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Cutaneous larval migrans

SRU
2011
Life Cycle (cutaneous larval migrans):
• Cutaneous larval migrans (also known as creeping
eruption) is a zoonotic infection with hookworm
species that do not use humans as a definitive host, the
most common being A. braziliense and A. caninum.
• Humans may also become infected when filariform
larvae penetrate the skin . With most species, the
larvae cannot mature further in the human host, and
migrate aimlessly within the epidermis, sometimes as
much as several centimeters a day. Some larvae may
persist in deeper tissue after finishing their skin
migration.
Life cycle in the definitive host
• The normal definitive hosts for these species are
dogs and cats. The cycle in the definitive host is
very similar to the cycle for the human species.
• Eggs are passed in the stool , and under favorable
conditions (moisture, warmth, shade), larvae
hatch in 1 to 2 days. The released rhabditiform
larvae grow in the feces and/or the soil , and after
5 to 10 days (and two molts) they become
filariform (third-stage) larvae that are infective .
• These infective larvae can survive 3 to 4 weeks in
favorable environmental conditions. On contact with
the animal host , the larvae penetrate the skin and are
carried through the blood vessels to the heart and then
to the lungs. They penetrate into the pulmonary
alveoli, ascend the bronchial tree to the pharynx, and
are swallowed. The larvae reach the small intestine,
where they reside and mature into adults.
• Adult worms live in the lumen of the small intestine,
where they attach to the intestinal wall. Some larvae
become arrested in the tissues, and serve as source of
infection for pups via transmammary (and possibly
transplacental) routes .
Geographic Distribution:
• Hookworm is the second most common
human helminthic infection (after
ascariasis). Hookworm species are worldwide
in distribution, mostly in areas with moist,
warm climate. Both N. americanus and A.
duodenale are found in Africa, Asia and the
Americas. Necator americanus predominates
in the Americas and Australia, while only A.
duodenale is found in the Middle East, North
Africa and southern Europe.
Ancylostoma caninum Ancylostoma sp
Hookworm eggs
Hookworm eggs in unstained
wet mounts
• The eggs of Ancylostoma
and Necator cannot be
differentiated
microscopically.
• The eggs are thin-shelled,
colorless and measure 60-
75 µm by 35-40 µm.
Hookworm larvae
Hookworm rhabditiform larva
(wet preparation).
• They have a long buccal canal
and an inconspicuous genital
primordium. Rhabditiform
larvae are usually not found in
stool, but may be found there
is a delay in processing the
stool specimen.
• If larvae are seen in stool,
they must be differentiated
from the L1 larvae of
Stronyloides stercoralis.
Hookworm larvae
Filariform (L3) hookworm larvae.
• Infective, third-stage (L3),
filariform larvae are 500-
600 µm long.
• They have a pointed tail
and a striated
sheath. These L3 are found
in the environment and
infect the human (animal)
host by penetration of the
skin.
Laboratory Studies

• Diagnosis of cutaneous larva migrans (CLM) is


based on physical examination and history.
• Skin biopsy is not usually helpful because the
larvae are usually located several centimeters
from the edge of the track.
• A peripheral eosinophilia may be observed.5
• Imaging Studies
• A new technique, optical coherence tomography,
has been found to identify the larvae in the
epidermis, allowing direct removal.6
Other Problems to Be Considered

• Dermatophytosis
• Erythema chronicum migrans of Lyme disease
• Ground itch
• Larva currens
• Migratory myiasis
• Phytophotodermatitis
• Stings by the Portuguese man-of-war or
jellyfish
Medical Care

• Treatment of cutaneous larva migrans (CLM) is


anthelminthics, with pruritus resolving within
24-72 hours and serpiginous tracts resolving
within 7-10 days.
• Antihistamines and topical corticosteroids can
be used in conjunction with anthelminthics for
symptomatic relief of pruritus.
• Oral antibiotics are used if secondary
impetiginization or cellulitis is present.
Surgical Care

• Prior to the availability of anthelminthics,


treatment by cryosurgery with liquid nitrogen,
ethyl chloride spray, or carbon dioxide slush was
effective in 60-70% of individuals with CLM.
• Cryosurgery is painful and often requires multiple
treatments. Cryosurgery at the leading edge of
the track was imprecise because the migrating
larvae are usually located several centimeters
beyond this point.
Consultations

• Consultation with a dermatologist, infectious


diseases specialist, or both may be
appropriate.
Medication

• Anthelmintics
• Anthelmintics are the drug of choice for
cutaneous larva migrans (CLM). Parasite
biochemical pathways are different from the
human host; thus, toxicity is directed to the
parasite, egg, or larvae. Mechanism of action
varies within the drug class. Antiparasitic
actions may include the following:
• Inhibition of microtubules causes irreversible
block of glucose uptake
• Tubulin polymerization inhibition
• Depolarizing neuromuscular blockade
• Cholinesterase inhibition
• Increased cell membrane permeability, resulting
in intracellular calcium loss
• Vacuolization of the schistosome tegument
• Increased cell membrane permeability to chloride
ions via chloride channels alteration
Ivermectin (Stromectol)

• Broad-spectrum anthelmintic that is not FDA


approved for the treatment of CLM but is
suggested as DOC by many studies. Single-dose
therapy makes this drug convenient. Available in
the United States because of FDA approval for
treatment of onchocerciasis and strongyloidiasis.
Selectively binds with glutamate-gated chloride
ion channels in invertebrate nerve and muscle
cells, causing cell death. Half-life is 16 h;
metabolized in liver. Available in 3 mg tabs.
Adult

• 0.2 mg/kg PO as a single dose


Typical weight-based doses (administer PO
once as a single dose)
46-60 kg: 12 mg
61-75 kg: 15 mg
76-90 kg: 18 mg
91-105 kg: 21 mg
106-120 kg: 24 mg
Pediatric

• Administer PO once as a single dose


≤ 15 kg: 3 mg
16-30 kg: 6 mg
31-45 kg: 9 mg
Interactions
• May interact with other ligand-gated chloride
channels (eg, those gated by GABA)
Precautions

Pregnancy
• C - Fetal risk revealed in studies in animals but
not established or not studied in humans; may
use if benefits outweigh risk to fetus
• Treat mothers who intend to breastfeed only
when risk of delayed treatment outweighs
possible risks to newborn caused by ivermectin
excretion in milk; may cause nausea, vomiting,
mild CNS depression, and drowsiness
Sumber
• Pediatric Cutaneous Larva Migrans: Treatment & Medication
• Author: Robert W Tolan Jr, MD, Chief, Division of Allergy,
Immunology and Infectious Diseases, The Children's Hospital at
Saint Peter's University Hospital; Clinical Associate Professor of
Pediatrics, Drexel University College of Medicine
Coauthor(s): Jining Wang, MD, Department of Dermatology, Dean
Health System; Kim Wang, MD, Staff Physician, Department of
Pathology, Northwestern University Medical School
Contributor Information and Disclosures
• Updated: Jan 20, 2011
• http://www.dpd.cdc.gov/dpdx/HTML/Cases.htm

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