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Journal of AgromedicinePublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t792303961

Cutaneous Larva Migrans in a Migrant Latino FarmworkerJennifer F. Condea; Steven R. Feldmanb; Quirina M. Vallejosc; Sara A. Quandtd; Lara E. Whalleyc; ThanhBrookse; Gonzalo Cabrale; Alan B. Fleischer Jr.b; Thomas A. Arcuryc

a Center for Dermatology Research, Wake Forest University School of Medicine, b Department ofDermatology, Wake Forest University School of Medicine, c Department of Family and CommunityMedicine, Wake Forest University School of Medicine, d Division of Public Health Sciences, WakeForest University School of Medicine, e Harvest Family Clinic, Carolina Family Health Centers, Inc.,USA

To cite this Article Conde, Jennifer F. , Feldman, Steven R. , Vallejos, Quirina M. , Quandt, Sara A. , Whalley, Lara E. ,Brooks, Thanh , Cabral, Gonzalo , Fleischer Jr., Alan B. and Arcury, Thomas A.(2007) 'Cutaneous Larva Migrans in aMigrant Latino Farmworker', Journal of Agromedicine, 12: 2, 45 — 48To link to this Article: DOI: 10.1300/J096v12n02_05URL: http://dx.doi.org/10.1300/J096v12n02_05

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REVIEWS, CASE HISTORIES

Cutaneous Larva Migransin a Migrant Latino Farmworker

Jennifer F. Conde, BASteven R. Feldman, MD, PhD

Quirina M. Vallejos, MPHSara A. Quandt, PhDLara E. Whalley, BAThanh Brooks, FNPGonzalo Cabral, MD

Alan B. Fleischer, Jr., MDThomas A. Arcury, PhD

ABSTRACT. Migrant farmworkers experience a high incidence of skin disease. This report pro-vides information on the case history of cutaneous larva migrans in a Latino migrant farmworker.Treatment options are reviewed, and information for prevention is discussed. doi:10.1300/J096v12n02_05[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mailaddress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2007 by TheHaworth Press, Inc. All rights reserved.]

KEYWORDS. Occupational skin disease, agromedicine, sanitation, Hispanic/Latino

Jennifer F. Conde is affiliated with the Center for Dermatology Research, Wake Forest University School ofMedicine.

Steven R. Feldman and Alan B. Fleischer, Jr. are affiliated with the Department of Dermatology, Wake ForestUniversity School of Medicine.

Quirina M. Vallejos, Lara E. Whalley, and Thomas A. Arcury are affiliated with the Department of Family andCommunity Medicine, Wake Forest University School of Medicine.

Sara A. Quandt is affiliated with the Division of Public Health Sciences, Wake Forest University School of Med-icine.

Thanh Brooks and Gonzalo Cabral are affiliated with Harvest Family Clinic, Carolina Family Health Centers,Inc.

Address correspondence to: Thomas A. Arcury, PhD, Department of Family and Community Medicine, WakeForest University School of Medicine, Winston-Salem, NC 27157-1084 (E-mail: tarcury@wfubmc.edu).

Grant sponsor: National Institute of Environmental Health Sciences R01 ES012358.

Journal of Agromedicine, Vol. 12(2) 2007Available online at http://ja.haworthpress.com

© 2007 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J096v12n02_05 45

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Cutaneous larva migrans (CLM) is a fre-quently encountered skin disease in tropicaland sub-tropical regions.1 This “creeping erup-tion,” first described in1874, has adistinctclin-ical presentation.2,3 Cases reported in theUnited States often occur among persons livingin coastal locations extending from New Jerseyto Texas, with Florida having the highest inci-dence.4 Physicians should be aware that thecondition is endemic in the Southeast U.S.While most reported cases of CLM involve ei-ther direct exposure to contaminated sand or toan infected domestic dog or cat,5 patients maybe exposed to contaminated soil throughfarmwork and may present to occupationalhealth workers.

CLM is caused by hookworms, intestinalparasites of domesticated animals. The larvalforms of the dog and cat hookworm (Ancylo-stoma braziliense) are the most common cul-pritscausingCLMintheU.S.3 Infectedanimalsshedeggsvia feces, andhumansbecometheac-cidental hosts by walking barefoot in contami-natedsoilor sand.1,5 The larva is capableofbur-rowing into the unbroken epidermis or throughhair follicles or sweat gland pores.5 The humanisadead-endhost for thelarva,as thelarvalacksenzymes needed to burrow through the base-ment membrane of the epidermis.3,4

An intensely pruritic and erythematous lin-ear or serpiginous creeping eruption developsat a rate of approximately 1 to 3 centimetersdaily as the larva migrates through the skin.3,4,6

These thread-like tracks are commonly slightlyraised and about 2 to 4 millimeters in width.4The distinct clinical presentation can becomeskewed if complicated by impetiginized, ec-zematous, vesiculobullous, or allergic pro-cesses.1-3 The typical eruption begins withinone to six days after exposure, although in rareinstances, larva may remain dormant for sev-eral months before migrating. The eruption isself-limited usually lasting no longer than eightweeks, except in rare instances where re-expo-sure is suspected.4

CASE

A 38-year-old Guatemalan male presentedto a clinic in North Carolina where migrant

farmworkers were seen as part of a clinicalinvestigation conducted to assess occupa-tion-related skin diseases. He reported that hehad worked in agriculture in the U.S. for eightyears. Data were collected both through de-tailed standard questionnaires and photo-graphs.Photographsweresentelectronicallytoa dermatologist at Wake Forest UniversitySchool of Medicine for consultationon diagno-sis and treatment.

The patient presented with a one week his-tory of an intensely pruritic rash on the dorsalsurface of the right foot (Figure 1). He deniedany pain or swelling. He described his pruritusas severe, but not limitinghis daily activities in-cluding cultivating and harvesting tobacco.There was a serpiginous eruption of the dorsalfoot and ankle. There were also scaly changesof the sole consistent with coexistent tinea in-fection.ThediagnosisofCLMwasmadeby theclinic staff and was confirmed by the dermatol-ogist.

The patient gave a history of occasionallyworking in the fields without shoes, althoughthe frequency of working barefooted was notobtained. No other person in the clinic popula-tion was identifiedwith CLM. The clinichealthcare provider prescribed mebendazole 200 mgtwice a day for four days. The patient did not re-turn to the clinic for a follow-up visit.

46 JOURNAL OF AGROMEDICINE

FIGURE 1. Erythematous, serpiginous eruption ondorsal right foot and ankle. Also evident is tineapedis infection which was treated as a separate en-tity (worker lived in a camp and shared a showerwith seven others).

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DISCUSSION

Themajorityof reportedcases of CLM in theU.S. are from the endemic areas of the South-east. The majority of imported cases are amongtravelers visiting Africa, Southeast Asia, theCaribbean, and Central and South America.3However, this entity can be misdiagnosed whenpersons do not present with a recent history oftravel.

It is possible that this patient contracted thislarva in the U.S. or in Guatemala prior to mi-grating to the U.S. The interview and skin examwere conducted in mid-August of 2006. Themajority of farmworkers come to North Caro-lina at the beginning of the agricultural season,in early June. A mean incubation period of 16days,7 and the patient being interviewed morethan a month into the agricultural season, makeGuatemalan origin of the infection less likely.Whether contracted here or in Latin America,patientswithCLMmaypresent toclinicworkersin the U.S.

Many workers in the Southeast U.S. havepotential exposure to contaminated soil andmay be susceptible to developing CLM, espe-cially if working without shoes. Most migrantfarmworkers do wear shoes while working.8However, a few farmworkers wear sandalswhile working. Longitudinal survey data col-lected from a sample of 304 migrant farm-workers in North Carolina during 2005 indi-cates that they did not wear closed-toe shoeswhile working about 1.5% of the time. More-over, many farmworkers wear sandals duringnon-work hours, andmigrant residentialcampsoften lack adequate sanitation.9,10 Farmworkersshould be encouraged to wear socks and shoesto protect their feet from contact with soil toavoid this parasitic infection while working.Efforts to improve sanitation of farmworkercamps should continue.

In this reported case, the clinical appearancewas typical of CLM, and the diagnosis was eas-ily made based on its distinct clinical presenta-tion. The most common site of presentation forCLM is the foot followed by the buttock, back,and thigh.6 Systemic signs such as peripheraleosinophilia and Loeffler’s pneumonitis can beassociated, but are rare. The differential diag-nosis for CLM among farmworkers may in-clude scabies, tinea, leishmaniasis, contactder-

matitis, erythema chronicum migrans, migra-tory myiasis, larva currens, gnathostomiasis,and loiasis.3,4 Treatments of choice include bothoraland topical thiabendazole,oralalbendazole,and oral ivermectin.5 Oral thiabendazole isdosed 25 to 50 mg/kg once or twice daily fortwo to five days. Alternately, it can be dosedweekly for a total of four doses, or can be givenin a 500 mg chewable tablet four times a day forfive days. Gastrointestinal intolerance is a sig-nificant limitation to its use. Topical thiabend-azole 10% cream is prepared by crushing a500mg tablet into five grams of a water solublecream.The topical treatment lacks the systemicside effects of thiabendazole, which includetransient dizziness, nausea, vomiting, and head-aches. The topical therapy should be applied tolesions three to four times daily for five days.Topical therapy is recommended when there isa single lesion, as use on multiple areas may beirritating to the skin. Recurrence rate may behigher for topical treatment. Oral albendazoleis dosed 400 to 800 mg daily for a course ofthree to five days.5 Albendazole’s side effectsinclude nausea, anorexia, headaches, and gas-trointestinaldisturbances.3 Both thiabendazoleand albendazole are teratogenic in animals,and, therefore, contraindicated during preg-nancy.3 Ivermectin usually has no adverse ef-fects when given as a single 12 mg dose and isefficacious in resolving CLM.5 These fourtreatment options are all extremely efficaciousand usually provide relief from pruritus withinseveral days.

Clinic outreach workers visiting farmworkercamps, particularly in the Southeast U.S., canidentifyCLMandprovideworkers treatmentaswell as information for the prevention of CLM.Prevention information should include wear-ing closed toed shoes or boots for work, a prac-tice that is important for the prevention ofgeneral occupational injury and exposure tooccupational toxicants. Farmworkers shouldalso be advised to wear closed shoes when out-doors at camps.

REFERENCES

1. Caumes E. Treatment of cutaneous larva migrans.Clin Infect Dis. 2000 May;30(5):811-4.

2. Caumes E, Danis M. From creeping eruption tohookworm-related cutaneous larva migrans. Lancet In-fect Dis. 2004 Nov;4(11):659-60.

Reviews, Case Histories 47

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3. Blackwell V, Vega-Lopez F. Cutaneous larvamigrans: clinical features and management of 44 casespresenting in the returning traveler. Br J Dermatol. 2001Sep;145(3):434-7.

4. Meinking TL, Burkhart CN, Burkhart CG.Changing paradigms in parasitic infections: commondermatological helminthic infections and cutaneousmyiasis. Clin Dermatol. 2003 Sep-Oct;21(5):407-16.

5. O’Quinn JC, Dushin R. Cutaneous larva migrans:case report with current recommendations for treatment.J Am Podiatr Med Assoc. 2005 May-Jun;95(3):291-4.

6. Malhotra SK, Raj RT, Pal M, Goyal V, Sethi S.Cutaneous larva migrans in an unusual site. DermatolOnline J. 2006 Feb 28;12(2):11.

7. Bouchaud O, Houze S, Schiemann R, Durand R,Ralaimazava P, Ruggeri C, Coulaud JP. Cutaneous larvamigrans in travelers: a prospective study, with assess-ment of therapy with ivermectin. Clin Infect Dis. 2000Aug;31(2):493-8.

8. Arcury TA, Quandt SA, Cravey AJ, Elmore RC,Russell GB. Farmworker reports of pesticide safety andsanitation in the work environment. Am J Ind Med. 2001May;39(5):487-98.

9. Holden C, George L, Smith A (Housing Assis-tance Council). No Refuge from the Fields: Findingsfrom a Survey of Farmworker Housing Conditions in theUnited States, September 2001; 69 pages. Available from:http://www.ruralhome.org/pubs/farmworker/norefuge/norefuge.pdf [cited 2007 Feb 23].

10. Early J, Davis SW, Quandt SA, Rao P, SnivelyBM, Arcury TA. Housing characteristics of farmworkerfamilies in North Carolina. J Immigr Minor Health.2006 Apr;8(2):173-84.

RECEIVED: 10/23/06REVISED: 12/11/06

ACCEPTED: 01/18/07

doi:10.1300/J096v12n02_05

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