Imported gnathostomiasis manifesting as cutaneous larva migrans and Löffler’s syndrome

FederationofInfectionSocietiesAnnualConference1stDecember2017WilliamHamilton

Patient ML • 32yearoldmale• RashonleftfootstartedwhileonholidayinCambodia• Transientepisodeoffever+diarrhoeajustbeforerashstarted• Noothersystemicsymptoms• Normallyfitandwell

• Describethelesions

• Morehistory?

• Differential?

• Investigations?

• Treatment?

Day1:LeftUKKualaLumpurfor2days

PhnomPenhSiemReapfor~1week

KohRongfor~1week KualaLumpar

Day27:FirstseeninACU

Day22:returntoUK

NoticesLeftfootrash

2-dayacutediarrhoealillness

~Day24:Lfootrashisserpiginous

Detailedtravelhistory

Investigations

•  U&E–NAD•  FBC–NAD

•  WCC8.4

•  CRP–26.6

•  LaterIx:•  Entericpathogens–Nonedetected

•  NostoolsamplesentforOCPinitially

•  HIV,syphilis,CMV,EBV–Negative•  Alphavirus,flavivirus,phlebovirus,RickettsiaandLeptospira–Allnegative

• Urinedip–NAD• MalariaRDT–Negative

Cutaneous Larva Migrans: Lost worms ;_;

Zoonotichookworms:•  Ancylostomabraziliense•  Ancylostomacaninum

•  Soil/sandexposure•  Exposuretodogs&cats•  Tropicalclimate

Larva currens

• TransdermalmigrationofStrongyloidesstercoralis• Movesfast!• “Itwaspossibleactuallytoseeadvancementofthelesionwithinamatterof10minutes.Afteraperiodofhoursthelesionwouldceasemoving,onlytoresumemovementatanunpredictabletimethefollowingday”-Authuretal.,1958

TropicalHealthSolutions

• Dischargedhomewithsingledose200micrograms/Kgivermectin

• Butthen...

• Nightafterdischargehedevelopedfever,nightsweats,chestpain,cough,greensputum•  SawGPwhogaveacourseofantibiotics•  Leftfootlesionsresolved,buthedevelopedmultiplenewlesionsoverhisrightcalfandbehindhisknee,whichhedescribedasshiftingpositionsoverthecourseofasingleday

Rising eosinophilia •  Eosinophilcounts:

•  Day32: 0.7x109/L 8%•  Day35: 1.4x109/L 12.3%

•  Day74: 1.1x109/L 81.9%

Day32

Day48

Differential •  Larvacurrens(Strongyloides)• CLM+pulmonarymanifestations(unusual)• Viscerallarvamigrans•  Toxacariasis• Gnathostomiasis

•  Treatedempiricallywithtwomoreivermectindosestaken24hoursapart,plusaseven-daycourseofalbendazole400mgBD

Löffler’s syndrome •  Transientpulmonaryinfiltrates• Respiratorysymptoms• Peripheraleosinophilia

• AssociatedwithinvasiveanthrophilichelminthssuchasAscaris• Pulmonarymigrationphasesintheirlifecycles.

~1monthlater....ResultsfromBangkok:GnathostomaimmunoblotDETECTD

StradyC,etal.AmJTropMedHyg2009;80:33–5.KraivichianK,etal.AmJTropMedHyg2004;71:623–8.

~15%relapseratesdespitetreatmentRelapsesmainlycutaneous

Treatment

Key learning points

• Caseofanunusualconditionmasqueradingassomethingcommon• GnathostomiasiscancauseCLM-likecutaneousmanifestations+moretypicalmigratoryswellings•  Löffler’sSyndromeistriadofperipheraleosinophilia,respiratorysymptomsandtransientpulmonaryinfiltrates• Considergnathostomiasisinpatientswitheosinophilia,migratorycutaneouslesionsandtravelhistory•  Tendencytorelapsedespitetreatment

Acknowledgements • DrDanielAgranoff,ConsultantinInfectiousDiseases•  TomRoperandcolleaguesatBrightonandSussexLibraryandKnowledgeService• PhotographsbyMaytyraTrim,RoyalSussexCountyHospital,ClinicalPhotography.

•  Thankyouforlistening!• Questions?