eMedicine Specialties > Infectious Diseases > Parasitic Infections

Tungiasis

Author: Paul McKinney, MD, Associate Dean for Public Health, Professor of Medicine, Department of Health Knowledge and Cognitive Sciences, University of Louisville
Contributor Information and Disclosures

Updated: May 15, 2009

Introduction

Background

Tungiasis is an infestation with the human flea, Tunga penetrans. The condition is rarely diagnosed in North America, but it should no longer be obscure to physicians because of increasing international travel to tropical destinations.1

This illustration shows some of the identifying m...

This illustration shows some of the identifying morphologic characteristics of the chigoe flea, Tunga penetrans. Courtesy of the CDC.

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This illustration shows some of the identifying m...

This illustration shows some of the identifying morphologic characteristics of the chigoe flea, Tunga penetrans. Courtesy of the CDC.

Tungiasis is spread by the parasitic flea known in various locations as chigger flea, sand flea, chigoe, jigger, nigua, pigue, and le bicho de pe. Tungiasis is common in Central America, South America, India, and tropical Africa.

Tungiasis may have been the first exotic infection experienced by European explorers to the West Indies in the late 15th century. Sailors traveling with Columbus in 1492 suffered chigoe flea infestation while in Haiti and probably were the first to introduce it to Europe. The flea was introduced to Africa in the 1600s and again around 1873. High rates of morbidity from T penetrans were noted among soldiers in the East African campaign of World War I and in Ethiopia during World War II.

Pathophysiology

Although both male and female fleas intermittently seek blood meals, only the female flea can produce the typical skin lesion of tungiasis.2 The pregnant flea burrows into the skin of the host near the plantar surfaces of the foot,3 in the webbing between the toes, and around the periungual region. Inflammation is marked by painful swelling that occurs at the site of infestation, leading to the development of a fibrous cyst at the site. Very heavy infestation may cause ulceration and fibrosis that may cause secondary infections such as bacteremias, tetanus, or gas gangrene.4

Frequency

United States

The incidence of tungiasis is unknown because it is not a reportable disease. A review article from 1989 cited 14 cases.5,6

International

Approximately 42% of Nigerian school children are infected. The average incidence in Trinidad is 21%. In a traditional fishing village in northeastern Brazil, the overall prevalence was 51%.7,8

Mortality/Morbidity

Uncomplicated infestation results in pain, swelling, tenderness, and some limitation in mobility. Ultimately, the risk of severe morbidity or mortality from tungiasis is dependent upon the occurrence of secondary infections, which may follow attempts to extract the flea. Bacteremia, tetanus, or gas gangrene complications carry extraordinarily high mortality rates.

Race

No racial predisposition is apparent. Infection rates among native inhabitants of developing countries, however, are much higher than among visitors.

Sex

In endemic regions such as Trinidad, males were consistently more likely than females to have an infestation and had higher chigoe flea burdens, with about twice the number of fleas detected per subject.9

Age

In Trinidad, tungiasis reaches a peak infestation rate of 54% among males aged 25-35 years. Among females, the peak occurs in those aged 55 years and older.9 In a village in northeastern Brazil, bimodal prevalence peaks were noted in children aged 5-9 years and in adults older than 60 years.7

Clinical

History

  • Travel to areas with T penetrans, including Central America, South America, India, and tropical Africa10
  • Walking along beach areas with bare feet or in sandals
  • Pain or itching and papular or nodular eruptions, usually on the feet (can occur on any area of the body to which the flea has access)

Physical

  • Typical areas of involvement include the plantar surface of the foot, the intertriginous regions of the toes, and the periungual regions. However, other ectopic sites of infection have also been reported, including the hands, elbows, thighs, and gluteal region.11
  • Infestation in its simplest form is manifested by the appearance of a white patch with a black dot. More advanced infestation manifests as crusted erythematous papules, painful pruritic nodules, crateriform lesions, and secondary infections, including lymphangitis and septicemia. More recently, a case presenting with a large bullous lesion has been described.12

Causes

  • The major risk factor for exposure to T penetrans is failure to wear shoes when walking in sand in an area with active infestation. Wearing shoes and not sitting or lying in the sand are the most important steps to reduce infection risk.

More on Tungiasis

Overview: Tungiasis
Differential Diagnoses & Workup: Tungiasis
Treatment & Medication: Tungiasis
Follow-up: Tungiasis
Multimedia: Tungiasis
References
Further Reading
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References

  1. Gibbs SS. The diagnosis and treatment of tungiasis. Br J Dermatol. Sep 2008;159(4):981. [Medline].

  2. Fein H, Naseem S, Witte DP. Tungiasis in North America: a report of 2 cases in internationally adopted children. J Pediatr. Nov 2001;139(5):744-6. [Medline].

  3. Escamilla-Martinez E, Gómez-Martín B, Sánchez-Rodríguez R, Martínez-Nova A, Martínez-Granada LJ, Altube-Arabiurrutia E. Tungiasis--traveler's ectoparasitosis of the foot: a case report. Foot Ankle Int. Mar 2008;29(3):354-7. [Medline].

  4. Bourée P, Ossé L, Rabenandrasana F. [Tungiasis, an uncommon ectoparisitic disease]. Rev Prat. Feb 20 2009;59(2):163-5. [Medline].

  5. Sanusi ID, Brown EB, Shepard TG, Grafton WD. Tungiasis: report of one case and review of the 14 reported cases in the United States. J Am Acad Dermatol. May 1989;20(5 Pt 2):941-4. [Medline].

  6. Hager J, Jacobs A, Orengo IF, Rosen T. Tungiasis in the United States: a travel souvenir. Dermatol Online J. Dec 15 2008;14(12):3. [Medline].

  7. Muehlen M, Heukelbach J, Wilcke T. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil. II. Prevalence, parasite load and topographic distribution of lesions in the population of a traditional fishing village. Parasitol Res. Aug 2003;90(6):449-55. [Medline].

  8. Damazio OR, Silva MV. Tungiasis in schoolchildren in Criciúma, Santa Catarina State, South Brazil. Rev Inst Med Trop Sao Paulo. Mar-Apr 2009;51(2):103-8. [Medline].

  9. Chadee DD. Tungiasis among five communities in south-western Trinidad, West Indies. Ann Trop Med Parasitol. Jan 1998;92(1):107-13. [Medline].

  10. Rathe M, Rafn A, Poulsen T, Mohey R. [Tungiasis case after a trip to Kenya]. Ugeskr Laeger. Mar 2 2009;171(10):818. [Medline].

  11. Heukelbach J, Wilcke T, Eisele M. Ectopic localization of tungiasis. Am J Trop Med Hyg. Aug 2002;67(2):214-6. [Medline].

  12. Veraldi S, Schianchi R, Cremonesi R. Bullous tungiasis. Int J Dermatol. Dec 2005;44(12):1067-9. [Medline].

  13. Di Stefani A, Rudolph CM, Hofmann-Wellenhof R. An additional dermoscopic feature of tungiasis. Arch Dermatol. Aug 2005;141(8):1045-6. [Medline].

  14. Cabrera R, Daza F. Dermoscopy in the diagnosis of tungiasis. Br J Dermatol. May 2009;160(5):1136-7. [Medline].

  15. Smith MD, Procop GW. Typical histologic features of Tunga penetrans in skin biopsies. Arch Pathol Lab Med. Jun 2002;126(6):714-6. [Medline].

  16. Eisele M, Heukelbach J, Van Marck E. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man. Parasitol Res. Jun 2003;90(2):87-99. [Medline].

  17. Heukelbach J, Eisele M, Jackson A. Topical treatment of tungiasis: a randomized, controlled trial. Ann Trop Med Parasitol. Oct 2003;97(7):743-9. [Medline].

  18. Feldmeier H, Heukelbach J, Eisele M. Bacterial superinfection in human tungiasis. Trop Med Int Health. Jul 2002;7(7):559-64. [Medline].

  19. Basler EA, Stephens JH, Tschen JA. Tunga penetrans. Cutis. Jul 1988;42(1):47-8. [Medline].

  20. Brothers WS, Heckmann RA. Tungiasis in North America. Cutis. Jun 1980;25(6):636-8. [Medline].

  21. Douglas-Jones AG, Llewelyn MB, Mills CM. Cutaneous infection with Tunga penetrans. Br J Dermatol. Jul 1995;133(1):125-7. [Medline].

  22. Goldman L. Tungiasis in travelers from tropical Africa. JAMA. Sep 20 1976;236(12):1386. [Medline].

  23. Lowry MA, Ownbey JL, McEvoy PL. A case of tungiasis. Mil Med. Feb 1996;161(2):128-9. [Medline].

  24. Mashek H, Licznerski B, Pincus S. Tungiasis in New York. Int J Dermatol. Apr 1997;36(4):276-8. [Medline].

  25. Poppiti R Jr, Kambour M, Robinson MJ, Rywlin AM. Tunga penetrans in south Florida. South Med J. Dec 1983;76(12):1558-60. [Medline].

  26. Zalar GL, Walther RR. Infestation by Tunga penetrans. Arch Dermatol. Jan 1980;116(1):80-1. [Medline].

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Keywords

Tunga penetrans, T penetrans, Sarcopsylla penetrans, S penetrans, Tungidae, chigger flea, sand flea, chigoe, jigger, nigua, pigue, le bicho de pe

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Contributor Information and Disclosures

Author

Paul McKinney, MD, Associate Dean for Public Health, Professor of Medicine, Department of Health Knowledge and Cognitive Sciences, University of Louisville
Paul McKinney, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Central Society for Clinical Research, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Mark Raymond Wallace, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

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