Cutaneous Larva Cutaneous Larva Migrans and and Myiasis Myiasis Migrans Terry L Dwelle Dwelle MD MPHTM MD MPHTM Terry L 1 1
General General ► Cutaneous ► Cutaneous Larva Larva Migrans Migrans (Creeping Eruption) is a (Creeping Eruption) is a cutaneous eruption resulting from exposure of the eruption resulting from exposure of the cutaneous skin to infective filariform filariform larvae of non larvae of non- -human human skin to infective hookworms and Strongyloides Strongyloides. . hookworms and ► Occurs in most warm humid tropical and ► Occurs in most warm humid tropical and subtropical areas (eg eg South USA along the coasts, South USA along the coasts, subtropical areas ( coasts of West, South and East Africa, South- -East East coasts of West, South and East Africa, South Asia, India, Malaysia, Sri Lanka and Thialand Thialand Asia, India, Malaysia, Sri Lanka and 2
Etiology - - CLM CLM Etiology ► ► Hookworms - Hookworms - CLM CLM � Ankylostoma � Ankylostoma caninum caninum (dog) (dog) � Ankylostoma � Ankylostoma braziliense braziliense (dog, cat) (dog, cat) – – most common most common � Urcinaria � Urcinaria stenocephala stenocephala (European dogs) (European dogs) � Bunostoma � Bunostoma phlebotomun phlebotomun (cattle) (cattle) ► Strongyloides – – CLM CLM ► Strongyloides � S � S pyoncyonis pyoncyonis ( (racoon racoon) ) � � S S myoptami myoptami ( (nutrea nutrea) ) � � ? ? Pelodara Pelodara ► ► Gnathostoma spinergium spinergium (dog, cat) (dog, cat) Gnathostoma ► ► Others Others � Loa � Loa Loa Loa ( (Calabar Calabar swelling) swelling) � Fasciola � Fasciola hepatic ( hepatic (ectopic ectopic migration) migration) 3
Clinical - - CLM CLM Clinical ► ► There is no protective immunity from a prior infection There is no protective immunity from a prior infection ► ► Larvae generally wander under the skin for months before they Larvae generally wander under the skin for months before they eventually die eventually die ► Symptoms start immediately after penetration of the skin ► Symptoms start immediately after penetration of the skin ► Generally there is an erythmatous erythmatous papule at the entry site which often papule at the entry site which often ► Generally there is an becomes a vesicle becomes a vesicle ► ► The larvae generally move a few mm The larvae generally move a few mm – – cm cm’ ’s per day leaving tunnels s per day leaving tunnels that become dry and crusted that become dry and crusted ► ► The track can be linear but also twists and turns The track can be linear but also twists and turns ► ► Causes intense pruritus pruritus and may become secondarily infected and may become secondarily infected Causes intense ► ► Generally there is little flare surrounding the indurated indurated track track Generally there is little flare surrounding the ► ► Strongyloides pyocyonis pyocyonis and and myoptami myoptami clinically present as described. clinically present as described. Strongyloides Strongyloides stercoralis stercoralis causes tracks that are less defined, have a red causes tracks that are less defined, have a red Strongyloides flare, move more rapidly (10 cm per hour) and persist for only a few few flare, move more rapidly (10 cm per hour) and persist for only a hours. This is not called CLM but larva hours. This is not called CLM but larva currens currens. . 4
5 Late Early Larva
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Treatment Treatment Drug Adult dosage Pediatric dosage Drug Adult dosage Pediatric dosage Albendazole 400 mg daily X 3 400 mg daily X 3 Albendazole 400 mg daily X 3 400 mg daily X 3 (drug of choice) days days (drug of choice) days days Ivermectin (drug (drug 200 ug ug / kg daily / kg daily 200 ug ug / kg daily / kg daily Ivermectin 200 200 of choice) X 1- -2 days 2 days X 1- -2 days 2 days of choice) X 1 X 1 Thiabendazole Topically Topically Thiabendazole Topically Topically (alternate) (generally daily (generally daily (alternate) (generally daily (generally daily for 5 days) for 5 days) for 5 days) for 5 days) Medical Letter, August 2004, Drugs for Parasitic Infections. 7
Adverse Reactions Adverse Reactions Albendazole Albendazole Occasional: diarrhea, abdominal pain Occasional: diarrhea, abdominal pain Rare: leukopenia Rare: leukopenia, alopecia, increased , alopecia, increased serum transaminase transaminase levels levels serum Ivermectin Occasional: eczematous skin rash, Ivermectin Occasional: eczematous skin rash, conjunctivitis conjunctivitis Rare: hypotension Rare: hypotension Thiabendazole Frequent: Nausea, vomiting, vertigo Thiabendazole Frequent: Nausea, vomiting, vertigo Occasional: Leudopenia Occasional: Leudopenia, , crystalluria crystalluria, , rash, hallucinations, olfactory rash, hallucinations, olfactory disturbance, erythema erythema multiforme multiforme, , disturbance, Steven’ Steven ’s Johnson syndrome s Johnson syndrome Rare: Shock, tinnitus, intrahepatic Rare: Shock, tinnitus, intrahepatic cholestasis, convulsions, , convulsions, angioneurotic angioneurotic cholestasis edema edema 8
9 9 Myiasis Myiasis
Myiasis Myiasis Family Family Subfamily Subfamily Genus and Species Genus and Species Other Names Other Names Calliphoridae Calliphoridae Calliphorinae Calliphorinae Metallic group Metallic group Chrysomyia bezziana bezziana Old world screw worm Chrysomyia Old world screw worm Callitroga Callitroga hominivorax hominivorax New world screw worm New world screw worm Lucilia spp spp Green bottles Lucilia Green bottles Calliphora Blue bottles Calliphora Blue bottles Non – Non – metallic group metallic group Auchmeromyia luteola Auchmeromyia luteola Congo floor maggot Congo floor maggot Cordylobia anthropophaga anthropophaga Tumbu or mango fly or mango fly Cordylobia Tumbu Sarcophaginae Sarcophaginae Wohlfahrtia Wohlfahrtia spp spp Flesh fly Flesh fly Sarcophaga Sarcophaga Flesh fly Flesh fly Oestridae Dermatobia hominis hominis Human bot bot fly fly Oestridae Dermatobia Human Hypoderma spp spp Larva migrans migrans Hypoderma Larva Gastrophilus spp Gastrophilus spp Larva migrans Larva migrans 10
General - - Myiasis Myiasis General ► Myiasis ► Myiasis is caused when fly larvae invade is caused when fly larvae invade living tissues or when they are harbored in living tissues or when they are harbored in the intestine or bladder the intestine or bladder 11
Myiasis Myiasis ► There are 3 categories of ► There are 3 categories of myiasis myiasis producing producing flies flies � Obligatory � Obligatory – – Larvae must develop in living Larvae must develop in living tissues tissues � Facultative � Facultative – – Larvae usually develop on carrion Larvae usually develop on carrion but can invade wounds but can invade wounds � Accidental � Accidental – – Larvae or eggs are accidentally Larvae or eggs are accidentally ingested and are not killed in the intestine ingested and are not killed in the intestine 12
Myiasis Myiasis ► Maggots may attack 3 parts of the body ► Maggots may attack 3 parts of the body � Cutaneous � Cutaneous tissues tissues – – invade sores, wounds, invade sores, wounds, burrow in the skin, suck blood burrow in the skin, suck blood � Body cavities � Body cavities – – nose, mouth, ears, orbit, anus, nose, mouth, ears, orbit, anus, vagina vagina � Gastrointestinal lumen � Gastrointestinal lumen – – fly eggs / larvae pass fly eggs / larvae pass through the stomach and bowel and emerge in through the stomach and bowel and emerge in the stool the stool 13
Myiasis – – Nose and Ears Nose and Ears Myiasis � Nasal and ear � Nasal and ear myiasis myiasis is caused by is caused by Chrysomyia Chrysomyia, , Oestrus, , Rhinoestrus Rhinoestrus, and , and Callitroga Callitroga flies. The flies lay flies. The flies lay Oestrus eggs in the the the nasal cavity particularly where there is nasal cavity particularly where there is eggs in the chronic nasal discharge. The larvae burrow into tissues chronic nasal discharge. The larvae burrow into tissues even to the nasal bone within a few hours. Symptoms even to the nasal bone within a few hours. Symptoms include tickling, sneezing, pain and nasal obstruction include tickling, sneezing, pain and nasal obstruction followed by a purrulent purrulent fetid odor and discharge. Can fetid odor and discharge. Can followed by a lead to local destruction of bone and cartiledge cartiledge, and , and lead to local destruction of bone and even migrate to the brain. Mortality with Callitroga even migrate to the brain. Mortality with Callitroga hominivorax is 8%. Treatment is with a few drops of is 8%. Treatment is with a few drops of hominivorax 15% chloroform in light vegetable oil which causes 15% chloroform in light vegetable oil which causes them to emerge where they can be removed. Control – – them to emerge where they can be removed. Control large scale release of male flies sterilized by gamma large scale release of male flies sterilized by gamma radiation. radiation. 14
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