outbreak of cutaneous larva migrans in naples, southern italy

2
TRANSACTIONS OF THE ROYAL. SOCIETY OF TROPICAL MEDICINE AND HYGIENE (2002) 96,491-492 Outbreak of cutaneous larva migrans in Naples, southern Italy B. Galanti, F. M. Fusco and S. Nardiello Diparti- memo Assistenziale di Malattie Infettive, Seconda Univer- sit& di Napoli, Napoli, Italy Abstract An outbreak of cutaneous larva migrans occur- ring in Naples, southern Italy, and involving 6 people is described. The infection was contracted in the area of Naples, through contact with material for dried floral arrangements most prob- ably contaminated with dog or cat faeces. The factors that contributed to creating ideal condi- tions for the development and spread of this infection in this area are discussed. Keywords: creeping eruption, cutaneous larva mi- grans, Italy Cutaneous larva migrans (CLM) or ‘creeping erup- tion’ is caused by the presence in the stratum germinati- vum of nematodes (hookworms) in the larval stage. The most frequent causative agent is Ancylostoma brazi- liense, but A. caninum and Uncinaria stenocephala (dogs), A. ceylanicum (dogs, cats, other carnivores), Necator suillum (pigs) and Bunostomum phlebotomum (cattle) can also be the cause. A. duodenale and Necator americanus are more rarely implicated. CLM is frequent in warm humid tropical and subtropical regions, parti- cularly in Africa, south-east Asia, South America, the Caribbean, Mexico and Florida, and frequently in- volves those who come into close contact with the soil, such as farmers, children and tourists on beaches. In Europe CLM is seen mainly in travellers to endemic areas (BOUCHAUD et al., 2000). Autochthonous cases are rare and are almost always isolated (HERBENER & BORAK, 1988; ALBANESE et al., 1995; ZIMMERMANN et al., 1995) and multiple cases are exceptional (CLOSE et al., 1996). This can be accounted for by the fact that ideal conditions for the development and spread of the infection rarely occur in temperate areas. Here we describe an outbreak of CLM that occurred in Nanles (southern Italy) and involved 6 people. The outbieak showed peculiar epidemiological characteristics. On 3 November 2001 a 28-year-old woman (patient 1) presented with intensely pruritic skin lesions on the chest and left arm. On examination there were found to be 9 raised, sinuous tracks 4-10 cm long with papules at the starting point. There were also 4 roundish isolated papules of less than 1 cm in diameter, with the same features as the tracks. The patient reported that the lesions had appeared 4 d earlier and had advanced by l-2 cm a day. A diagnosis of CLM was made. She also reported that a 40-year-old friend of hers had complained of the same symptoms 7 d earlier. She also stated that 3 d before the onset of her symptoms her friend had given her an ornamental basket of dried flowers, bark and ears of corn that she had arranged herself. The friend (natient 2). examined bv us on 4 November, presente‘;l with si&ilar, but less intense, pruritic lesions on the abdomen and thighs. At presen- Address for correspondence: Prof. Bruno Galanti, Diparti- mento Assistenziale di Malattie Infettive, Seconda Universith di Napoli, c/o Ospedale Gesti e Maria, Via D. Cotugno 1, 80135 Napoli, Italy; phone and fax +39 081 5666215, e-mail [email protected] tation she reported that the intensely pruritic lesions had appeared 8 d earlier and had improved after apply- ing a cortisone ointment. She reported the purchase of materials used to make the ornamental basket arrange- ment from a florist on 25 October and that the materi- als had been collected in her presence from a shed where they had lain since August 2000. The shed was readily accessible to local stray cats and dogs, and the temperature and humidity were high. In addition, she recalled that one of the workers in the shop had numerous lesions on his arms and neck which had appeared a few days earlier and caused ‘unbearable’ itching. With the materials purchased from the florist she had made 2 ornamental arrangements and had given the other basket to another friend (patient 3) about a week later. Three days after receiving the gift, this friend, her husband (patient 4) and only daughter (patient 5) developed skin lesions. Five or 6 d after the appearance of the lesions they presented at our Institute with papules and raised pruritic tracks. The lesions (3 to 9 in number), which were already improving accord- ing to the patients, resolved spontaneously afier 9-12 d. Lastlv. a 20-vear-old friend of our first 2 patients. I< I --~, who had used the left-over material to make an oma- mental basket arrangement for herself, suffered skin lesions, which patients 1 and 2 reported as being similar to theirs. Unfortunately, we did not have the opportu- nity to examine her. None of the subjects infected had travelled to areas endemic for CLM in the past year. Only one of the subjects (patient 2) had 2 house cats, but parasitologi- cal tests carried out on the faeces of these animals moved negative. The subiects with CLM described here showevd symptoms w&in l-4 d after contact. The number of lesions varied from 3 to 10, probably in relation to the intensity of contact. The parts of the body infected were bare, except in the case of patient 2, for whom the larvae had reached the abdomen and thighs through jersey-knit leggings. The infection was self-limited and only patient 1 received anthelmintic therapy (albendazole 400 mg/d for 3 d) because of the persistent progression of the tracks and the increasing intensity of the itching. Two points make our report interesting: the means of infection and the high proportion of subjects in- fected. All the subjects infected had contact with the materials for the dried floral arrangements. Although we did not examine the material used, we can safely say this was the vehicle of infection; this is supported by the site of the skin lesions. Patient 2 had made the floral arrangements with the basket and materials on her lap. The others had the lesions on the chest and arms, i.e. the parts of the body in contact while handling and carrying. The materials used were most probably con- taminated with dog or cat faeces while stored in the shed; the incidence of infection with Ancylostoma (A. braziliense, A. caninum, A. ceylanicum) among stray cats and dogs in the Naples area is rather high. We think a cat is more likely to have been responsible, as Ancylosto- ma infection in the cat causes liquid diarrhoea with ample spreading of the faeces which is difficult to see on the contaminated material. The Ancylostoma eggs laid on the dried floral material found the ideal condi- tions for their hatching and release of filariform larvae. Numerous factors probably contributed to creating the ideal conditions for the development and spread of this infection in our area. The climatic conditions in the store-shed, protected against desiccation and direct sunlight, were extremely favourable to the development of the Ancylostoma larvae. Another favourable factor was the peculiarity of the vehicle: dried flowers, bark and ears of corn can readily irritate or scratch the skin and favour the penetration of the larvae. Lastly the rapid distribution of the baskets may have contributed to the spread of the infective agent and prevented it from dying out.

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Page 1: Outbreak of cutaneous larva migrans in Naples, southern Italy

TRANSACTIONS OF THE ROYAL. SOCIETY OF TROPICAL MEDICINE AND HYGIENE (2002) 96,491-492

Outbreak of cutaneous larva migrans in Naples, southern Italy

B. Galanti, F. M. Fusco and S. Nardiello Diparti- memo Assistenziale di Malattie Infettive, Seconda Univer- sit& di Napoli, Napoli, Italy

Abstract An outbreak of cutaneous larva migrans occur- ring in Naples, southern Italy, and involving 6 people is described. The infection was contracted in the area of Naples, through contact with material for dried floral arrangements most prob- ably contaminated with dog or cat faeces. The factors that contributed to creating ideal condi- tions for the development and spread of this infection in this area are discussed.

Keywords: creeping eruption, cutaneous larva mi- grans, Italy

Cutaneous larva migrans (CLM) or ‘creeping erup- tion’ is caused by the presence in the stratum germinati- vum of nematodes (hookworms) in the larval stage. The most frequent causative agent is Ancylostoma brazi- liense, but A. caninum and Uncinaria stenocephala (dogs), A. ceylanicum (dogs, cats, other carnivores), Necator suillum (pigs) and Bunostomum phlebotomum (cattle) can also be the cause. A. duodenale and Necator americanus are more rarely implicated. CLM is frequent in warm humid tropical and subtropical regions, parti- cularly in Africa, south-east Asia, South America, the Caribbean, Mexico and Florida, and frequently in- volves those who come into close contact with the soil, such as farmers, children and tourists on beaches. In Europe CLM is seen mainly in travellers to endemic areas (BOUCHAUD et al., 2000). Autochthonous cases are rare and are almost always isolated (HERBENER & BORAK, 1988; ALBANESE et al., 1995; ZIMMERMANN et al., 1995) and multiple cases are exceptional (CLOSE et al., 1996). This can be accounted for by the fact that ideal conditions for the development and spread of the infection rarely occur in temperate areas. Here we describe an outbreak of CLM that occurred in Nanles (southern Italy) and involved 6 people. The outbieak showed peculiar epidemiological characteristics.

On 3 November 2001 a 28-year-old woman (patient 1) presented with intensely pruritic skin lesions on the chest and left arm. On examination there were found to be 9 raised, sinuous tracks 4-10 cm long with papules at the starting point. There were also 4 roundish isolated papules of less than 1 cm in diameter, with the same features as the tracks. The patient reported that the lesions had appeared 4 d earlier and had advanced by l-2 cm a day. A diagnosis of CLM was made. She also reported that a 40-year-old friend of hers had complained of the same symptoms 7 d earlier. She also stated that 3 d before the onset of her symptoms her friend had given her an ornamental basket of dried flowers, bark and ears of corn that she had arranged herself. The friend (natient 2). examined bv us on 4 November, presente‘;l with si&ilar, but less intense, pruritic lesions on the abdomen and thighs. At presen-

Address for correspondence: Prof. Bruno Galanti, Diparti- mento Assistenziale di Malattie Infettive, Seconda Universith di Napoli, c/o Ospedale Gesti e Maria, Via D. Cotugno 1, 80135 Napoli, Italy; phone and fax +39 081 5666215, e-mail [email protected]

tation she reported that the intensely pruritic lesions had appeared 8 d earlier and had improved after apply- ing a cortisone ointment. She reported the purchase of materials used to make the ornamental basket arrange- ment from a florist on 25 October and that the materi- als had been collected in her presence from a shed where they had lain since August 2000. The shed was readily accessible to local stray cats and dogs, and the temperature and humidity were high. In addition, she recalled that one of the workers in the shop had numerous lesions on his arms and neck which had appeared a few days earlier and caused ‘unbearable’ itching. With the materials purchased from the florist she had made 2 ornamental arrangements and had given the other basket to another friend (patient 3) about a week later. Three days after receiving the gift, this friend, her husband (patient 4) and only daughter (patient 5) developed skin lesions. Five or 6 d after the appearance of the lesions they presented at our Institute with papules and raised pruritic tracks. The lesions (3 to 9 in number), which were already improving accord- ing to the patients, resolved spontaneously afier 9-12 d. Lastlv. a 20-vear-old friend of our first 2 patients.

I< I --~,

who had used the left-over material to make an oma- mental basket arrangement for herself, suffered skin lesions, which patients 1 and 2 reported as being similar to theirs. Unfortunately, we did not have the opportu- nity to examine her.

None of the subjects infected had travelled to areas endemic for CLM in the past year. Only one of the subjects (patient 2) had 2 house cats, but parasitologi- cal tests carried out on the faeces of these animals moved negative. The subiects with CLM described here showevd symptoms w&in l-4 d after contact. The number of lesions varied from 3 to 10, probably in relation to the intensity of contact. The parts of the body infected were bare, except in the case of patient 2, for whom the larvae had reached the abdomen and thighs through jersey-knit leggings. The infection was self-limited and only patient 1 received anthelmintic therapy (albendazole 400 mg/d for 3 d) because of the persistent progression of the tracks and the increasing intensity of the itching.

Two points make our report interesting: the means of infection and the high proportion of subjects in- fected. All the subjects infected had contact with the materials for the dried floral arrangements. Although we did not examine the material used, we can safely say this was the vehicle of infection; this is supported by the site of the skin lesions. Patient 2 had made the floral arrangements with the basket and materials on her lap. The others had the lesions on the chest and arms, i.e. the parts of the body in contact while handling and carrying. The materials used were most probably con- taminated with dog or cat faeces while stored in the shed; the incidence of infection with Ancylostoma (A. braziliense, A. caninum, A. ceylanicum) among stray cats and dogs in the Naples area is rather high. We think a cat is more likely to have been responsible, as Ancylosto- ma infection in the cat causes liquid diarrhoea with ample spreading of the faeces which is difficult to see on the contaminated material. The Ancylostoma eggs laid on the dried floral material found the ideal condi- tions for their hatching and release of filariform larvae. Numerous factors probably contributed to creating the ideal conditions for the development and spread of this infection in our area. The climatic conditions in the store-shed, protected against desiccation and direct sunlight, were extremely favourable to the development of the Ancylostoma larvae. Another favourable factor was the peculiarity of the vehicle: dried flowers, bark and ears of corn can readily irritate or scratch the skin and favour the penetration of the larvae. Lastly the rapid distribution of the baskets may have contributed to the spread of the infective agent and prevented it from dying out.

Page 2: Outbreak of cutaneous larva migrans in Naples, southern Italy

492 B. GALANTI ETAL.

References Albanese, G., Di Cintio, R., Beneggi, M., Crippa, D., Galbia-

ti, G., Nicoletti, A., Rossi, E. & Sala, G. (1995). Larva migrans in Italy. International Journal of Dermatology, 34, 464-465.

Bouchaud, O., Houze, S., Schiemann, R., Durand, R., Ralai- mazava, I’., Ruggieri, C. & Coulaud, J. P. (2000). Cuta- neous larva migrans in travellers: a prospective study, with assessment of therapy with ivermectin. Clinical Infectious Diseases, 31, 493-498.

Klose, C., Mravak, S., Geb, M., Bienzle, U. & Meyer, C. G. (1996). Autochthonous cutaneous larva migrans in Ger- many. Tropical Medicine and International Health, 1, 503- 504.

Zimmermann, R., Combemale, P., Piens, M. A., Dupin, M. & Le Coz, C. (1995). Larva migrans cutanee autochtone en France. Annales de Dermatologie et Venereologiq 122, 71 l- 714.

Herbener, D. & Borak, J. (1988). Cutaneous larva migrans in northern climates. American Journal of Emergency Medicine, 6,462-464.

Received 25 April 2002; accepted for publication 24 May 2002

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