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The Journal of Emergency Medicine, Vol. 26, No. 3, pp. 347�349, 2004Copyright © 2004 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/04 $–see front matter

doi:10.1016/j.jemermed.2003.11.017

Visual Diagnosisin Emergency Medicine

SEVERE INFESTATION OF CUTANEOUS LARVA MIGRANS

Scott C. Sherman, MD and Natalie Radford, MD

Department of Emergency Medicine, Cook County Hospital, Chicago, IllinoisReprint Address: Scott C. Sherman, MD, Cook County Hospital, 1900 W Polk Ave., 10th floor, Chicago IL 60612

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CASE REPORT

27-year-old otherwise healthy man presented tomergency Department (ED) complaining of a rashis buttock and right leg. The rash appeared aftamping trip on the beach in Florida 3 weeks prior.tated the rash was intensely pruritic. The patient soreatment in a local hospital and was prescribed ceexin, steroids, and diphenhydramine, but despiteompliance with the medications, the rash did notrove.

Physical examination revealed an erythematousovering the patient’s right and left buttocks and exteng down to include the entire right leg (Figure 1). Aloser look revealed multiple excoriations and multerpiginous skin eruptions consistent with cutanearva migrans (Figure 2).

DISCUSSION

he creeping eruption of cutaneous larva migrans behen the epidermis of the host is penetrated byarasitic larvae of the dog or cat hookworm(1). Ancy-

ostoma braziliense is the most common cause in testern Hemisphere, but other species have bee

orted. Pruritic papules appear at the site of initial ination and remain until migration of the larva beginsbout day 4. The characteristic serpiginous skin erupan spread at a rate of a couple of millimeters t

ECEIVED: 27 August 2003; ACCEPTED: 5 November 2003

347

entimeters a day, but trails the current location ofarvae by 1–2 cm(2).

The larva form of the hookworm develops in soil aggs are released in the feces of infected animals. Sawarm, humid environment is the optimum location

arva to mature. Once mature, the filariform larvaeroteases to penetrate the skin through the hosts’

ollicles or intact skin. The most common site of peration is the feet. The longer the contact time, the mikely infestation is to occur(2). Our patient slept on theach for several nights and this most likely explainsxtensive disease.

Infestation is endemic in the southeastern Untates, Central and South America, and in other sub

cal areas. Florida is the most common state in the Untates for infestation to occur, but it has been repo

rom New Jersey to Texas.Cutaneous larva migrans tends to have a benign

hough rather uncomfortable, disease course. Resof the rash usually occurs with the death of the larvato 8 weeks, but persistent infestations up to 2 y

ave been reported(2). Superinfection secondarycratching and pneumonia with eosinophilia, Loffleyndrome, are the most common complications.

Treatment options include topical thiabendazoleension (500 mg/5 mL) or thiabendazole cream (1pplied to the rash b.i.d.-q.i.d. for 15 days. Treatm

ailures may occur if the organism depth is beyondenetration of the topical anti-helminthic agent. In sases, systemic therapy with albendazole (200 mg t

F

F

348 S. C. Sherman and N. Radford

igure 1. Multiple lesions of cutaneous larva migrans on the thigh.

igure 2. Serpiginous lesion of cutaneous larva migrans.

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3

Cutaneous Larva Migrans Infestation 349

day for 3 days), thiabendazole (1500 mg b.i.d. for 3ays) or ivermectin is highly effective. Albendazole andvermectin are better tolerated and more efficacious thanhiabendazole and, therefore, are the preferred agents. Aingle dose of ivermectin (12 mg) results in cure ratesetween 81% and 100% (3). Our patient was prescribed3-day course of oral albendazole secondary to the

xtensive nature of his disease and was scheduled to

ollow up with a dermatologist.

REFERENCES

. Davies HD, Sakuls P, Keystone JS. Creeping eruption. A review ofclinical presentation and management of 60 cases presenting to atropical disease unit. Arch Dermatol 1993;129:588–91.

. Richey TK, Gentry RH, Fitzpatrick JE, Morgan AM. Persistentcutaneous larva migrans due to Ancylostoma species. South Med J1996;89:609–11.

. Caumes E. Treatment of cutaneous larva migrans. Clin Infect Dis2000;30:811–4.