Thorax 1985;40:76-77

Pulmonary eosinophilia associated with cutaneous larva migrans

RJA BUTLAND, IH COULSON

From the Department of Medicine I, St George's Hospital Medical School, and the Skin Department, StGeorge's Hospital, London

Transient pulmonary eosinophilia (synonyms Loeffler' ssyndrome, pulmonary infiltration with eosinophilia) wasobserved in a patient with cutaneous larva migrans(synonyms creeping eruption, plumber's itch), a rareassociation only previously reported from the UnitedStates.' 2

Case reportA 58 year old non-smoking caucasian woman noticed anitchy rash on her buttocks on 29 October 1983, two daysbefore returning to London from her holiday in Barbados.Her travelling companions were unaffected. On her returnsimilar lesions developed on her legs and abdomen. On 15November she noticed a cough, which was dry until 25November, when she produced a little white sputum.There was no wheeze, breathlessness, or haemoptysis. Shewas anorexic and lost 4*4 kg in weight. Bowel function wasnormal. Her medication consisted of atenolol 100 mg andchlorthalidone 25 mg daily for hypertension. There was nohistory of allergic conditions such as rhinitis, asthma, oreczema.On examination on 8 November she had at least 20

slightly raised, erythematous, serpiginous burrows typicalof cutaneous larva migrans on her abdomen, buttocks, andlegs (fig). Treatment with antipruritic drugs did not help

Characteristic serpiginous tract ofcutaneous larva migranson the patient's abdomen just below the umbilicus.

Address for reprint requests: Dr RJA Butland, Skin Department,St George's Hospital, London SW17 OQT.

Accepted 24 September 1984

but topical thiobendazole on 11 November led to a promptimprovement in the skin lesions. Ova, cysts, and parasiteswere not present in the stool. On 18 November, threeweeks after the rash had appeared, the white cell count was10-4 X 10-9/1 (4.6 X 10-9/l neutrophils and 3*0 x 10-'9/eosinophils) and a chest radiograph showed ill definedpatchy shadowing in the left upper and middlezones, consistent with an inflammatory process. The rightlung was clear. On 25 November the white cell count was14-3 x 10-9/l (10-5 x 10-9/l neutrophils and 1-1 x 10-9/leosinophils/l). On 9 December the chest radiographshowed only minimal consolidation persisting behind theleft first rib. The left mid zone consolidation had cleared.At this stage she was still coughing but the skin lesionswere healing. By January 1984 the rash had resolved, thechest radiograph was clear, and the serum IgE concentra-tion was normal and there was no blood eosinophilia.

Discussion

Cutaneous larva migrans is usually caused by the larvae ofthe nematode Ancylostoma braziliense, the dog or cathookworm. Dogs and cats contaminate the ground throughtheir faeces, which contain ova. These ova progress toactive filariform larvae, which penetrate human skin. Thelarvae appear unable in most cases to penetrate the dermisof human skin and they wander aimlessly in the lower por-tion of the epidermis for two to 50 weeks before they die.

Simple pulmonary eosinophilia (Loeffler's syndrome)has been associated with the following parasites: Ascaris,Trichuris, Trichiura, Strongyloides, Taenia saginata, Fas-ciola hepatica, Entamoeba histolytica, Trichinella,Brucella.' Wright and Gold's prospective study of cutane-ous larva migrans in 1946 found 26 cases of pulmonaryinfiltration among 76 cases of creeping eruption, withalmost complete absence of clinical signs or symptoms ofsystemic disease. Only 12% of patients experienced acough. There have only been two subsequent case reports,indicating the rarity of symptomatic pulmonary infiltration.The pathogenesis of the pulmonary infiltrates remains

unclear. Muhleisen found A braziliense larvae in thesputum of one patient with larva migrans for 24 days but,although he developed asthma and systemic eosinophilia,there were no pulmonary infiltrates.3 On the other hand,Wright and Gold examined 381 sputum specimens from 76patients with larva migrans (26 with pulmonaryeosinophilia) without identifying nematodal larvae. Ourpatient was unable to produce sputum for analysis. Thusthere is scant evidence that pulmonary infiltration is

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Pulmonary eosinophilia associated with cutaneous larva migrans

associated with the presence of larvae in the lungs (as hasbeen suggested with Ascaris lumbricoides). Possibly thehookworm in the skin led to a generalised sensitisation andreaction with soluble antigen in the lung produced theeosinophilic pulmonary infiltration. The resolution of thepulmonary shadows after the skin was treated withthiobendazole is consistent with this hypothesis.

Cutaneous larva migrans is a fairly common eruption intropical and subtropical areas. With increasing interna-tional travel it may be seen more frequently in Britain inthe future, and physicians should be aware of the pulmo-nary complications.

We are grateful to Professor KB Saunders and to Dr KVSanderson for permission to report the case and for read-

ing the manuscript, and to Mrs R Perry for typing themanuscript.

References

1 Wright DO, Gold EM. Loefflers syndrome associated withcreeping eruption (cutaneous helminthiasis). Arch Intern Med1 946;78:303-12.

2 Guill MA, Odon RB. Larva migrans complicated by Loeffler'ssyndrome. Arch Dermatol 1978; 114:1525-6.

3 Muhleisen JP. Demonstration of pulmonary migration of thecausative organism of creeping eruption. Ann Intern Med1953;38: 595-600.

Book noticesThe Lung: Radiologic-pathologic Correlations. 2nd ed. ERobert Heitzman. (Pp 546; £56.) C V Mosby Company.1984.

Because clinicians, radiologists, and pathologists diagnosepulmonary lesions in different ways, they frequently havedifficulty in communicating with each other. This book,now in its second edition, cuts across the specialties andeffectively bridges the gaps between them. The openingchapters deal with techniques for the preparation of lungspecimens, embryology, anatomy, developmentalanomalies, and radiological pattern recognition. These arefollowed by sections on circulatory, inflammatory, andneoplastic disorders. The last chapter covers pleural dis-ease. The text throughout is lucid, the illustrations are ofhigh quality, and each topic is followed by a comprehensivelist of references. Dr Hertzman states rather apologeticallythat it is not his intention to produce an all embracing atlasof correlated pulmonary pathology. Coincidentally he hassucceeded in doing so, although he goes much further thanthe standard bench books. His presentation is factual, butat the same time thought provoking and open ended,avoiding the dead hand of rigid classification. For thisreason The Lung will not suit candidates preparing formultiple choice examinations, nor those unfortunates pos-sessed of slot machine minds. It is, however, recommendedreading for anyone seeking a more flexible approach to thediagnosis of chest disease.-CWF

Immunopathologie Broncho-pulmonaire. 2nd ed. CMolina. (Pp 319; price not known.) Masson. 1984.

This French language text provides a comprehensivereview of manageable length of the immunological aspectsof a wide variety of lung disorders. After a preliminarysection which deals in general with hypersensitivityresponses, host defence mechanisms, and methods ofinvestigating these the remainder is subdivided into twosections. The first deals with immunological disorderswhere the brunt of the disease is borne by the parenchymaand the second section concentrates on asthma, with a finalchapter on pleural disorders. The style is difficult to assessin a foreign text but the pleasures of encountering "Lepoumon du Neffa" in the allergic alveolitis section makesthe effort worthwhile. The section on allergic alveolitis inparticular is extremely comprehensive but the chapters onpulmonary vasculitis, fibrosing alveolitis, and connectivetissue disorders are disappointingly slim. The illustrationsare, on the whole, adequate, with some splendid photomic-rographs, but the presentation of radiographs in the posi-tive form is unhelpful. There are several equally goodsources of pulmonary immunopathology in the Englishlanguage and this text will therefore have limited appeal tothose with a modest command of French. For those withthe time and the talent to struggle through it, however, itprovides an interesting insight into the cross-Channelapproach to an important aspect of pulmonary disease.-RMAB

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migrans.associated with cutaneous larva Pulmonary eosinophilia

R J Butland and I H Coulson

doi: 10.1136/thx.40.1.761985 40: 76-77 Thorax

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