Helminth in Cutaneous, Subcutaneous and E

Dr. Sitti Wahyuni, PhD

Parasitology Department, Medical Faculty
Hasanuddin University

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Case report: An itchy holiday

• A 33-year-old woman from the Netherlands developed an itchy rash on her trunk
and upper legs during her stay in Thailand
• On the first day of her holiday she had been lying on a sandy beach without a
towel.
• Not recall any insect bites or stings.
• Developed an increasing number of small papules of ± 3mm in which changed
colour from bluish to red and became increasingly itchy.
• No medical or dermatological history & not taking any medications.
• Her partner was unaffected.
• Treatment given by Thailand GP:
• amoxicillin/ clavulanic acid
• H1-receptor blocker
• No effect.

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 Visited Netherland GP Netherlands dermatologist
4 week later because of persisting • Lab: leucocyte count :15.2 x 109/l (4.3-10.0),
itchy abdominal and submammary eosinophils 44% (0-5%), Hb 8.3 mmol/l (7.5-
erythematous papules, with 10.0) , aspartate transaminase 43 IU/l (<31
purpuric lesions: IU/l), alanine aminotransferase (<31 IU/l) and
IgE titre 169 kU/l (<100 kU/l).
• Suspected scabies • Stool : No parasite Skin biopsy:
• Treated her with lindane • Eosinophilic infiltrates, no microorganisms.
• No success. • The follicular canal did not seem to be
affected.
• Interpreted: eosinophilic invasion of the skin
as the consequence of a hookworm infection
• Treated with mebendazole.
• 3-4 weeks later, skin lesions had not improved
• She complained severe itching

8/8/20 S. Wahyuni, Parasitology Dept, Medical Faculty, 4

Department of infectious diseases in the Netherlands
(3 months after onset)
• Physical examination: pink to red papular and pustular lesions,
mainly localized in the pubic region, trunk and breasts.
• No creeping dermatitis within these cutaneous lesions.
• Stool test: did not show hookworm.
• But suspected of hookworm folliculitis
• Treated with albendazole 1000 mg/day for 5 days.
• The pruritic lesions disappeared within 2 weeks.

8/8/20 S. Wahyuni, Parasitology Dept, Medical Faculty, 5

 Animal Ankylostoma

• A condition where animal

hookworm infect human • Predilection site
incidentally called cutaneous larva • Skin that come into contact with
migrant soil
• Parasite • Pathologic manifestation is caused
• Ancylostoma braziliense (Cat by larvae filariform invade human
hookworm) skin
• A. caninum (Dog hookworm)
• Host definitive
• Ancylostoma braziliense (Cat)
• A. caninum (Dog)
• Host definitive: Human

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 How to get infection? Life cycle
Survive 3-4 weeks
in favorable environmental conditions

5-10 days

• Larva filariform penetrate

into human skin
• Migrate between the
stratum germinativum & Hatch in 1-2 days.
stratum corneum.
• After 4,5 Several days, severely
itchy cutaneous lesions appear
 called creeping erruption.

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Adult morphology

Difficult to differentiate from other hookworms.

Males are smaller than females
Have three pairs teeth

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Clinical feature
• Persistent itching folliculitis in a
patient who has recently returned
from tropic.
• Histological confirmation is required
to make a definite diagnosis of a
hookworm folliculitis in the absence of
the characteristic
• 2-3 days the migratory larvae
produce an intracutaneous tunnel =
creeping eruption
• Self-limiting
• Treatment (if symptoms continue) :
• Local application of thiabendazole
• Systemic therapy : albendazole
or ivermectin
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Creeping eruption
• Narrow, linear, slightly elevated,
erythematous, serpiginous,
• Diameter 1-2 mm
• Move from a fraction an inch per day but
rarely pass beyond a few inches from the entry
• Vesicles form along the tunnels
• The surface is dry and crust
• The itching is intense especially at night
• The scratching may lead secondary infection
• May persist for weeks
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Creeping eruption

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 Kasus 5
• Seorang gadis 24 tahun dating ke puskesmas karena keluhan gatal di kaki yang dialami sejak
seminggu lalu. Pada pemeriksaan ditemukan garis garis merahseperti pada gambar Pasien
sudah meminum CTM tapi tetap gatal. Sebulan lalu pasien mendapatkan hadiah 1 ekor anjing
dari temannya karena ulang tahun. Tidak ada demam dan tidak ada riwayat alergi.
• Tugas
1. Penyakit apa saja yang bisa menyebabkan gatal pada tungkai seperti itu?
2. Sebutkan 5 pertanyaan yang harus ditanyakan pada pasien untuk memastikan adanya
larva migran
3. Bagaimana mekanisme terjadinya garis garis merah pada kasus diatas
4. Jelaskan pemeriksaan fisik khusus yang harus dilakukan
5. Jelaskan pemeriksaan penunjang yang diperlukan dan interpretasinya
6. Bagaimana penatalaksanaannya

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 Fast-flowing water, a typical breeding site for larvae of the blackfly

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• A 19-year-old Egyptian male living in Pittsburgh, USA. He complained 1 mo
irritation and watering of the right eye without any visual loss.
• He had received topical steroids for possible allergic conjunctivitis, which did not
resolve his irritation.
• He had traveled to New Delhi, India, and Siwa (an oasis in the West of Egypt)
more than a year prior to this presentation.
• He has never had any pets such as dogs and cats.
• Ophthalmologic examination: Subconjunctival nodule (1.5 cm × 1 cm) in the
medial aspect of the right eye. Retina and the posterior chamber normal
• Surgical exploration of the nodule under local anesthesia: 12 dead and living
worm fragments, each about 1 cm in length and 0.2 to 0.3 mm in thickness.

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• He had positive IgG4 for filariasis, no
eosinophilia, and no microfilaria
(blood smear).
• Histopathological: Adult female
Onchocerca sp was found
without microfilaria (mf) in the
uteri.
• R/ Ivermectin (100 mg/kg) once and
has had no further recurrence of his
symptoms after two years of follow
up

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 Onchocerca volvulus

• Disease:
• Pathologic manifestation caused by
• Onchocerciasis
• Adult worm: Subcutaneous nodule
• Onchocercosis and toxic product
• River blindness
• Microfilaria: Toxic product & allergy
• Host
• Predilection site
• Defenitive: human
• Adult: Subcutaneous
• Intermediate: Simulium (black
• Microfilaria: Typically reside in skin
flies)
but may be found in blood or urine
• S. damnosum and S. neavei in during heavy infections, or invade the
Africa eye and cause a condition known as
• S. ochraceum, S. callidum, S. river blindness
metallicum in Guatemala &
Mexico
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How to get infection?

Simulium (Black fly)

• Highlands area
• Along streams and river
• Eggs are laid in the water of
fast flowing rivers
• Adults emerge 8-12 days
• live for up to 4 weeks
• Can fly several hundred km
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Life cycle

May live 15
years,
Grow in 1
year

3000 mf/ day

for 9 years

Life span microfilaria

may reach 2 years
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Adult morphology

• Visible with naked eye

• White or cream transparent &
transverse striation in the cuticle
• Male: 19 to 42 mm by 130 to 210 µm
• Female: 33 to 50 mm in length and 270
to 400 µm in diameter, produce 1000-
3000 mf/day for 9 years
• Tightly coiled in couples in
subcutaneous tissues and in nodules
• Longevity of 10-15 years

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Microfilaria
• 220 to 360 µm by 5 to 9 µm
• Unsheathed The tail tapers to a point and
is often sharply bent
• Life span that may reach 2 years.
• live 7-10 days in flies

Taken from a skin nodule of a patient

stained with H&E.1000x oil magnification.

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Clinical feature

• Nodulus subcutaneous contains with

adult Onchocerca volvulus
• May appear in area exposure of
air & sunlight
• Size 5-25 mm in size
• Usually enclosed in loose folds of
skin
• Symptoms
• Skin rashes
• extreme itching
• Loss of skin elasticity, which can
make skin appear thin and brittle
• changes to skin pigmentation

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Clinical feature
• Microfilariae can migrate into the ocular
tissues
• Live microfilariae: Difficult to see in the cornea
& do not stimulate an inflammatory response.
• Dead microfilaria: causing small inflammatory
lesions which leave scars.
• The accumulation of small scars in the cornea
and the retina cause blindness.
• Manifests 7-9 years after initial infection
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Ocular symptoms
• First: photophobia, lacrimation, blepharospasm,
& sensation of a foreign body
• Early manifestations of serious
involvement: conjunctival hyperemia, iritis,
& small areas of corneal opacity
• Ocular pathology has been attributed to:
• Mechanical action and secretory products of the
living mf
• Toxins from dead mf
• Toxins from the adult worm
• Hypersensitiveness of the patient.
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2
Laboratory diagnosis
• Routine blood: Eosinophilia
• The parasite
• Adult: Biopsy skin nodules or remove the nodule Skin snips
• Microfilariae: Skin snips
• Should be thin enough, include the outer part of the dermal palpillae but
not so thick as to produce bleeding.
• Should be placed immediately in normal saline or distilled water, just
enough to cover the specimen.
• Microfilariae tend to emerge more rapidly in saline, however in either
medium the microfilariae typically emerge in 30-60 min and can be seen
in wet mount preparations.
• For a definitive diagnosis, allow the wet mount to dry, fix in methanol, and
stain with Giemsa or hematoxylin-and-eosin.

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Management

• Removal of sources of infection: by extirpation of nodulus

• Chemotherapy:
- Ivermectin to kill adult worm
- DEC for mf
- Doxycycline to kills Wolbachia
• Control of the vector
• Protection from simulium bite

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Kasus 6

• Seorang pria 35 tahan datang ke RS Unhas, dengan keluhan kulit bentol bentol
dan terasa gatal yang dialami sejak setahun yang lalu. Tidak ada keluhan demam,
Pernah bekerja di pertambangan di Afrika selama 10 tahun dan pulang dua bulan
yang lalu
• Tugas
1. Penyakit apa saja yang bisa menyebabkan kulitberbentol seperti itu
2. Sebutkan 5 pertanyaan yang harus ditanyakan pada pasien untuk
memastikan infeksi Onchocerca
3. Bagaimana mekanisme terjadinya bentol dikulit pada kasus diatas
4. Jelaskan pemeriksaan fisik khusus yang harus dilakukan
5. Jelaskan pemeriksaan penunjang yang diperlukan dan interpretasinya
6. Bagaimana penatalaksanaannya

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 Hello, is it me you looking for?
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• Disease:
• Loasis, African eye worm,
• Fugitive swellings/ calabar swellings
• Host
• Defenitive: human
• Intermediate: Chrysops
• Live in forest swamp land
• Breed in muddy streams &
swamps
• Attack the ankles, back of leg
and outer side of the hand
• Bite dark skins more than
whites
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Loa loa
• Pathologic manifestation caused by
• Adult worm has no serious damage to
the host
• Trouble when passing in front of the
eyeball or across the bridge of the nose
• Eye symptom: Irritation, congestion,
pain, and impaired vision
• Predilection site
• Adult: Subcutaneous
• Microfilaria: Typically reside in skin but
may be found in blood or urine during
heavy infections, or invade the eye and
cause a condition known as river
blindness
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Epidemiology

• Endemic in rain forest

Africa especially di Kongo
dan Sudan.
• Attack visitor/ tourist

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How to get infection?

Develop 2 molts
(10-12 days)

• Microfilaria is passed on to
humans through the become
repeated bites flies order adult
Diptera, Family Tabanidae), in 2 months may live for
>= 15
Genus Chrysops,
• Chrysops silacea (Austen)
• C. dimidiata (Wulp)
are forest canopy
dwellers.
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Adult morphology

• Visible with naked eye

• White or cream transparent
• Male: 30 to 34 mm in length and 0.35
to 0.43 mm in diameter
• Female: 40 to 70 mm in length and 0.5
mm
• The female produce microfilaria

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 Microfilaria

250 to 300 µm by 6 to 8 μm
Sheathed and have diurnal periodicity.
Can be found from spinal fluids, urine, and sputum.
During the day they are found in peripheral blood
During the noncirculation phase, they are found in the lungs.

Microfilaria of L. loa a thick blood smear

from a patient from Cameroon, stained
with Giemsa. Note the nuclei extending
to the tip of the tail to the left of the
image.

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Clinical feature

• Incubational period: vague symptoms

of slight fever, paresthesia, pruritus,
sometimes urticaria
• First signs: Calabar swellings or
appearance of the worm under
the conjunctiva
• Clinical symptoms attributable to
the wandering worm in conjunctiva

Fugitive or Calabar swellings

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• Temporary inflammatory reactions manifestations
• Only in Sspersensitiveness to the parasite or
its products
• Painless, nonpitting, subcutaneous swellings
• May reach the size of a hen's egg
• most frequently observed on the hands
• Appear spontaneously at irregular intervals
& disappear in 3 days
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Diagnosis

• Blood routine: Eosinophilia • Management

• Laboratory: • Remove the worm from eye
• Recovering the adult worms • Control of Chrysops with
from eyes larvicides
• Microfilariae in the blood • Elimination of carriers by
during the day treatment DEC
• Microfilariae detectable only in • Protection of persons from the
20-30% of patients flies by nets, screens, and
repellents.

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Kasus 7

• Seorang wanita 40 tahun tahun datang ke RS Unhas, dengan keluhan terasa ada
yang bergerak didalam matanya yang dirasakan sejak sebulan lalu. Tidak ada
gangguan penglihatan
• Tugas
1. Penyakit apa saja yang bisa menyebabkan gangguan pada mata seperti itu
2. Sebutkan 5 pertanyaan yang harus ditanyakan pada pasien untuk
memastikan infeksi Loa loa
3. Bagaimana mekanisme terdapatnya parasite dimata pada kasus diatas
4. Jelaskan pemeriksaan fisik khusus yang harus dilakukan
5. Jelaskan pemeriksaan penunjang yang diperlukan dan interpretasinya
6. Bagaimana penatalaksanaannya

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