Case Studies

Case Study #1: Beware the Beach

This case is noteworthy because it shows how CLM, though a mild condition, can be exacerbated by postponing treatment.

Case study from Richey, et. al.

"A 47-year-old healthy white man had an eruption on his back while vacationing in Rio de Janeiro in February 1991. His activities included
sunbathing on a beach frequented by numerous dogs and cats. He was seen by two dermatologists, one of whom did a biopsy, and the patient was
told he had dermatitis. He was treated with topical steroids, but the eruption persisted. Seventeen months after the onset, a 4 mm punch biopsy was
done in Washington, DC, by a third dermatologist. The biopsy was initially interpreted as nonspecific histologic changes, but deeper sections
revealed a filariform structure deep in a hair follicle. The structure was morphologically compatible with Ancylostoma larvae, and
cutaneous larva migrans was diagnosed.

The patient was not treated at this time because he was in transit to his new home in Colorado. Physical examination revealed a healthy-appearing white man with multiple red papules on the mid and lower back. Several erythematous serpiginous lesions consistent with burrows were noted . Physical examination was otherwise unremarkable, and no adenopathy was
present.
Two 6 mm punch biopsy specimens were taken of suspected burrows. No parasites were seen, but several round to oval spaces in the lower
epidermis were filled with neutrophils and eosinophils. These were compatible with older burrows.

He was initially treated with the topical application of thiabendazole suspension (500 mg/5 mL) to affected areas at bedtime and again in the
morning for 2 weeks. He noticed a prompt response but quickly had relapse when the drug was discontinued. Because of his busy schedule, he
was not able to return for almost 3 months. Physical examination again revealed multiple red papules, some showing a serpiginous pattern on the
back. Despite symptomatic and clinical improvement, persistent cutaneous larva migrans was suspected. The patient was treated with oral
thiabendazole, 1,500 mg bid for 4 days. He rapidly responded and had no further complaints."

Case Study #2 The Plumber's Itch

Case Study and pictures taken from Kirby-Smith, et. al.

"A plumber, aged 40, with hundreds of lesions, became infected on the forewarm while installing a furnace during the construction of an ew school building. His helper was as extensively infected. While both had a been on the ground numerous times during the day, it was while making a pipe connection near the base of a small stump that both experienced the same sensation resembling the stinging from nettles. The infection developed similarly and with equal reapididty in both men, the migration taking place on the fifth day. Nine days after the penetration of the larvae, four skin sections were obtained, and from these one parsite was recovered from serial sections. Sixteen days after the infection, four other skin excisions believed to be a complete series of this parasite in cross section was obtained."

A 47-year-old healthy white man had an eruption on his back while vacationing in Rio de Janeiro in February 1991. His activities included
sunbathing on a beach freqented by numerous dogs and cats. He was seen by two dermatologists, one of whom did a biopsy, and the patient was
told he had dermatitis. He was treated with topical steroids, but the eruption persisted. Seventeen months after the onset, a 4 mm punch biopsy was
done in Washington, DC, by a third dermatologist. The biopsy was initially interpreted as nonspecific histologic changes, but deeper sections
revealed a filariform structure deep in a hair follicle. The structure was morphologically compatible with Ancylostoma larvae (Fig 1 and Fig 2), and
cutaneous larva migrans was diagnosed. A 4 mm punch biopsy of perilesional skin for immunofluorescence was negative. The patient was not
treated at this time because he was in transit to his new home in Colorado.
Physical examination revealed a healthy-appearing white man with multiple red papules on the mid and lower back. Several erythematous
serpiginous lesions consistent with burrows were noted (Fig 3). Physical examination was otherwise unremarkable, and no adenopathy was
present.
Two 6 mm punch biopsy specimens were taken of suspected burrows. No parasites were seen, but several round to oval spaces in the lower
epidermis were filled with neutrophils and eosinophils. These were compatible with older burrows.
Laboratory data included a normal complete blood count without eosinophilia, a negative serology for human immunodeficiency virus, and normal
findings on a general health panel. A routine chest roentgenogram showed no abnormality.
He was initially treated with the topical application of thiabendazole suspension (500 mg/5 mL) to affected areas at bedtime and again in the
morning for 2 weeks. He noticed a prompt response but quickly had relapse when the drug was discontinued. Because of his busy schedule, he
was not able to return for almost 3 months. Physical examination again revealed multiple red papules, some showing a serpiginous pattern on the
back. Despite symptomatic and clinical improvement, persistent cutaneous larva migrans was suspected. The patient was treated with oral
thiabendazole, 1,500 mg bid for 4 days. He rapidly responded and had no further complaints.