Cutaneous Larva Migrans

Background

This skin rash is a manifestation of parasites migrating through the skin, predominately within the spinous layer of the epidermis or follicular infundibula. Hookworms are the most common parasite. The classic clinical presentation are serpiginous winding lesions with intense itching. Any area of skin which has had contact with the ground is at risk, including the hands, feet, buttocks, and knees. The hookworm larvae advance about a few millimeters to centimeters a day.

EPIDEMIOLOGY CHARACTERIZATION

GEOGRAPHY
Especially in areas withere hookworms are prevalent
Some 96% of dogs in Uruguay are infected by hookworms

DISEASE ASSOCIATIONS CHARACTERIZATION

Loffler syndrome
(Pulmomary eosinophilia) May accompany the cutaneous eruption

PATHOGENESIS CHARACTERIZATION

Most common cause are hookworms Int J Dermatol 1995;34:464-465
Ancylostoma braziliense and A. caninum

HISTOLOGICAL TYPES CHARACTERIZATION

General
Limited use since the larva have already moved from the site of the biopsy.
Usually a spongiotic dermatitis with involvment of the follicular infundibula with eosinophils, neutrophils, and mononuclear cells

Papillary dermis may be edematous

A burrow may be seen in the epidermis

VARIANTS

Eosinophilic Granuloma of the Liver A Characteristic Lesion With Relationship to Visceral Larva Migrans

Keith J. Kaplan, M.D.; Zachary D. Goodman, M.D., Ph.D.; Kamal G. Ishak, M.D., Ph.D.

From the Department of Pathology, Walter Reed Army Medical Center (K.J.K.) and the Department of Hepatic and Gastrointestinal Pathology (Z.D.G., K.G.I.), and the Veterans Administration Special Reference Laboratory for Pathology (Z.D.G.), Washington, DC, U.S.A.

Am J Surg Pathol 2001;25:1316-1321 Abstract quote

Children with the clinical syndrome of visceral larva migrans as a result of Toxocara species have typical lesions in the liver and other viscera, consisting of palisading granulomas that contain numerous eosinophils and often Charcot–Leyden crystals; recognizable parasites are uncommon. Similar eosinophilic granulomas that are found incidentally in adults often cause diagnostic problems.

To define better the clinical, laboratory, and pathologic features of these lesions, we reviewed 43 cases of hepatic eosinophilic granuloma (excluding cases of Langerhans' cell histiocytosis) collected in the files of the AFIP over a period of 31 years. The eosinophilic granulomas were found in patients of all ages (range 12 months to 77 years); 30% were younger than 20 years. There were 26 male and 17 female patients. Most patients (26 of 43; 60%) were asymptomatic, and the lesions were discovered incidentally. Others had fever (20%) or abdominal pain (20%). The granulomas were typically multiple (61%), with central necrosis surrounded by a mixed inflammatory infiltrate with numerous eosinophils and variable numbers of neutrophils, lymphocytes, and a palisade of epithelioid histiocytes and/or giant cells. Charcot–Leyden crystals were present in 19 cases (44%). Remnants of parasites (eight Toxocara sp., two Capillaria sp.) were identified in the tissue in 10 patients. There was a positive serologic test for Toxocara sp. in five additional cases. Immunohistochemical staining using polyclonal antiserum against Toxocara canis larvae demonstrated positivity in macrophages in eight of 13 cases tested.

We conclude that identification of an eosinophilic granuloma in the liver should suggest the diagnosis of visceral larva migrans and prompt a search for the causative organism with serial sectioning of the block and serologic tests for Toxocara and other causative parasites.

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

GANGLION CYST

Serpiginous ganglion cyst of the foot mimicking cutaneous larva migrans.

Friedli A, Saurat JH, Harms M.

Department of Dermatology, Geneva University Hospital.
J Am Acad Dermatol 2002 Nov;47(5 Suppl):S266-7 Abstract quote
A patient had a serpiginous lesion on the foot that turned out to be a ganglion cyst. This lesion is more common on the hands. On the lower extremity, ganglion cysts tend to have a misleading clinical appearance.

Histologic examination shows pseudocysts formed by mucoid degeneration of collagen structures. The pathogenesis is unclear. Many ganglions are asymptomatic, but pain occurs in 50% of cases. Management of symptomatic lesions is surgical excision. Recurrence is possible.

PROGNOSIS AND TREATMENT CHARACTERIZATION

Prognostic Factors Most cases are self limited lasting 1-6 months though rare cases may last for a year or longer

Treatment Int J Dermatol 1997;36:700-703
Oral Albendazole (400 mg/d) for three days

Topical thiabendazole

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.

Commonly Used Terms

Parasites

Skin

Last Updated 11/18/2002

EPIDEMIOLOGY	CHARACTERIZATION
GEOGRAPHY	Especially in areas withere hookworms are prevalent Some 96% of dogs in Uruguay are infected by hookworms

DISEASE ASSOCIATIONS	CHARACTERIZATION
Loffler syndrome (Pulmomary eosinophilia)	May accompany the cutaneous eruption

PATHOGENESIS	CHARACTERIZATION
Most common cause are hookworms	Int J Dermatol 1995;34:464-465 Ancylostoma braziliense and A. caninum

HISTOLOGICAL TYPES	CHARACTERIZATION
General	Limited use since the larva have already moved from the site of the biopsy. Usually a spongiotic dermatitis with involvment of the follicular infundibula with eosinophils, neutrophils, and mononuclear cells Papillary dermis may be edematous A burrow may be seen in the epidermis
VARIANTS
Eosinophilic Granuloma of the Liver A Characteristic Lesion With Relationship to Visceral Larva Migrans Keith J. Kaplan, M.D.; Zachary D. Goodman, M.D., Ph.D.; Kamal G. Ishak, M.D., Ph.D. From the Department of Pathology, Walter Reed Army Medical Center (K.J.K.) and the Department of Hepatic and Gastrointestinal Pathology (Z.D.G., K.G.I.), and the Veterans Administration Special Reference Laboratory for Pathology (Z.D.G.), Washington, DC, U.S.A.	Am J Surg Pathol 2001;25:1316-1321 Abstract quote Children with the clinical syndrome of visceral larva migrans as a result of Toxocara species have typical lesions in the liver and other viscera, consisting of palisading granulomas that contain numerous eosinophils and often Charcot–Leyden crystals; recognizable parasites are uncommon. Similar eosinophilic granulomas that are found incidentally in adults often cause diagnostic problems. To define better the clinical, laboratory, and pathologic features of these lesions, we reviewed 43 cases of hepatic eosinophilic granuloma (excluding cases of Langerhans' cell histiocytosis) collected in the files of the AFIP over a period of 31 years. The eosinophilic granulomas were found in patients of all ages (range 12 months to 77 years); 30% were younger than 20 years. There were 26 male and 17 female patients. Most patients (26 of 43; 60%) were asymptomatic, and the lesions were discovered incidentally. Others had fever (20%) or abdominal pain (20%). The granulomas were typically multiple (61%), with central necrosis surrounded by a mixed inflammatory infiltrate with numerous eosinophils and variable numbers of neutrophils, lymphocytes, and a palisade of epithelioid histiocytes and/or giant cells. Charcot–Leyden crystals were present in 19 cases (44%). Remnants of parasites (eight Toxocara sp., two Capillaria sp.) were identified in the tissue in 10 patients. There was a positive serologic test for Toxocara sp. in five additional cases. Immunohistochemical staining using polyclonal antiserum against Toxocara canis larvae demonstrated positivity in macrophages in eight of 13 cases tested. We conclude that identification of an eosinophilic granuloma in the liver should suggest the diagnosis of visceral larva migrans and prompt a search for the causative organism with serial sectioning of the block and serologic tests for Toxocara and other causative parasites.

PROGNOSIS AND TREATMENT	CHARACTERIZATION
Prognostic Factors	Most cases are self limited lasting 1-6 months though rare cases may last for a year or longer
Treatment	Int J Dermatol 1997;36:700-703 Oral Albendazole (400 mg/d) for three days
	Topical thiabendazole