: A Case Report in a Traveler Child. Annals of Clinical
and Medical Case Reports. 2020; 3(3): 1-3.
live in the intestine of dogs and cats and their eggs are shed through
feces that contaminate the environment. Humans are accidental
host where the parasite cannot complete its life cycle. The larvae
penetrate the intact skin and travel in the epidermis, but are unable
to cross the skin basal membrane and to develop into adults. Clini-
cal manifestations mainly depend on environmental and behavior-
al factors such as walking barefoot in contaminated sand. The in-
cubation period is generally of few days followed by the appearance
of itching erythematous tunnels, which can be linear or tortuous.
Creeping eruption usually appears 1–5 days after skin penetration,
but the incubation period may be ≥1 month. In adults CLM can
rarely be bilateral or present as folliculitis or urticarial papules. The
speed of migration depends on the parasite species, being usually
of one centimeter per day. The numbers of larvae that can infect the
area vary from one to hundreds (so there are also variations of the
lesion topography). The infection is generally self-limiting, as the
larvae cannot progress further in the human skin [2, 3].
CLM infection is observed in travelers returning from tropical lo-
cations and autochthonous cases are rare in Italy. The diagnosis is
clinical and based on the detection of the typical skin lesions. The
feet and buttocks are the more frequent localizations, but CLM can
also infect the arms, hands, and trunk [4]. Face and scalp site CLM
lesions are atypical and very rare, even if they were described in a
5 years boy [5].The occurrence in infants is rare, due to their lim-
ited mobility, while children can be easier affected because they
are used to walk barefoot on beaches while they were on vacation
and sand is one of the most frequent high-risk environment for the
infection acquisition [6]. CDC reported an outbreak of CML in a
children's aquatic sports day camp in Florida involving 22 people.
Erythema, pruritic rashes, serpiginous lesions, changing location
rash or lesions were reported. Manifestations were noted on the
buttocks, feet, legs, hands, groin, and abdomen and 9 of the pa-
tients had lesions in more than one location [7]
.
In our case the child returned from a travel in an endemic region,
the mother reported that the child has played barefoot on the sand
and the high number of peripheral eosinophils on CBC was com-
patible with parasitic infection.
The diagnosis is based on history and clinical examination, biopsy
is not recommended and laboratory exams, as peripheral hyper-
eosinophilia, leucocytosis, hypergammaglobulinemia and positive
serology, are useful to confirm diagnosis.
Differential diagnosis that should be considered are: Dirofilariasis,
Fascioliasis, Gnathostomiasis, hookworm infection, Paragonimia-
sis, Pediatric Toxocariasis, Scabies, Strongyloidiasis, Visceral Larva
Migrans [3]
. A curious differential diagnosis is Pili migrans, a very
rare condition that mimic CML infection, but it is due to a foreign
body penetration in the skin, in their case hair [8].
Even if the disease is usually benign and can be self-limiting, com-
plications may occur. Super-infection with Staphylococcus Aureus
and/or Streptococcus Pyogeneshas been reported, facilitated by
scratching the area. This may cause edema making the parasite
tunnels less visible. Moreover, allergic reactions to the parasite
could worsen the erythema and the pruritus in the involved area
[9]. The association of CML with Löffler’s syndrome is particularly
Volume 3 Issue 3 -2020 Case Report
Copyright ©2020 Decembrino L et al. This is an open access article distributed under the terms of the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and build upon your work non-commercially.
2
Figure 1a: two points of entrance, marked by a round crusted lesion
Figure 1b: serpiginouse tracks underneath the outer skin layer caused by the par-
asite
Figure 1c: the lesions after 15 days from the ER admission.
rare in children. It can occur when there is a heavy infestation of
larvae.Löffler’s syndrome is characterized by migratory pulmonary
infiltrates, peripheral eosinophilia, transient fever, cough and mal-
aise [10]. This association with CLM was first reported by Wright
and Gold in 1946. The exact pathogenesis remains unknown but
now type Ihypersensitivity reactionis the better hypothesis [10].
Even if complications associated to CLM aree primarily local, the
previously stated complications and intense pruritus may require
systemic treatments for a longer time.
Treatment depends on the localization and on the extent of in-
fection. Treatment by cryosurgery was routinely used prior to the
availability of anthelminthics such as albendazole, mebendazole,
thiabendazole and diethylcarbamazine [11]. The efficacy of liquid
nitrogen alone is limited as larvae can be far from the erythema,
while its combination with oral anti-helminths is more effective
than albendazole treatment alone. Ivermectin is the treatment
of choice, even if its safety has not been established in children
weighting less than 15 kg. A single oral dose (200 microgram/kg
body weight) is enough to kill the parasite effectively. When the
treatment fails, a second dose could be administered. Generally, a
single dose of ivermectin is more effective than albendazole (400
mg a day for 3 days). In case of Löffler’s syndrome Albendazole 10–
15 mg/kg/d for 3-5 days or longer seems to be the best treatment
approach [10]. An alternative treatment with 10% topical thiaben-
dazole ointment 4 times a day for at least 2 days is also reported in
children. German guidelines suggest to apply albendazole 10% in
a lipophilic base 3 times daily for 7-10 days in a large area as larvae
can be far from the visible lesion [10]. Topical albendazole can be
used in different concentrations (5 to 50%), and it is considered
safe in children. Ivermectin cream 1% seems to be an ineffective
treatment [11]. Antihistamine is used for the symptomatic treat-
ment of pruritus.
Recently, Del Giudice et al [12] reported 5 cases of autochthonous
CLM infection in France and they gave an overview of the autoch-
thonous cases in Europe, giving advertisement to view of CLM not
only as a typical and exclusive tropical diseases.
1. 4. Conclusions: In the era of modern medicine, it is important to
be aware of CLM infection that, even if rare, can easily be acquired
by international travelling children when playing on contaminated
ground. Prevention by wearing slippers and clothes is important to
avoid this infection along with policies for pets deworming. Even if
prognosis is good, early recognition and treatment help in prevent-
ing complication. The surveillance of CLM infection, imported or
autochthonous, can be helpful to monitor its incidence in Italy and
Europe.
Volume 3 Issue 3 -2020 Case Report
http://www.acmcasereport.com/ 3
References
1.	 Cunha PR, Flora TB, Kroumpouzos G. Travelers’ tropical skin dis-
eases: Challenges and interventions. Dermatol Ther. 2019; 32(4):
e12665.
2.	 Veraldi S, Çuka E, Vaira F. Cutaneous larva migrans. In: Dermatolog-
ical Cryosurgery and Cryotherapy. 2016; 11: 475-477.
3.	 Muller ML. Pediatric Cutaneous Larva Migrans. Medscape. 2015.
4.	 Paul IS, Singh B. Cutaneous larva migrans in children: A case series
from Southern India. Indian J Paediatr Dermatology. 2017; 18: 36-
38. doi:10.4103/2319-7250.188454
5.	 Dimitre Luz F. Silva JDCVB. A Boy With a Facial Pruritic Eruption
From Cutaneous Larva Migrans | Consultant360. www.consul-
tant360.com/articles/boy-facial-pruritic-eruption-cutaneou.
6.	 Heukelbach J, Feldmeier H. Epidemiological and clinical character-
istics of hookworm-related cutaneous larva migrans. Lancet Infect
Dis. 2008; 8: 302-309.
7.	 O’Connell E, Suarez J, Leguen F. Outbreak of cutaneous larva mi-
grans at a children’s camp-Miami, Florida, 2006. Morb Mortal Wkly
Rep. 2007; 56: 1285-1287.
8.	 Kim JY, Silverman RA. Migrating hair: A case confused with cutane-
ous larva migrans. Pediatr Dermatol. 2010; 27: 628-630.
9.	 Tianyi FL, Agbor VN, Kadia BM, Dimala CA. An unusual case of
extensive truncal cutaneous larva migrans in a Cameroonian baby:
A case report. J Med Case Rep. 2018; 12: 270.
10.	 Wang S, Xu W, Li LF. Cutaneous Larva Migrans Associated with Löf-
fler’s Syndrome in a 6-Year-Old Boy. Pediatr Infect Dis J. 2017; 36:
912-914.
11.	 Veraldi S, Angileri L, Parducci BA, Nazzaro G. Treatment of hook-
worm-related cutaneous larva migrans with topical ivermectin. J
Dermatolog Treat. 2017; 28:263-263.
12.	 Del Giudice P, Hakimi S, Vandenbos F, Magana C, Hubiche T. Au-
tochthonous Cutaneous Larva Migrans in France and Europe. Acta
Derm Venereol. 2019; 99:805-808.

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Cutaneous Larva Migrans: A Case Report in a Traveler Child

  • 1. Annals of Clinical and Medical Case Reports Case Report Cutaneous Larva Migrans: A Case Report in a Traveler Child Decembrino L1, * , Michetti G1 ,Licardi G1 , Grecchi C2 , Pantaleo D1 , Grignani M1 , Colombo R4 , Capodieci C1 and Mazzucchelli I3 1 Department of Pediatrics and Neonatology, Civil Hospital Vigevano - ASST Pavia, Vigevano, Italy 2 Department of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo,Pavia, Italy 3 Department of Internal Medicine and Therapeutics, Rheumatology Unit, University of Pavia and Fondazione IRCCS Policlinico San Matteo; Pavia, Italy 4 Service de Pedaitrie, Hopital du Jura, 2800-Deleèmont, Switzerland Volume 3 Issue 3- 2020 Received Date: 16 Feb 2020 Accepted Date: 10 Mar 2020 Published Date: 16 Mar 2020 2. Key words Child; Cutaneous larva migrans; Diagnosis; Therapy; Epidemiology 1. Abstract Cutaneous Larva Migrans (CLM) is the most common skin disease of tropical origincaused by hookworms larvae, occurring in international travelers. Typical manifestations consist of er- ythematous, serpiginous slightly elevated linear cutaneous lesions. We describe the case of an 8-year-old boy, with CLM infection acquired during travel to Burkina-Faso, and successfully treated with Ivermectin. Epidemiology, clinicaldiagnosis and therapeutic are debated. 1.1. Background: Skin diseases are a common occurrence in international travellers and repre- sent the third reason for seeking medical attention in returning travellers. As some skin diseases can have life-threatening complications, especially in children, it is important to discriminate whether the skin complaint represents a serious condition [1]. In these cases, history taking is very important and must include specific destination of travel and all possible exposures to in- sects and animals. 1.2. Case Presentation: An 8-year-old boy came to our pediatric Emergency Room because of a skin lesion on the median left foot (Figure 1a, 1b). Physical examination showed an erythem- atous, non-itching, slightly elevated both tortuous and linear lesion, extended for 3 cm. On the foot plant, there were some round crusted lesions. The lesion was noted 5 days after the return from travel to Burkina Faso. Traumas, insect bites or animal contacts were excluded. The boy had a normal chest and abdominal physical examination, no fever, no lymph-adenomegaly, no neurological signs. Apart from the foot lesion, the skin examination was unremarkable. Complete blood count (CBC) showed marked eosinophilia (13.0% of WBC corresponding to 1296/L). Treatment with an antihistamine agent was started and we referred the patient to the nearby Tropical Infectious Disease Center for further assessments, where the diagnosis of Cutaneous Larva Migrans (CML) was confirmed and he was prescribed oral ivermectin. A follow-up visit was planned in the outpatient clinic of our center; after 15 days the boy showed complete remis- sion (Figure 1c) and a decreased eosinophils count (8.1% of WBC corresponding to 740/ ) was observed. 1. 3. Discussion: CLM is the most common skin disease of tropical origin caused by hookworms, most commonly Ancylostoma vermemiense, Ancylostoma caninum, Necator Americanus, Unci- naria stenocephala and Strongyloides stenocephala. It is endemic in the Caribbean, Central and South America, Africa, Southeast Asia, and Australia. A temperature between 23°C and 30°C, the presence of humid soil, and proper aeration favor larval growth. The degree of contamination and the duration of contact with the soil also influence the occurrence of the disease. The adult worms *Corresponding Author (s): Lidia Decembrino, Department of Pediatrics and Neonatology, Civil Hospital Vigevano (PV) 27029, Italy, Tele: +39 3492121800, E-mail: lidia_decembrino@asst-pa- via.it http://www.acmcasereport.com/ Citation: Decembrino L, Cutaneous Larva Migrans: A Case Report in a Traveler Child. Annals of Clinical and Medical Case Reports. 2020; 3(3): 1-3.
  • 2. live in the intestine of dogs and cats and their eggs are shed through feces that contaminate the environment. Humans are accidental host where the parasite cannot complete its life cycle. The larvae penetrate the intact skin and travel in the epidermis, but are unable to cross the skin basal membrane and to develop into adults. Clini- cal manifestations mainly depend on environmental and behavior- al factors such as walking barefoot in contaminated sand. The in- cubation period is generally of few days followed by the appearance of itching erythematous tunnels, which can be linear or tortuous. Creeping eruption usually appears 1–5 days after skin penetration, but the incubation period may be ≥1 month. In adults CLM can rarely be bilateral or present as folliculitis or urticarial papules. The speed of migration depends on the parasite species, being usually of one centimeter per day. The numbers of larvae that can infect the area vary from one to hundreds (so there are also variations of the lesion topography). The infection is generally self-limiting, as the larvae cannot progress further in the human skin [2, 3]. CLM infection is observed in travelers returning from tropical lo- cations and autochthonous cases are rare in Italy. The diagnosis is clinical and based on the detection of the typical skin lesions. The feet and buttocks are the more frequent localizations, but CLM can also infect the arms, hands, and trunk [4]. Face and scalp site CLM lesions are atypical and very rare, even if they were described in a 5 years boy [5].The occurrence in infants is rare, due to their lim- ited mobility, while children can be easier affected because they are used to walk barefoot on beaches while they were on vacation and sand is one of the most frequent high-risk environment for the infection acquisition [6]. CDC reported an outbreak of CML in a children's aquatic sports day camp in Florida involving 22 people. Erythema, pruritic rashes, serpiginous lesions, changing location rash or lesions were reported. Manifestations were noted on the buttocks, feet, legs, hands, groin, and abdomen and 9 of the pa- tients had lesions in more than one location [7] . In our case the child returned from a travel in an endemic region, the mother reported that the child has played barefoot on the sand and the high number of peripheral eosinophils on CBC was com- patible with parasitic infection. The diagnosis is based on history and clinical examination, biopsy is not recommended and laboratory exams, as peripheral hyper- eosinophilia, leucocytosis, hypergammaglobulinemia and positive serology, are useful to confirm diagnosis. Differential diagnosis that should be considered are: Dirofilariasis, Fascioliasis, Gnathostomiasis, hookworm infection, Paragonimia- sis, Pediatric Toxocariasis, Scabies, Strongyloidiasis, Visceral Larva Migrans [3] . A curious differential diagnosis is Pili migrans, a very rare condition that mimic CML infection, but it is due to a foreign body penetration in the skin, in their case hair [8]. Even if the disease is usually benign and can be self-limiting, com- plications may occur. Super-infection with Staphylococcus Aureus and/or Streptococcus Pyogeneshas been reported, facilitated by scratching the area. This may cause edema making the parasite tunnels less visible. Moreover, allergic reactions to the parasite could worsen the erythema and the pruritus in the involved area [9]. The association of CML with Löffler’s syndrome is particularly Volume 3 Issue 3 -2020 Case Report Copyright ©2020 Decembrino L et al. This is an open access article distributed under the terms of the Creative Commons Attribution Li- cense, which permits unrestricted use, distribution, and build upon your work non-commercially. 2 Figure 1a: two points of entrance, marked by a round crusted lesion Figure 1b: serpiginouse tracks underneath the outer skin layer caused by the par- asite Figure 1c: the lesions after 15 days from the ER admission.
  • 3. rare in children. It can occur when there is a heavy infestation of larvae.Löffler’s syndrome is characterized by migratory pulmonary infiltrates, peripheral eosinophilia, transient fever, cough and mal- aise [10]. This association with CLM was first reported by Wright and Gold in 1946. The exact pathogenesis remains unknown but now type Ihypersensitivity reactionis the better hypothesis [10]. Even if complications associated to CLM aree primarily local, the previously stated complications and intense pruritus may require systemic treatments for a longer time. Treatment depends on the localization and on the extent of in- fection. Treatment by cryosurgery was routinely used prior to the availability of anthelminthics such as albendazole, mebendazole, thiabendazole and diethylcarbamazine [11]. The efficacy of liquid nitrogen alone is limited as larvae can be far from the erythema, while its combination with oral anti-helminths is more effective than albendazole treatment alone. Ivermectin is the treatment of choice, even if its safety has not been established in children weighting less than 15 kg. A single oral dose (200 microgram/kg body weight) is enough to kill the parasite effectively. When the treatment fails, a second dose could be administered. Generally, a single dose of ivermectin is more effective than albendazole (400 mg a day for 3 days). In case of Löffler’s syndrome Albendazole 10– 15 mg/kg/d for 3-5 days or longer seems to be the best treatment approach [10]. An alternative treatment with 10% topical thiaben- dazole ointment 4 times a day for at least 2 days is also reported in children. German guidelines suggest to apply albendazole 10% in a lipophilic base 3 times daily for 7-10 days in a large area as larvae can be far from the visible lesion [10]. Topical albendazole can be used in different concentrations (5 to 50%), and it is considered safe in children. Ivermectin cream 1% seems to be an ineffective treatment [11]. Antihistamine is used for the symptomatic treat- ment of pruritus. Recently, Del Giudice et al [12] reported 5 cases of autochthonous CLM infection in France and they gave an overview of the autoch- thonous cases in Europe, giving advertisement to view of CLM not only as a typical and exclusive tropical diseases. 1. 4. Conclusions: In the era of modern medicine, it is important to be aware of CLM infection that, even if rare, can easily be acquired by international travelling children when playing on contaminated ground. Prevention by wearing slippers and clothes is important to avoid this infection along with policies for pets deworming. Even if prognosis is good, early recognition and treatment help in prevent- ing complication. The surveillance of CLM infection, imported or autochthonous, can be helpful to monitor its incidence in Italy and Europe. Volume 3 Issue 3 -2020 Case Report http://www.acmcasereport.com/ 3 References 1. Cunha PR, Flora TB, Kroumpouzos G. Travelers’ tropical skin dis- eases: Challenges and interventions. Dermatol Ther. 2019; 32(4): e12665. 2. Veraldi S, Çuka E, Vaira F. Cutaneous larva migrans. In: Dermatolog- ical Cryosurgery and Cryotherapy. 2016; 11: 475-477. 3. Muller ML. Pediatric Cutaneous Larva Migrans. Medscape. 2015. 4. Paul IS, Singh B. Cutaneous larva migrans in children: A case series from Southern India. Indian J Paediatr Dermatology. 2017; 18: 36- 38. doi:10.4103/2319-7250.188454 5. Dimitre Luz F. Silva JDCVB. A Boy With a Facial Pruritic Eruption From Cutaneous Larva Migrans | Consultant360. www.consul- tant360.com/articles/boy-facial-pruritic-eruption-cutaneou. 6. Heukelbach J, Feldmeier H. Epidemiological and clinical character- istics of hookworm-related cutaneous larva migrans. Lancet Infect Dis. 2008; 8: 302-309. 7. O’Connell E, Suarez J, Leguen F. Outbreak of cutaneous larva mi- grans at a children’s camp-Miami, Florida, 2006. Morb Mortal Wkly Rep. 2007; 56: 1285-1287. 8. Kim JY, Silverman RA. Migrating hair: A case confused with cutane- ous larva migrans. Pediatr Dermatol. 2010; 27: 628-630. 9. Tianyi FL, Agbor VN, Kadia BM, Dimala CA. An unusual case of extensive truncal cutaneous larva migrans in a Cameroonian baby: A case report. J Med Case Rep. 2018; 12: 270. 10. Wang S, Xu W, Li LF. Cutaneous Larva Migrans Associated with Löf- fler’s Syndrome in a 6-Year-Old Boy. Pediatr Infect Dis J. 2017; 36: 912-914. 11. Veraldi S, Angileri L, Parducci BA, Nazzaro G. Treatment of hook- worm-related cutaneous larva migrans with topical ivermectin. J Dermatolog Treat. 2017; 28:263-263. 12. Del Giudice P, Hakimi S, Vandenbos F, Magana C, Hubiche T. Au- tochthonous Cutaneous Larva Migrans in France and Europe. Acta Derm Venereol. 2019; 99:805-808.