Introduction

Cutaneous larva migrans (CLM), also having been termed for the clinical sign of creeping eruption, is an infectious syndrome caused by multiple types of hookworms. This is most commonly transmitted by animal feces depositing eggs in the soil, with larvae entering humans through direct contact with skin. Cutaneous larva migrans is distinguished from the cutaneous manifestation of Strongyloides stercoralis infection termed larva currens. The latter demonstrating fast movement through the skin. Other non-larval cutaneous migrations, including loiasis, scabies, or larva with dermal penetration, are also excluded from CLM.[1]

• This disease is classically seen in warmer climates, including the southeast United States. Latin America, Southeast Asia, and Africa.
• Symptomatology includes a progressive migrating serpiginous rash commonly with pruritus. While the disease can affect any exposed area, the most common location is the feet.
• The natural progression of the disease is self-limited as the organisms are unable to produce a collagenase to penetrate the basement membrane and reach the gastrointestinal (GI) tract to reproduce. When treatment is given, topical thiabendazole, oral albendazole, or ivermectin are the drugs of choice.
• Complications often arise from secondary bacterial superinfection or complications from inappropriate empiric therapy.[1], [2], [3]

Etiology

CLM is a clinical manifestation demonstrated by creeping migration of larva through the skin. Organisms include animal vector nematode hookworms Ancylostoma braziliense, Ancylostoma caninum, and Uncinaria stenocephala. Human hookworms Ancylostoma duodenale and Necator americanus also can cause disease.[4]

Epidemiology

Organisms responsible for the disease are most commonly found in tropical climates such as the southeastern United States, Latin America, the Caribbean, Southeast Asia, and Africa. The prevalence of the disease is often highest during wet seasons. Tourists traveling to endemic areas who are affected have been tended to be younger.[1][3]

Pathophysiology

Adult hookworms live in the intestines of dogs and cats. Eggs are shed in feces and after deposition into the soil hatch within one day. Over the course of the proceeding week, these develop into infective larvae. Worms respond to physical vibration and increased temperature and move in a snake-like fashion. Upon contacting a host organism, penetrate the corneal layer by secreting a hyaluronidase. Despite burrowing through the superficial cutaneous layers, they are unable to penetrate the basal membrane to enter lymphatics are, therefore, are unable to complete their lifecycle. Hookworms subsequently die without reproducing, and disease is self-limited.[1][2][4]

Histopathology

Biopsy of affected areas show the larvae in the epidermis or below surrounded by eosinophilic infiltrate. Spongiotic dermatitis with vesicles containing neutrophils and eosinophils may also be present.[2][5]

History and Physical

Patient history often involves travel to endemic areas and a history of walking barefoot. The most common initial finding is a small reddish papule that progresses to a serpiginous pruritic rash with a slow rate of progression from less than 1 to 2 cm per day. The initial presentation may vary depending on species. Disease from A. braziliense manifests within 1 hour, while papular lesions may take days to appear when U. stenocephala is the organism that infects a person. Vesiculobullous disease may occur as well, and papulopustular inflammation of the follicles has been documented, although this is not common.[2][6][7]

Evaluation

Diagnosis is usually made clinically based on the history of recent travel to endemic areas in combination with a classic serpiginous rash. The rash is very pruritic, raised, and has a slower rate of millimeters up to 2 cm per day. This distinguishes it from other migrating infections. Blood tests are not necessary for diagnosis. Not only is eosinophilia found in less than 40% of patients with CLM, but it is also not specific. Non-invasive optical coherence tomography has been used to establish the diagnosis, although this is not often used. Skin biopsy is occasionally performed and may reveal the nematode larvae within a circular canal. A biopsy is not sensitive, and while secondary changes and infiltrate assist in diagnosis, it is not necessary to confirm this clinical diagnosis.[2][5]

Differential Diagnosis

While the creeping eruption and clinical signs lead to a diagnosis in most cases, other organisms may be confused about this infective processes. Scabies, loiasis, myiasis, schistosomiasis, tinea corporis, and contact dermatitis may have some overlapping features. These are all easily differentiated by a lack of serpentine migration. The most similar disease is the migrating lesion of Strongyloides stercoralis, termed larva currens. This progressing serpiginous infection is differentiated by its rate of progression with intermittent movement and rates of several centimeters by the hour. Additionally, the pattern is haphazard, and disease more often occurs on the perianal skin, thighs, or the trunk. A human trematode, Fasciola gigantica, causes a disease called fascioliasis and is also in the differential. Non-infectious linear or serpiginous dermatoses include jellyfish stings, lichenoid eruptions, and phytophotodermatitis, which again are non-migratory. Creeping ingrown hair may present but is rare. [2][4][6]

Prognosis

The disease is often self-limited, and resolution without treatment is the rule rather than the exception. However, migration may continue for months, and during this time, pruritus may be severe, often interfering with sleep. Treatment, topical or systemic results in cure rates near 100%, and although recurrence can occur, it is also well prevented and responsive to systemic therapy.[3][6][7]

Complications

Complications include secondary infection, most commonly with Staphylococcus aureus and Streptococcal species. Secondary impetiginization occurs in up to 8% of cases. If the infection is prolonged post-streptococcal glomerulonephritis has been reported. Although it is well accepted that larvae cannot penetrate the basement membrane of skin, visceral disease has been rarely reported. Larvae have been identified in sputum, found in viscera of a human host, and also found in skeletal musculature. Host response to infection has rarely occurred as erythema multiforme. [9]

Enhancing Healthcare Team Outcomes

The interprofessional healthcare team, including clinicians, pharmacists, and nurses should work together to help educate the public on strategies to avoid this disease in endemic areas as well as the importance of following treatment guidelines. While the clinician directs the course of treatment, dermatology nurses provide education, monitor patients, and educate patients and their families. Pharmacists review medications, check for drug-drug interactions, and provide patient and family education. WIth an interprofessional team approach, these cases can achieve better outcomes. [Level 5]