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Cutaneous larva migrans on the scalp: atypical presentation of a common disease* * Work performed in a Private Clinic - Rio de Janeiro (RJ), Brazil.

Abstract

Cutaneous larva migrans is a pruritic dermatitis due to the inoculation of helminths larvae in the skin, and it often occurs in children in tropical and subtropical areas. The authors describe an atypical case of cutaneous larva migrans in a 11 year-old child with scalp involvement, an unusual topography for this lesion.

Larva migrans; Scalp; Scalp dermatoses


INTRODUCTION

Cutaneous larva migrans (CLM), also known as "migrant linear epidermitis", "beach worm", "migrant helminthiasis", "dermatitis serpiginosus", "creeping eruption" or "sand worm" is a zoodermatosis caused by cutaneous penetration of helminth larvae, usually parasites of the small intestines of cats and dogs.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7. It is a common occurrence in tropical and subtropical countries and in people who visit beaches or sandy terrains which are polluted with feces of dogs and cats.22. Rey L. Parasitologia: Parasitos e Doenças Parasitárias do Homem nas Américas e na África. 3.ed. Rio de Janeiro: Guanabara-Koogan; 2001. 856 p.

Clinically it is characterized by the presence of intensely pruritic erythematous tunnels of linear and serpiginous character. From the point where there is larva penetration, tunnels are formed that usually draw an irregular and capricious path, progressing 2 to 5 cm per day.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,33. Lupi O. Infections, Infestations and bites. Cutaneous larva migrans. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2nd. New York: Mosby Elsevier; 2008. p. 1276-83. Sometimes, the wiggling line is restricted to a small area and in others, it extends itself like the drawing of a map. The lesion topography usually depends on the area which is in wider contact with the ground, like feet, legs or gluteal regions.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,44. Upendra Y, Mahajan VK, Mehta KS, Chauhan PS, Chander B. Cutaneous larva migrans. Indian J Dermatol Venereol Leprol. 2013;79:418-9.

According to the literature, scalp involvement by CLM is rare, as shown in a review of 158 cases of the disease, none of which presented scalp lesions.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,55. Guimarães LC, Silva JH, Saad K, Lopes ER, Meneses AC. Larva migrans within scalp sebaceous gland. Rev Soc Bras Med Trop. 1999;32:187-9.,66. Saka B, Kombaté K, Mouhari-Toure A, Balaka A, Agbo YM, Tatoa M, et al. Hookworm-related cutaneous larva migrans in dermatology departments in Lomé, Togo, between 2006 and 2011. Ann Dermatol Venereol. 2012;139:564-6. The number of larvae and, therefore, the number of inflammatory linear routes varies from a single one to tens or hundreds of them.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,44. Upendra Y, Mahajan VK, Mehta KS, Chauhan PS, Chander B. Cutaneous larva migrans. Indian J Dermatol Venereol Leprol. 2013;79:418-9. The authors report a case of cutaneous larva migrans on scalp with the objective of demonstrating an atypical presentation of the disease.

CASE REPORT

Male patient, 11-year-old, was admitted presenting intense pruritus on elbows, legs and scalp for approximately two weeks. He denied previous treatment and comorbidities. He reported practicing recreational activities on the beach, like soccer, every weekend. At the dermatological exam, we observed the presence of hair rarefaction on the left parietal region, with an erythematous string of serpiginous and irregular path in its center (Figure 1); eczema-like lesions of linear and angular path on anterior lateral face of the distal-third of the left leg, ankle and foot (Figure 2).

FIGURE 1:
Erythematous string of sinuous and irregular path on the left parietal region
FIGURE 2:
(a) Erythematous and eczematoid lesions of linear and angular path located on the lateral anterior of the distal-third of the left leg, ankle and foot

The clinical characteristics of the lesions and epidemiological history with weekly activities on beach sand are very suggestive for the diagnose of cutaneous larva migrans. Therefore, considering the diagnosis, a treatment was prescribed with a single dose of ivermectin 6mg and tiabendazole ointment, 50mg/g, 3x per day for 7 days. A clinical cure was achieved after one week of use of the drugs.

DISCUSSION

The main species responsible for the clinical picture of CLM are Ancylostoma caninum and Ancylostoma braziliense, with both species presenting approximately 1 cm of length.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,22. Rey L. Parasitologia: Parasitos e Doenças Parasitárias do Homem nas Américas e na África. 3.ed. Rio de Janeiro: Guanabara-Koogan; 2001. 856 p. Among the agents that can also cause the disease are other parasitic larvae of dogs and cats, such as Uncinaria stenocephala, Ancylostoma tubaeforme, Gnathostorna spinigerum and some strains of Strongyloides stercoralis; bovine parasites, Bunostornum phlebotomum; rodents parasites, Strongyloides myopotami and of wild dogs, Strongyloides procyonis. Larvae of Gasterophilus and Hypoderma flies and ants of Solenopis geminata species may also cause the same clinical manifestations.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,77. Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med. 2007;14:326-33.,88. Bowman DD, Montgomery SP, Zajac AM, Eberhard ML, Kazacos KR. Hookworms of dogs and cats as agents of cutaneous larva migrans. Trends Parasitol. 2010;26:162-7.,99. Feldmeier H, Schuster A. Mini review: Hookworm-related cutaneous larva migrans. Eur J Clin Microbiol Infect Dis. 2012;31:915-8. Another parasitic larva of dogs that deserves emphasis is the species Toxocara canis, which on men can cause visceral and ocular larva migrans.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,33. Lupi O. Infections, Infestations and bites. Cutaneous larva migrans. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2nd. New York: Mosby Elsevier; 2008. p. 1276-83.

The diagnosis is based on clinical history, on the serpiginous and migratory aspect of lesions, which may be made more difficult by eczematization and secondary infections.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,1010. Lesshafft H, Schuster A, Reichert F, Talhari S, Ignatius R, Feldmeier H. Knowledge, attitudes, perceptions, and practices regarding cutaneous larva migrans in deprived communities in Manaus, Brazil. J Infect Dev Ctries. 2012;6:422-9. In the present case, the clinical diagnosis of CLM was considered by association of clinical characteristics, intense pruritus and history of frequent recreational activities on beach sand.

Depending on the number of lesions and their localization, the treatment can be topical or systemic. The drugs of choice are: albendazole 400mg/day for 3 days, ivermectin 200mcg/kg in a single dose or tiabendazole 25mg/kg/day, divided into two doses for 5 days. If there are few lesions, the tiabendazole ointment or cream 10% may be used.11. Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.,44. Upendra Y, Mahajan VK, Mehta KS, Chauhan PS, Chander B. Cutaneous larva migrans. Indian J Dermatol Venereol Leprol. 2013;79:418-9. Due to posological convenience and considering greater compliance to the treatment with a single oral dose, ivermectin was indicated as the drug of choice. The association of the topical drug was the option of the authors to ensure fast improvement of the pruritus.

We consider of fundamental importance for a correct diagnosis and adequate treatment that dermatological semiology be carefully conducted. The publication of this clinical case is of interest because the patient presented CLM in an uncommon topography. Concomitant typical lesions on other sites facilitated the diagnosis.

REFERENCES

  • 1
    Kalil CLPV, Webber A. Zoodermatoses. In: Ramos-e-Silva M, Castro MCR, editores. Fundamentos de Dermatologia. Rio de Janeiro: Atheneu; 2010. p.1055-7.
  • 2
    Rey L. Parasitologia: Parasitos e Doenças Parasitárias do Homem nas Américas e na África. 3.ed. Rio de Janeiro: Guanabara-Koogan; 2001. 856 p.
  • 3
    Lupi O. Infections, Infestations and bites. Cutaneous larva migrans. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2nd. New York: Mosby Elsevier; 2008. p. 1276-83.
  • 4
    Upendra Y, Mahajan VK, Mehta KS, Chauhan PS, Chander B. Cutaneous larva migrans. Indian J Dermatol Venereol Leprol. 2013;79:418-9.
  • 5
    Guimarães LC, Silva JH, Saad K, Lopes ER, Meneses AC. Larva migrans within scalp sebaceous gland. Rev Soc Bras Med Trop. 1999;32:187-9.
  • 6
    Saka B, Kombaté K, Mouhari-Toure A, Balaka A, Agbo YM, Tatoa M, et al. Hookworm-related cutaneous larva migrans in dermatology departments in Lomé, Togo, between 2006 and 2011. Ann Dermatol Venereol. 2012;139:564-6.
  • 7
    Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med. 2007;14:326-33.
  • 8
    Bowman DD, Montgomery SP, Zajac AM, Eberhard ML, Kazacos KR. Hookworms of dogs and cats as agents of cutaneous larva migrans. Trends Parasitol. 2010;26:162-7.
  • 9
    Feldmeier H, Schuster A. Mini review: Hookworm-related cutaneous larva migrans. Eur J Clin Microbiol Infect Dis. 2012;31:915-8.
  • 10
    Lesshafft H, Schuster A, Reichert F, Talhari S, Ignatius R, Feldmeier H. Knowledge, attitudes, perceptions, and practices regarding cutaneous larva migrans in deprived communities in Manaus, Brazil. J Infect Dev Ctries. 2012;6:422-9.
  • Financial funding: None
  • How to cite this article: P Meotti CD, Plates G, Nogueira LLC, Silva RA, Paolini KS, Nunes EM, Bernardes Filho F. Cutaneous larva migrans on the scalp: unusual presentation in a typical clinical presentation. An Bras Dermatol. 2014;89(2):332-3.
  • *
    Work performed in a Private Clinic - Rio de Janeiro (RJ), Brazil.

Publication Dates

  • Publication in this collection
    Mar-Apr 2014

History

  • Received
    18 July 2013
  • Accepted
    02 Aug 2013
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