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8/13/2019 Case Presentation CLM

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Case presentation 1CUTANEOUS LARVA

MIGRANS

Shinta dewi / Sawitri



BACKGROUND

• creeping verminous dermatitis, sandworm eruption,plumber’s itch, duck hunter’s itch

Cutaneous Larva Migrans

• animal hookworms ( Ancylostoma braziliense, A.

caninum , Uncinaria stenocephala,Bustonum phlebotonum)

Most common cause

• (Carribean, Africa, Central and South America, India, Southeast Asia)

Most common areas



BACKGROUND

Whois atrisk

Barefoot beachcombers and sunbathers

Children in sandpits

FarmersGardeners

Plumbers

Hunters

Electricians

Carpenters

Pest exterminators



Related Physical Findings:

Wheezing, dry cough andurticaria

Time fromexposure to onset

of symptomsusually 1 to 6 days

Skin changes is themost prominent

findings

The most commonanatomic sites isfeet and buttocks

The eruption lastbetween

2 and 8 weeks



BACKGROUND

CLM

• condition in which larvae of any animal nematodes

infect humans, and the infected human is a dead endhost.

Creeping Eruption• the clinical findings of a migratory serpiginous lesion.



Case Identity • Name : Ms. Y

• Sex : Female

• Age : 45 y.o

• Occupation : housewife

• Address : Sidoarjo

• Reg No : 12198383

• Outpatient clinic : 12 Agustus2013



• Itchy red linear lesion at the left breast

since 5 days before she came to

outpatient clinic

• At first the lesion was small, like an acne

then increase in length and became curvy

• She never take oral or applied topical

medication



• She loves gardening, history of last

gardening 1 weeks ago, in which she never

wore gloves

• No history of having the same disease

before

• No history of family or surrounding people

having the same disease as patient.

• No history of having pet in her home



PHYSICAL EXAMINATION

VITAL SIGN

BP 120/80, PR : 80, RR : 20, BT : 36.5 oC

GENERAL STATUS Compos mentis, look well Head/Neck : anemia-, icterus-,cyanosis-,dyspnea- Thorax : Cor and pulmo within normal limit Abdomen : Soepel, liver and spleen not palpable Extremity : Warm, no edema



DERMATOLOGICAL STATUS

12 August 2013

• Regio mamae

sinistra : Curvy

erythematous linear

papule and pustule



ASSESSMENT

CUTANEOUS LARVA MIGRANS + SECUNDER INFECTION



DIAGNOSIS

• -

TERAPI

• Natrium Fusidat u.e for 4

days

Planning



• Patient complain

• Progression of the lesion

• Control to outpatient clinic Monitoring

• Do not manipulate thelesion

• Wear protection, such as

gloves, when come incontact with soilEducation



12-08-13

16-08-13

23-08-13

02-09-13



FOLLOW UP 2013 2013 2013

Subjective :

-Itchy

-Burn sensation-pustule

++

+++

++

+-

+

--

-

--

Objective:

-Curvy

erythematous

linear papule

-Scale

-Erosion

-Hiperpigmentation

-Pustule

+ +

++

++

-

+

++

++

-

-

-

+

-

-

-

-

-

-

-

-

+

-

Theraphy -Natrium

Fusidat

2%

-

Loratadin

e 10 mgtab

-chlorethyl

spray

-Albendazole

1x1tab, 3 days

-loratadine 10

mg tab

- Chlorethyl

spray

- Loratadin

10 mg tab



About CLM

• Cutaneous larva migrant is a parasitic skin

disease caused by the migration of animal

hookworm larvae in the epidermis

• most common hookworm species being

A.braziliense n A.caninum.

•

Contact with sand or soil contaminated withanimal feces is required for infection to occur.



• Larvae penetrate the human skin and migrate

up to several cm a day, usually between

stratum germinativum and stratum corneum.

• Induces localized eosinophilic inflammatory

reaction.

• Cannot penetrate through basal membrane-

Self limiting.



Differential Diagnose

• Scabies

• Contact dermatitis

•

Dermatophytosis



CLINICAL MANIFESTATION

THEORY

Subjective

• itching

• burning

• Contact with

contaminated sand or

soil skin lesion 1-5 days

after exposure• Movement up to

several cm per day

My patient

• Subjective

• Itching (+)

• Burning (+)

• Contact with Last soil, last7

days (+)

• Increase in length (+)



Theory

Physical examination

• Erythematous, raised,vesicular, linear orserpentine cutaneoustrail

• Vesicular or bullouslesions at the site of

penetration• predilection: buttocks,

feet

My Patient

Physical examination

• Erythematous, raised,

vesicular, linear +,serpentine cutaneous trail

• Mamae sinistra



Diagnosis

* Clinical findings

- Skin biopsy, skin scraping

Diagnosis* Clinical findings (+)



THEORY THERAPY

- Albendazole 400mg p.o daily for 3days

- Ivermectin 200ug/kg daily for 1-2

days

- Topical tiabendazole oralbendazole 10%

- Chlorethyl spray along lesion

- Surgical excision or cryotherapy notrecommended

My Patient

- Albendaxole 400 mg p.o daily for3 days

- Chlorethyl spray along lesion



Histophatology

orthokeratosis, multiple intraepidermal bullae, spongiosis,

dilated vascular channels, lymphocytic exocytosis, and

numerous eosinophils



Mechanism of action Albendazole

1. Inhibit the polymerization of the parasite

tubulin into microtubules

• (There is a higher affinity of albendazole to

the parasite tubulin, so the activity is

mediated mainly againts the parasite rather

than on the host)

2. Inhibition of the enzyme fumarate reductase

which is helminth specific



MECHANISM OF ACTION

INVERMECTINE

• Ivermectin kills the larval Onchocerca volvulusworms – microfilariae – that live in thesubcutaneous tissue of an infected person.

• Ivermectin does not kill the adult worms butsuppresses the production of microfilariae byadult female worms for a few monthsfollowing treatment, so reduces transmission,As the adult worms can continue to producemicrofilariae until they die naturally

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