A case of extensive cutaneous larva migrans: An unusual presentation

Dear Sir,

Cutaneous larva migrans (CLMs) are a parasitic dermatosis characterized by serpiginous, erythematous, and intensely pruritic tracts caused by the migration of hookworm larvae within the epidermis. The most commonly affected sites are the feet, buttocks, and abdomen due to frequent contact with contaminated soil or sand. Involvement of unusual sites, such as the trunk, is rare and sparsely reported. We present a case of CLM involving the back in a middle-aged woman.

A 56-year-old female farmer presented to the dermatology outpatient department with complaints of burning skin eruptions over the entire back for the past 5 days. The patient denied recent travel or exposure to beaches but reported frequent occupational contact with moist soil while farming. On examination, multiple erythematous and serpiginous tracts were observed over the back, suggestive of larval migration [Figures 1a and b]. There was no involvement of the feet or other classical sites. No history of any long-term intake of immunosuppressants was found. A clinical diagnosis of CLM with unusual truncal involvement was made. Routine tests (complete blood count, liver and renal function tests, stool and urine examination, and serum immunoglobulin E) were within normal limits. Serology for human immunodeficiency virus (I, II) and hepatitis C and B was found to be negative. Parasite-specific serological tests were not available in our setup and hence were not performed. The patient was treated with tablet albendazole 400 mg once daily for 5 days and oral antihistamines for symptomatic relief. On follow-up after 2 weeks, marked improvement was observed with resolution of lesions and pruritus [Figures 2a and b].

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Figure 1:

(a): Lesions at presentation. (b):Same patient after treatment with Albendazole.

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Figure 2:

(a) Lateral view at presentation. (b): Lateral view of same patient after treatment with Albendazole.

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CLM is most often caused by Ancylostoma braziliense, Ancylostoma caninum, and occasionally Strongyloides species. Other known causes include Fasciola hepatica, Dirofilaria repens, Spirometra spp., Uncinaria stenocephala, and Bunostomum phlebotomum. Subcutaneous granulomas with slow migration are associated with Dirofilaria and Spirometra. This disease is endemic in tropical and subtropical climates, where warmth, humidity, and poor sanitation facilitate larval survival. Transmission typically occurs through direct skin contact with contaminated soil, with larvae penetrating hair follicles or sweat gland ducts.^[1,2] While the feet, buttocks, and abdomen are the most commonly affected regions, involvement of the trunk is unusual and rarely documented. A literature review showed that only a total of 20 articles depicting 22 patients of extensive CLM have been published to date.^[3] This atypical presentation may be due to prolonged direct contact of the back with contaminated soil during agricultural work. The diagnosis of CLM is made primarily on clinical grounds, and biopsy is seldom needed.^[2] A close differential diagnosis is larva currens, which is caused by larvae of Strongyloides stercoralis and can be differentiated on the basis of the transient nature of the eruption and fast movement of the larva (5–15 cm/h) [Table 1]. Gnathostomiasis is characterized by chronicity, recurrent nature of eruptions at 2–6 weekly intervals, and the possibility of cerebral infestation, which can be fatal.^[2,4] Larva migrans can be managed effectively with ivermectin or albendazole. Thiabendazole (oral and topical) has been used in the past but is now seldom used due to an increased risk of toxicity and lesser efficacy compared to ivermectin or albendazole. Freezing of larval tips has been tried; however, this has a limited value or none at all as the worm larva is already beyond the end of the track by the time it is visible.^[5]

We report a rare case of CLM with extensive truncal involvement in a middle-aged farmer. Such cases with extensive involvement without any background of immunosuppression have been rarely reported from North India, and this report thus contributes to the existing literature. Awareness of such atypical presentations is crucial for timely diagnosis, especially in endemic regions, to prevent unnecessary investigations and ensure rapid relief with antihelminthic therapy.