Cutaneous larva migrans contracted in England: a reminder

M. A. B. Roest and R. RatnavelDepartment of Dermatology, Stoke Mandeville, Aylesbury, UK

Summary We report a case of cutaneous larva migrans contracted in England. This case serves as

a reminder that the lack of travel abroad should not preclude the diagnosis. We discuss

clinical presentation and management of cutaneous larva migrans.

Report

Cutaneous larva migrans is a common condition in

tropical and subtropical areas but is rarely contracted in

temperate climates. The majority of cases seen in Britain

will have acquired the infestation abroad. The earliest

reported (and we assume endemic) case occurring in

London was documented in 1875.1 However cutaneous

larva migrans is not well recognized as an endemic

problem as we illustrate here. We highlight that the lack

of preceding travel abroad should not preclude the

diagnosis.

A 47-year-old painter and decorator presented with a

5-week history of a gradually enlarging intensely itchy

plaque on his right buttock in September 1999. This had

started with two small red papules which he had

attributed to insect bites whilst staying on a dairy farm

in Cornwall during which time he had also visited several

beaches in the area. He had not been abroad. His general

practitioner had treated him with a 7-day course of

erythromycin 250 mg four times per day orally followed

by 7 days of cephalexin 250 mg twice per day orally with

no improvement. His previous medical history included

an urticarial reaction with penicillin and hypertension

treated with atenolol 10 mg once per day orally.

Examination revealed a 10-cm erythematous indu-

rated exudative plaque on the right buttock extending

into the natal cleft and onto the saccral area (Fig. 1). A

number of serpiginous urticated tracks were seen at the

periphery of the lesion.

The differential diagnoses included tinea infection,

discoid eczema with secondary bacterial infection and

atypical herpes simplex infection; however, these did not

explain the serpiginous tracks at the periphery of the

lesion which were suggestive of cutaneous larva

migrans. The patient had not been abroad thereby

excluding the possibility of Strongyloides stercoralis

infection which through autoinfection typically affects

the perianal region.

Culture of skin swabs grew coliforms and skin flora.

Microscopy of skin scrapings and fungal culture were

negative. Herpes simplex virus culture of a wound swab

was negative. Full blood count revealed a mild

eosinophilia (total white cell count 5.9 � 109/L, eosi-

nophils 0.6 � 109/L). Urea and electrolytes, liver

function tests, glucose, erythrocyte sedimentation rate

and c-reactive protein were within the normal range.

Toxocara antibodies were initially positive (consistent

with previous infection) and subsequently borderline

2 months after successful treatment. Skin biopsy taken

at the advancing margins revealed an intraepidermal

blister with associated spongiosis and a marked under-

lying eosinophilic dermal infiltrate but no larvae.

The patient was initially treated for possible cattle

ringworm with oral itraconazole 200 mg once per day

for 14 days and 1 : 10 000 potassium permanganate

soaks applied topically with little improvement. On his

return, he was started on oral albendazole 400 mg once

per day for 1 week resulting in a marked decrease in

itching within 2 days and marked regression of the

burrows and plaque on completing the 7-day course. He

experienced no side-effects and his symptoms did not

recur following treatment. The rapid response to

q 2001 Blackwell Science Ltd X Clinical and Experimental Dermatology, 26, 389±390 389

Clinical dermatology X Concise report

Correspondence: M. A. B. Roest, Department of Dermatology, Amersham

Hospital, Whielden Street Amersham, Bucks HP7 OJD, UK.

Tel.: 144 1494 734600. Fax: 144 1494 734620.

E-mail: mroest@doctors.org.uk

Accepted for publication 10 January 2001

albendazole, an anti-helminth drug, supported the

diagnosis of cutaneous larva migrans.

Cutaneous larva migrans is caused by the infective

larva of dog and cat hookworms2 which occur world-

wide. The most common causative organisms are

Ankylostoma caninum and Ankylostoma braziliense,

respectively. Larvae found in faeces burrow through

skin in contact with contaminated sand or soil. Our

patient wore nonlined thin nylon swimming shorts

which presumably did not provide protection against

penetration as he denied visiting a naturist beach.

Humans are incidental hosts and most lesions will

resolve spontaneously after 1±3 months as the larvae

are unable to complete their life cycle. The diagnosis is

made clinically by the appearance of linear intensely

pruritic serpiginous lesions which delineate the route of

the migrating larva. Histology is often unhelpful as the

larva advances beyond the tip of the urticated track and

thus is often not seen in biopsy specimens. Sites

commonly affected are the feet, lower leg and buttocks

as well as hands, elbows, breasts and thighs.

The most effective treatment for cutaneous larva

migrans is albendazole 400 mg once per day orally for

3 days although reports of lack of cure or recurrence3,4

support a longer regime of 7 days5 as used in our case.

Cutaneous larva migrans also responds to oral ivermec-

tin6 and topical thiabendazole2 although the former

is available on a named-patient basis only and the latter

is difficult to obtain in the UK. Oral thiabendazole7 is

frequently associated with side-effects making it a less

popular choice. Cryosurgery is a painful alternative in

more limited disease and owing to the difficulty in

precisely locating the larva may be ineffective.

Cutaneous larva migrans has become increasingly

common in the UK as more British people travel to

tropical countries on holiday. Recent reports confirm

that this eruption can also rarely be contracted in

Northern European countries8,9 particularly during

warm weather. This makes it essential that practitioners

recognize the disease and treat it appropriately. The

large exudative plaque seen in our case was unusual

although the serpiginous tracks seen at the edge of the

lesion were fairly typical. Cutaneous larva migrans can

occur worldwide, but conditions are often unfavourable

for infection to occur in temperate climates.

References

1 Lee RJ. Case of creeping eruption. Trans Clin Soc Lond 1875;

viii:44±47.

2 Davies HD, Sakuls P, Keystone JS. Creeping eruption. A

review of clinical presentation and management of 60 cases

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3 Jones SK. Cutaneous larva migrans ± `recurrens'. Br J

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4 Sanguigni S, Marangi M, Teggi A, de Rosa F. Albendazole in

the therapy of cutaneous larva migrans. Trans R Soc Trop

Med Hyg 1990; 84: 831.

5 Veraldi S, Rizzitelli G. Effectiveness of a new therapeutic

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6 Van Den Enden E, Stevens A, Van Gompel A. Treatment of

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8 Zimmermann R, Combemale P, Piens MA, Dupin M, Le Coz

C. Cutaneous larva migrans, autochthonous in France.

Apropos of a case. Ann Dermatol Venereol 1995; 122: 711±

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9 Klose C, Mravak S, Geb M, Bienzle U, Meyer CG.

Autochthonous cutaneous larva migrans in Germany. Trop

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Figure 1 Large exudative plaque with serpiginous tracks at theperiphery.

Cutaneous larva migrans X M. A. B. Roest and R. Ratnavel

q 2001 Blackwell Science Ltd X Clinical and Experimental Dermatology, 26, 389±390390