Tungiasis Workup

  • Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 15, 2011
 

Approach Considerations

Extraction of the gravid flea using a sterile needle is diagnostic and therapeutic. A skin biopsy of a suspected papule or nodule may be performed.

In general, no laboratory studies are indicated other than a histologic examination of excised tissue to confirm the presence of the flea. No imaging studies are indicated unless there is a secondary infection with a complication such as gas gangrene.

Dermoscopy

Dermoscopy (direct skin microscopy) may be helpful in identifying typical features, including an irregular, central, brown discoloration with a plugged opening in the middle or a gray-blue discoloration.[25, 26, 27] Sometimes, a serosanguineous exudate oozes from the central opening, and eggs may be seen on microscopic examination.

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Histologic Findings

Microscopically, the flea has a thick cuticle and a band of striated muscle stretching from the head to the abdominal orifice. Also visible are hollow, ring-shaped elements from the flea's tracheal and digestive system and numerous round or oval eggs. A report from a small series of skin biopsies indicated that the exoskeleton, hypodermal layer, trachea, digestive tract, and developing eggs were present in all biopsy specimens; striated muscle and the hindquarters were present in about half of the samples; and the head was found in none of the specimens.[28] Detailed histopathologic findings from 86 cases, including scanning electron microscopy images, elucidated the stages of infestation. (See the images below.)[29]

A. Tangential cut through a fully developed, graviA. Tangential cut through a fully developed, gravid flea embedded in the stratum corneum of the epidermis. The flea's head and thorax are enfolded in the hypertrophic anterior abdominal segments. The epidermis is hyperplastic and shows papillomatosis, parakeratosis, and hyperkeratosis.B. Tangential cut through the posterior abdominal segments of an embedded sand flea. Next to the chitinous cuticle, a microabscess has formed.C. Dead parasite; the exoskeleton of the posterior abdominal segment has remained intact; the cuticle has disintegrated at the epidermal–dermal interface. The carcass is infiltrated by neutrophils, and pus has formed.D. The head of the flea is located at the epidermal–dermal interface, has penetrated the basal membrane, and is surrounded by many erythrocytes, presumably having leaked from a blood vessel. The abdomen of the parasite is separated from host tissue by a thick, chitinous cuticle.

Histologic examination reveals an intraepidermal cavity lined by an eosinophilic cuticle, which represents the body of the flea. In the cavity are round to oval eggs, hollow ringlike components of the tracheal system, and the digestive tract (see image below). A thick band of striated muscle runs from the head to the terminal orifice. Usually, an inflammatory infiltrate is present in the subjacent dermis.

Histopathologic findings in tungiasis. Histopathologic findings in tungiasis.
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Contributor Information and Disclosures
Author

Darvin Scott Smith, MD, MSc, DTM&H  Adjunct Assistant Professor, Department of Microbiology and Immunology, Stanford University School of Medicine; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital

Darvin Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International Society of Travel Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Abdul-Ghani Kibbi, MD  Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Neil F Gibbs, MD  Voluntary Associate Professor, Departments of Pediatrics and Medicine, University of California, San Diego School of Medicine; Program Director, Pediatric Dermatologist, Department of Dermatology, Naval Medical Center, San Diego

Neil F Gibbs, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Zachary S Wettstein  Stanford University

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Thomas M Kerkering, MD  Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

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.

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Paul McKinney, MD, to the development and writing of a source article.

References

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This illustration shows some of the identifying morphologic characteristics of the chigoe flea, Tunga penetrans. Courtesy of the CDC.
A. Tangential cut through a fully developed, gravid flea embedded in the stratum corneum of the epidermis. The flea's head and thorax are enfolded in the hypertrophic anterior abdominal segments. The epidermis is hyperplastic and shows papillomatosis, parakeratosis, and hyperkeratosis.B. Tangential cut through the posterior abdominal segments of an embedded sand flea. Next to the chitinous cuticle, a microabscess has formed.C. Dead parasite; the exoskeleton of the posterior abdominal segment has remained intact; the cuticle has disintegrated at the epidermal–dermal interface. The carcass is infiltrated by neutrophils, and pus has formed.D. The head of the flea is located at the epidermal–dermal interface, has penetrated the basal membrane, and is surrounded by many erythrocytes, presumably having leaked from a blood vessel. The abdomen of the parasite is separated from host tissue by a thick, chitinous cuticle.
A tungiasis lesion in substage 3a.
Scanning electron micrograph of flea on day 3 after penetration. The hypertrophic zone between abdominal segments 2 and 3 is gaining a bulging shape and looks like a life-belt (x100).
Scanning electron micrograph of flea on day 8 after penetration. The hypertrophy zone has taken the shape of a sphere. The 3 parts of abdominal segment 2 are completely bent apart. Together with the newly developed, crescent-shaped chitinous clasps, the anterior part of the flea looks like a 3-leafed clover (x32).
Scanning electron micrograph of flea 6 hours after beginning of penetration. The penetration is almost completed; only the last abdominal segments protrude through the skin (x240).
Scanning electron micrograph of flea in stage 2. The rear end, the genital opening, and the 4 pairs of stigmata form a miniature cone, which towers above the crater caused by pushing in abdominal segments 7 and 8 (x190).
Life cycle of Tunga penetrans - Fortaleza stages included.
Histopathologic findings in tungiasis.
 
 
 
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