Case presentation 1

CUTANEOUS LARVA MIGRANS Shinta dewi / Sawitri

BACKGROUND
Cutaneous Larva Migrans
• creeping verminous dermatitis, sandworm eruption, plumber’s itch, duck hunter’s itch

Most common cause
• animal hookworms (Ancylostoma braziliense, A. caninum, Uncinaria stenocephala,Bustonum phlebotonum)

Most common areas
• (Carribean, Africa, Central and South America, India, Southeast Asia)

BACKGROUND

Who is at risk

Barefoot beachcombers and sunbathers
Children in sandpits Farmers

Gardeners
Plumbers Hunters Electricians Carpenters Pest exterminators

Related Physical Findings: Wheezing, dry cough and urticaria

The eruption last between 2 and 8 weeks

Time from exposure to onset of symptoms usually 1 to 6 days

The most common anatomic sites is feet and buttocks

Skin changes is the most prominent findings

BACKGROUND
CLM
• condition in which larvae of any animal nematodes infect humans, and the infected human is a dead end host.

Creeping Eruption
• the clinical findings of a migratory serpiginous lesion.

Case Identity
• • • • • • • Name : Ms. Y Sex : Female Age : 45 y.o Occupation : housewife Address : Sidoarjo Reg No : 12198383 Outpatient clinic : 12 Agustus 2013

CHIEF COMPLAINT

Itchy red linear lesion at the left breast

• Itchy red linear lesion at the left breast since 5 days before she came to outpatient clinic • At first the lesion was small, like an acne then increase in length and became curvy • She never take oral or applied topical medication

• She loves gardening, history of last gardening 1 weeks ago, in which she never wore gloves • No history of having the same disease before • No history of family or surrounding people having the same disease as patient. • No history of having pet in her home

PHYSICAL EXAMINATION
VITAL SIGN BP 120/80, PR : 80, RR : 20, BT : 36.5 oC GENERAL STATUS  Compos mentis, look well  Head/Neck : anemia-, icterus-,cyanosis-,dyspnea Thorax : Cor and pulmo within normal limit  Abdomen : Soepel, liver and spleen not palpable  Extremity : Warm, no edema

DERMATOLOGICAL STATUS
12 August 2013

• Regio mamae sinistra : Curvy erythematous linear papule and pustule

ASSESSMENT

CUTANEOUS LARVA MIGRANS + SECUNDER INFECTION

Planning
DIAGNOSIS
•-

TERAPI
• Natrium Fusidat u.e for 4 days

Monitoring

• Patient complain • Progression of the lesion • Control to outpatient clinic

Education

• Do not manipulate the lesion • Wear protection, such as gloves, when come in contact with soil

23-08-13 12-08-13

16-08-13
02-09-13

12 August 2013
Subjective : -Itchy -Burn sensation -pustule

16 August 2013

FOLLOW UP
+ -

23 August 2013

10 Sept 2013

++ ++ +

++ + -

Objective: -Curvy erythematous linear papule -Scale -Erosion -Hiperpigmentation -Pustule
Theraphy

++

++

+

+ -

++ ++ + -Natrium Fusidat 2% Loratadin e 10 mg tab

++ -chlorethyl spray -Albendazole 1x1tab, 3 days -loratadine 10 mg tab

- Chlorethyl spray - Loratadin 10 mg tab

About CLM
• Cutaneous larva migrant is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis • most common hookworm species being A.braziliense n A.caninum. • Contact with sand or soil contaminated with animal feces is required for infection to occur.

• Larvae penetrate the human skin and migrate up to several cm a day, usually between stratum germinativum and stratum corneum. • Induces localized eosinophilic inflammatory reaction. • Cannot penetrate through basal membraneSelf limiting.

Differential Diagnose
• Scabies • Contact dermatitis • Dermatophytosis

CLINICAL MANIFESTATION
THEORY Subjective • itching • burning • Contact with contaminated sand or soil skin lesion 1-5 days after exposure • Movement up to several cm per day My patient • Subjective • Itching (+) • Burning (+) • Contact with Last soil, last7 days (+) • Increase in length (+)

Theory Physical examination • Erythematous, raised, vesicular, linear or serpentine cutaneous trail • Vesicular or bullous lesions at the site of penetration • predilection: buttocks, feet

My Patient Physical examination • Erythematous, raised, vesicular, linear +, serpentine cutaneous trail • Mamae sinistra

Diagnosis
* Clinical findings - Skin biopsy, skin scraping

Diagnosis * Clinical findings (+)

THEORY THERAPY - Albendazole 400mg p.o daily for 3 days - Ivermectin 200ug/kg daily for 1-2 days

My Patient

- Albendaxole 400 mg p.o daily for 3 days
- Chlorethyl spray along lesion

- Topical tiabendazole or albendazole 10%
- Chlorethyl spray along lesion - Surgical excision or cryotherapy not recommended

Histophatology
orthokeratosis, multiple intraepidermal bullae, spongiosis, dilated vascular channels, lymphocytic exocytosis, and numerous eosinophils

Mechanism of action Albendazole
1. Inhibit the polymerization of the parasite tubulin into microtubules • (There is a higher affinity of albendazole to the parasite tubulin, so the activity is mediated mainly againts the parasite rather than on the host) 2. Inhibition of the enzyme fumarate reductase which is helminth specific

MECHANISM OF ACTION INVERMECTINE
• Ivermectin kills the larval Onchocerca volvulus worms – microfilariae – that live in the subcutaneous tissue of an infected person. • Ivermectin does not kill the adult worms but suppresses the production of microfilariae by adult female worms for a few months following treatment, so reduces transmission, As the adult worms can continue to produce microfilariae until they die naturally

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