Emerging imported parasitoses in Italy

ARTICLE

Auteur(s) : Clara RomanO¹, Giancarlo ALBANESE², Claudia GIANNI³

¹ Institute of Dermatological Sciences, University of Siena, Via Monte Santo, 3, 53100 Siena, Italy
² Dermatology Department, Mycology and Tropical Dermatology, S. Gerardo Hospital, Monza, Italy
³ Scientific Institute, San Raphael Hospital, Milan University, Italy

Article accepted 21/11/2003

Creeping eruption, tungiasis and myiasis are the most common dermatoses due to parasites and associated with travel to tropical countries. Creeping eruption manifests with linear or serpiginous tracks, tungiasis with nodular, often verrucoid lesions having a typical black pore through which the parasite breathes and expels feces and eggs, myiasis with a boil or nodular lesion, in the centre of which the tail of the larva can sometimes be seen. The number of cases of these imported parasitoses described in Europe has increased in the last few years [1-12], however lack of familiarity with these infections can delay their diagnosis and therapy. We report a retrospective study of 111 cases of imported parasitoses observed in Italy for which data on symptoms, lesion localization, incubation period and treatment was available.

Case reports

One hundred and eleven consecutive cases of parasite infection were diagnosed in the dermatology clinics of Milan, Siena and Monza in travellers in the period 1987-2001: specifically, 1987-1991, 17 cases (4 tungiasis, 2 myiasis, 11 creeping eruption); 1992-1996, 38 cases (7 tungiasis, 3 myiasis, 28 creeping eruption), 1997-2001 as many as 56 cases (11 tungiasis, 6 myiasis, 39 creeping eruption). In the same period 221 cases of non parasitic skin infections (pyoderma, cutaneous herpes simplex, cutaneous non tubercular Mycobacterium infections, sexually transmitted diseases, cutaneous fungal infections) were diagnosed in travellers. The patients with parasite infection were 73 males and 38 females, ranging in age from 18 to 65 years (mean age 37 years); 108 had been abroad as tourists and three for work. All responded to treatment and none required hospitalisation. Of the 22 patients with tungiasis, 18 had a single nodular verrucoid lesion on a foot and four had multiple lesions of the feet. The most frequent site was the periungual region (14 cases), followed by the sole (6 cases) and heel (2 cases). Medical history indicated stays in Africa or Brazil. When lesions were compressed, eggs, feces and internal organs of the parasite emerged and were examined under the microscope. The eggs were oval and mixed with pus. All patients recovered after removal of the flea by excision or curettage and cautery of the residual cavity. Sometimes the parasite was no longer present and only eggs were found.
Of the 11 subjects with furuncular myiasis, the scalp was affected in four and a limb in seven (a leg in five and an arm in two). The infection manifested as a weeping nodular lesion from which a larva protruded in some cases. Lesions were multiple in three cases and single in the other eight cases. All patients had been on trips to Africa or central America. Specimens of Dermatobia hominis were extracted in eight cases (Fig. 1) and Cordilobia anthropofaga in three. The lesions were treated with incision and removal of the larva, sometimes after occlusion with vaseline.
The 78 cases of creeping eruption manifested as itching tortuous tracks on the foot, leg, groin, abdomen, trunk or breast (Fig. 2), depending on the skin region that had been in contact with sand. The lesions extended to most of the body in eight cases (Table I). Four patients had extensive long-standing papular pyodermic lesions. The patients contracted the infection in central America (38 cases), Africa (14 cases), south America (13 cases) and Asia (13 cases). Three patients had been misdiagnosed with scabies. Twenty-one patients were treated with cryotherapy. Systemic therapy was used in generalised forms with multiple tracks. The three centres chose either albendazole or thiabendazole at doses suggested in the literature or by our experience [13, 14]. 45 patients were treated with oral albendazole 400 mg/day for three consecutive days and three with albendazole for five consecutive days, repeated for a further three days after an interval of a week. Albendazole was associated with cryotherapy in one case. No side effects were experienced during albendazole therapy. Seven patients were treated with thiabendazole alone at a dose of 25 mg/kg/day for 2 days and five of them experienced side-effects (nausea, diarrhoea, dizziness); in one case, the drug was combined with cryotherapy. The median time of onset of creeping eruption, after return from tropics, was 9 days (range 0-30 days). The median time of onset of cutaneous myiasis was 3 days (range 0-4 days). The lesions of tungiasis appeared while the patient was still abroad in half the cases. In 11 cases, the median interval between return and manifestation was 7 days (range 3-11 days).

Table I. Creeping eruption: lesion localization

Discussion

Tungiasis is caused by the sand flea Tunga penetrans, an arthropod widespread in warm sandy soil of tropical and subtropical deserts and beaches in central and southern America, Africa and central and eastern Asia where it represents a substantial public health problem for poor people who go barefoot [15]. The most frequent site of infection is the extremity of a toe. Tunga often causes tetanus, irritation and secondary infection which may manifest with lymphangitis, necrosis and gangrene [16]. Differential diagnosis is necessary with respect to tick bites, impetiginous warts, certain tropical ulcers and cutaneous myiasis.
Myiasis is caused by larvae of dipterans that may infest human body tissues, giving rise to nasopharyngeal, urinogenital and intestinal forms. Cutaneous forms include furuncular myiasis, the most frequent, wound myiasis and creeping eruption. Most cases of furuncular myiasis are caused by Cordilobia anthropophaga (widespread in Africa) and Dermatobia hominis (widespread in south America). Cordilobia infections involve soil or sand contaminated with mammal excreta. Exposed skin (face, limbs) is the most frequently affected part of the body. Myiasis should be differentiated from bacterial abscess or furuncle.
Cutaneous larva migrans is a skin disease that may occur in any part of the world, but is more frequent in warmer climates (sub-Saharian Africa, West Indies, Madagascar, SE Asia, southern USA). The disease is generally caused by nematode larvae (Ancylostoma caninum, brasiliens and ceylanicum), intestinal parasites of dogs, cats and other vertebrates which expel them with feces. Infection sites include hands, feet, buttocks, limbs and in general areas that have had contact with contaminated soil. Creeping eruption should be distinguished from scabies, eruption due to larva currens and erythema chronicum migrans of Lyme disease. With regard to therapy of the three parasitoses, surgical excision is the most appropriate for tungiasis and furuncular myiasis. A method for extracting larvae causing myiasis with a venom extractor was recently described [17]. Localised cases of creeping eruption can be treated with cryosurgery or with topical antihelminthic agents, such as thiabendazole solution [18, 19]. Systemic therapies based on benzoimidazoles, especially albendazole, are increasingly used [20, 21]. Oral albendazole is regarded by some as the most effective treatment, although there have been sporadic reports of non recovery or recurrence. The drug has fewer side-effects than thiabendazole [22]. Ivermectin, is also reported to be effective and well-tolerated [23].
Autochthonous cases of tungiasis and creeping eruption have been recently described. A life-saver at Forte dei Marmi, NE Tyrrhenian sea, who had never been to countries where tungiasis is endemic, presumably contracted the infection from sand of a beach frequented by barefoot African hawkers from endemic areas [8]. Similarly, autochthonous cases of creeping eruption have been reported from various European countries: France [24] Italy [25, 26] and Germany [27], suggesting that larva migrans may be contracted at all latitudes if climatic conditions favour its development. In the particularly hot summer of 1993, four cases were diagnosed from Berlin, Germany, in subjects who had not been to endemic areas and did not have contact with infected animals [27]. Among cutaneous parasitoses endemic to the tropics tungiasis, furuncular myiasis and creeping eruption are increasingly reported in Italy [21, 28-38], whereas strongyloidiasis remains rare [39]. To our knowledge no cases of these parasitoses had been reported in Milan, Siena or Monza before 1987. Half of the 111 patients described here were diagnosed in the last five years, suggesting that these diseases are emerging. This is the first retrospective study in Italy, all previous articles being case reports. The most frequent parasitosis in our series was creeping eruption with 78 cases. Three patients with creeping eruption had been misdiagnosed with scabies. No cases of tetanus or secondary infection were documented in patients with tungiasis. The incubation period of cutaneous larva migrans, tungiasis and myiasis was short. None of the parasitosis cases was autochtonous. All patients were cured. Prophylaxis of these parasitoses is difficult, requiring systematic elimination of dogs and cats from beaches, swimming pools and other places at risk, in endemic areas. Since larvae cannot be eradicated from endemic areas, the best prevention is to avoid direct contact with sand and soil. Travellers to tropical areas should be advised of the risk of acquiring these diseases. The considerable increase in the number of cases of myiasis, tungiasis and creeping eruption in Europe makes it worthwhile having detailed knowledge of these parasitoses that heal readily if treated correctly. n

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