4. GENERAL DATA
This is a case of Carlos V. Amador 59 y/o
male,married, Roman Catholic,from 48 Baes
rd. San Gregorio Vill. Pasay, City.
Retired company driver.
6. HISTORY OF PRESENT ILLNESS
Patient was apparently well until 1month
PTC, patient developed multiple papules
arranged in annular formation erythematous,
and slightly prutic, located at the hypogastric
area and is associated in contact with ceramic
tiles in the garden.
2 wks PTC, patient sought consult to private
MD where he was prescribed with clobetasol +
gentamycin ointment which he used with good
compliance. Few days after using the ointment
the lesion turned into plaque non pruritic and
hyperpigmented.
7. HISTORY OF PRESENT ILLNESS
However there is a development of a new
papular annular erythemathous, slightly pruritic
lesion adjacent to the old skin lesion on the
hypogastric area plus extension elongation of the
lesion. Hence consult .
8. PAST MEDICAL HISTORY
(-) allergy to food/medication
(-) Asthma
(-) HTN
(-) DM
(-) PTB
9. IMMUNIZATION HISTORY
No Adult Immunization
FAMILY HISTORY
(-) Family history of similar skin condition
(-) HTN - father
(-) DM
(-) Asthma
(-) CA
10. FAMILY GENOGRAM
FAMILY GENOGRAM
Amador – Villanueva
(As of September 4, 2013 @ OMMC)
I
Gregorio , 60 Lorena, 51 Germie,? Norma,?
II
Carlos, 59 Leslie, 55 Ernie, 50 Ester, 48 Arman,47
III
Chino, 32 Kim, 29 Macky, 27
Hypertension
diabetes vehicular accident
May 23, 1979
11. Adaptation Ako'y nasisiyahan dahil nakakaasa ako ng tulong
sa aking pamilya sa oras ng problema
2
Partnership Ako'y nasisiyahan sa paraang
nakikipagtalakayan sa akin ang aking pamilya
tungkol sa aking problema
2
Growth Ako'y nasisiyahan at ang aking pamilya ay
tinatanggapat sinusuportahan ang aking mga
nais na gawin patungo sa mga bagong landas
para sa aking ikauunlad.
2
Affection Ako'y nasisiyahan sa paraang ipinadama ng
aking pamily ang kanilang pagmamahal at
nauunawaan ang aking damdamin katuladng
galit, lungkot, at pag-ibig.
2
Resolve Ako'y nasisiyahan na ang aking pamilya at ako
ay nagkaroon ng panahon sa isa't-isa
2
TOTAL: 10
Functional
12. RESOURCE PATHOLOGY
SOCIAL Has regular interaction with
neighbours
CULTURAL Filipino culture of utmost respect
to parents has been identified
RELIGIOUS Regularly attending Sunday mass
provides spiritual satisfaction
ECONOMIC Incomeis good coming from his
private taxi sufficient to meet
financial needs. And lands of wife
from zambales which earns money
EDUCATIONAL Finishing a college course has been
adequate to comprehend and
solve most of the problems
MEDICAL Medical care is available thru
several near-by hospitals
13. Sexual History
last sexual contact was a month ago
coitarche: 18y/o
Total 4 sexual partners
Currently monogamous
14. PERSONAL / SOCIAL / SPIRITUAL HISTORY
Retired company driver, non-smoker, occ’l
alcoholic beverage drinker, has his own taxi
which he occ. Drives, no hx of substance
abuse, no food preference. Lives in a 2 storey
house, 4 bed rooms, 2 cr/bathroom. Purified
water used for drinking. Garbage collected
regularly.
Catholic, attends Sunday Mass regularly, not
involved in any community group, expects
his physician to resolve his skin problem for
him to relieve him on the symptoms.
15. REVIEW OF SYSTEMS
General: no weight loss, no easy fatigability
HEENT: no dizziness, no blurring of vision, no ear
discharge, no epistaxis
Cardiovascular: no chest pain, no orthopnea, no PND, no
palpitation
Respiratory: no dyspnea, no cough, no hemoptysis
Gastrointestinal: no change in bowel habits, no abdominal
pain, no melena, no hematochezia
Genitourinary: no frequency of urination, no dysuria, no
incontinence
Muskuloskeletal: no weakness, no muscle pain
Neurologic: no headache, no seizure, no tremors
Hematologic: no easy bruising
Endocrine: no heat or cold intolerance, no polyuria, no
polydipsia
16. PHYSICAL EXAMINATION
conscious, coherent, ambulatory, not in cardio-respiratory
distress
BP 110/70 mm/Hg, CR 72bpm,
RR 17cpm, T 36.6°C
Ht 175cm, Wt 66Kg
BMI: 21.5 (Normal)
Skin: (+) Multiple, well-defined, erythematous plaques in a
serpentine trail measuring 1x1 to 2x2 cm located at the
hypogastric area of the abdomen
17. PHYSICAL EXAMINATION
HEENT: anicteric sclerae, pink palpebral conjunctivae, no
naso-aural discharge, no nasal flaring, no cervical lymph
adenopathy, no tonsillo-pharyngeal congestion, no neck
vein engorgement
C/L: symmetric chest expansion, no retraction, no costo-
vertebral angle tenderness, clear breath sounds
HEART: adynamic precordium, PMI @ 5th ICS LMCL,
normal rate, regular rhythm, no murmur
ABDOMEN: flat, normo-active bowel sounds, soft, non-
tender
EXT: grossly normal, full and equal pulses, no inguinal
lymphadenopathy, no edema, no cyanosis
18. PHYSICAL EXAMINATION
NEURO EXAM: oriented to time, place, person
GCS: 15 (E4 V5 M6)
CN I: can smell
CN II: good visual acuity
CN III, IV, IV: intact EOMs
CN V: can clench teeth
CN VII: no facial asymmetry
CN VIII: can hear
CN IX, X: good gag
CN XI: good shoulder shrug
CN XII: tongue midline
20. SALIENT FEATURES
59y/o Male
Hx of frequent gardening as his hobby
(+) Multiple, well-defined, erythematous plaques in a
serpentine trail measuring 1x1 to 2x2 cm located at
the hypogastric area of the abdomen No allergy to
food/medication
22. Bacterial infection (i.e. Beginning cellulitis)
Ruled in because of the appearance of an
erythematous lesion
However lesion lacks the typical warm and
tender lesions associated with bacterial infections
and nonresponse with 2 weeks course of gentamycin
treatment rules this out.
Fungal infection
(Dermatophytoses)
Ruled in since common cause of pruritic lesions
are fungal infections
To rule out with KOH examinations
23. Contact Dermatitis
Erythematous lesions on hypogastric area in
contact with belt
However lesion nonresponsive to 2 weeks course
of clobetasol and removal of offending belt.
Parasitic infection (CLM)
Ruled in because of the typical serpiginous
appearance of an erythematous lesion
Patient has risk of parasite exposure because of
gardening hobby
25. DISCUSSION
Cutaneous Larva Migrans
Key Highlights
Superficial, self-limiting dermatosis caused by migration
of dog or cat hookworm larvae in the epidermis following
invasion of the skin.
One of the most common parasitic infestations affecting
travelers returning from beach destinations in the
Caribbean, Mexico, Brazil, and Southeast Asia.
Characterized by intensely pruritic serpiginous or linear
raised erythematous tracks. Lesions occur on unprotected
skin (most commonly involving the feet) that has come
into contact with sandy, moist soil contaminated by dog or
cat feces containing hookworm eggs.
Diagnosis made on clinical grounds.
26. DISCUSSION
Definition of Cutaneous larva migrans (CLM)
It is a self-limiting dermatosis caused by the
migration of animal hookworm larvae (most
commonly the dog hookworm Ancylostoma caninum
and the cat hookworm Ancylostoma braziliense) in
the skin.
It is characterized by serpiginous or linear raised
erythematous tracks that are usually intensely
pruritic and occur on unprotected skin (most
commonly involving the feet) that has come into
contact with sandy, moist soil contaminated by dog
or cat feces containing hookworm eggs in areas of
the tropics and subtropics.
28. PATHOPHYSIOLOGY
In cutaneous larva migrans (CLM), the life
cycle of the parasites begins when eggs are
passed from animal feces into warm, moist,
sandy soil, where the larvae hatch. They
initially feed on soil bacteria and molt twice
before the infective third stage. By using
their proteases, larvae penetrate through
follicles, fissures, or intact skin of the new
host. After penetrating the stratum
corneum, the larvae shed their natural
cuticle. Usually, they begin migration
within a few days.
29. PATHOPHYSIOLOGY
In their natural animal hosts, the larvae of
cutaneous larva migrans are able to
penetrate into the dermis and are
transported via the lymphatic and venous
systems to the lungs. They break through
into the alveoli and migrate to the trachea,
where they are swallowed. In the intestine
they mature sexually, and the cycle begins
again as their eggs are excreted
30. PATHOPHYSIOLOGY
Humans are accidental hosts, and the
larvae are believed to lack the collagenase
enzymes required to penetrate the
basement membrane to invade the dermis.
Therefore, cutaneous larva migrans
remains limited to the skin when humans
are infected
31.
32.
33. DIAGNOSTIC APPROACH AND
CLINICAL PRESENTATION
Diagnosis is based on a typical clinical presentation
together with suggestive history.
Travel history is essential in determining risk of
exposure to infection.
History of walking barefoot and/or sunbathing on a
beach in an endemic area will provide further
diagnostic clues.
34. DIAGNOSTIC APPROACH AND
CLINICAL PRESENTATION
Predispositions to contracting cutaneous larva
migrans include the following:
-Hobbies and occupations that involve contact with
warm, moist, sandy soil
-Tropical/subtropical climate travel
-Barefoot beachgoers/sunbathers
-Children in sandboxes
-Carpenter
-Electrician
-Plumber
-Farmer
-Gardener
-Pest exterminator
35. DIAGNOSTIC APPROACH AND
CLINICAL PRESENTATION
diagnosis mostly based on the classic clinical
appearance of the eruption
some patients demonstrate peripheral eosinophilia
on a CBC count & increased immunoglobulin E (IgE)
levels
A skin biopsy sample in cutaneous larva migrans,
taken just ahead of the leading edge of a tract, may
show a larva (periodic acid-Schiff positive)
36. TREATMENT
Even though CLM is self-limited, the intense pruritus
and risk for infection mandate treatment.
Thiabendazole is currently considered the agent of
choice
50mg/kg q12 for 2 days maximum daily dose of 3gm.
Other effective alternative treatments include
albendazole, mebendazole, and ivermectin.
albendazole: 400 mg orally once a day for 3 days
mebendazole: 100 mg PO q12hr for 3 days
ivermectin: 0.2 mg/kg orally once
The treatment course includes decreased pruritus
within 24-48 hours and lesions/tracts resolve in 1 week.
37. TREATMENT
Antibiotics indicated in secondary bacterial
superinfections if they occur.
Patients should be advised to avoid scratching the
creeping eruption, and to keep the area clean and
dry to reduce the risk of bacterial superinfection.
Patients should be instructed to follow-up should
symptoms not begin to resolve within 1 week of
treatment, because retreatment may be required.
38. PRIMARY PREVENTION
INDIVIDUAL LEVEL:
aimed at avoiding unprotected skin coming into
contact with contaminated soil.
wear shoes or sandals when walking to and on
beaches and to avoid beaches frequented by stray
cats and dogs
COMMUNITY LEVEL:
treat dogs and cats regularly with anthelmintic
drugs
banning animals from beaches and playgrounds
collection of feces by pet owners immediately after
defecation of pets in public areas
39. PROGNOSIS
Entirely benign prognosis
Among individuals living in endemic areas with
frequent episodes of infection, quality of life may be
significantly impaired.
Without treatment, migrating larvae will die in the
skin after about 2 to 8 weeks.
Once treated, symptoms rapidly resolve and skin
findings disappear, usually within 1 week.
40. PROGNOSIS
Relapse
Symptoms and skin findings may recur after an
initial positive response to treatment, likely
because the hookworm larvae were damaged but
not completely killed.
Relapse usually occurs within weeks of the initial
presentation and responds in most cases to a
repeated course of treatment
41. PLAN
Diet: balanced diet of CHO, CHON, vegetables and
fruits
Diagnostics: SGOT, SGPT once normal give
Therapeutics: Albendazole 400 mg/tab x 3 days,
cetirizine 10mg tab OD-BID PRN for pruritus, Mild
soap, Emollients
Health Education and Advise: Reassured the
patients case is curable. Using gloves as protection
and proper handling of garden tools.
42. DIAGNOSTICS result
SGOT
Result: 22.75 U/L (Normal)
Normal value: up to 37 U/L
SGPT
Result: 30.89 U/L ( Normal)
Normal value: up to 38 U/L
