eMedicine Specialties > Pediatrics: General Medicine > Parasitology

Cutaneous Larva Migrans

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Jining Wang, MD, Department of Dermatology, Dean Health System; Kim Wang, MD, Staff Physician, Department of Pathology, Northwestern University Medical School
Contributor Information and Disclosures

Updated: Jan 21, 2009

Introduction

Background

Cutaneous larva migrans (CLM) is a serpiginous eruption usually confined to the skin of the feet, buttocks, or abdomen caused by dog and cat hookworms, which are types of nematodes (roundworms).1 Skin findings are due to a hypersensitivity reaction to the worms and their byproducts.

Although CLM can occur in the temperate zones in the warmer months of the year, infection is most commonly found in tropical and subtropical climates. Modern ease of travel necessitates inclusion of CLM in the differential diagnosis of serpiginous pruritic lesions, regardless of the location of practice.

Pathophysiology

Larvae from animal nematodes that infect humans usually cause CLM. The normal hosts for these hookworms are cats and dogs, in which the roundworm eggs pass through the feces. The eggs optimally hatch in warm, shady, moist, sandy soil found in tropical and subtropical areas. Humans are infected with the larvae by walking barefoot on the sand. The larvae quickly penetrate the skin upon contact.

Beaches are the most common reservoir for the larvae that cause CLM; however, infection can occur from sandboxes and soil under houses or at construction sites. The prohibition of dogs and cats on beaches is a way to limit transmission of the infection.

Frequency

United States

Exact incidence is unknown; however, Jelinek et al reported that 6.7% of the 13,300 travelers visiting a travel-related disease clinic presented with CLM.2 In the United States, most cases occur in eastern and southern coastal areas from New Jersey to Texas. The highest incidence is in Florida.

International

Worldwide distribution is predominantly reported in tropical zones. CLM is indigenous to the Caribbean, Central and South America, Africa, and Southeast Asia.

Mortality/Morbidity

Mortality from the infection is not reported. Most episodes of CLM resolve with or without treatment and with no long-term adverse consequences. Morbidity is associated with an intensely pruritic rash, which leads to secondary impetiginization and cellulitis. In rare incidents of CLM in which nematodes use a human as a definitive host, infection can lead to the completion of the nematode life cycle with adult worms residing in the intestines. This causes diarrhea, malabsorption, and malnutrition.

Race

CLM has no racial predilection.

Sex

No sex predilection is observed.

Age

CLM affects all ages in the appropriate environment.

Clinical

History

  • The patient with cutaneous larva migrans (CLM) may recall a stinging sensation upon initial penetration of the larvae.
  • An erythematous papule or a nonspecific dermatitis can develop hours after penetration.
  • The most common location for penetration is the feet (39%), from walking barefoot in the sand, followed by the buttocks (18%) and the abdomen (16%).

Physical

  • The migration of the larvae produces a 2-mm to 4-mm wide, erythematous, elevated, vesicular serpiginous track. Vesiculobullous and papular lesions may be observed in association with the linear track.
  • Migration of the larvae through the skin occurs from a week to several months after initial penetration, depending on the type of roundworm. The rate of larval migration is from 2 mm to 2 cm per day, depending on the species of larva. Unlike in animals, the larvae are unable to penetrate the epidermal basement membrane of human skin; therefore, the larvae roam haphazardly in the epidermis and are unable to complete their life cycle.
  • An allergic immune response of the patient to the larvae or byproducts causes the pruritic erythematous track. The actual location of the larvae is usually 1-2 cm beyond the erythematous track.
  • Untreated lesions resolve after the larvae die (ie, within weeks to months).

Causes

  • The most common cause of CLM is Ancylostoma braziliense, which is a dog and cat hookworm found in the United States, Central America, South America, and the Caribbean.
  • Other reported, less common, animal roundworms that cause CLM include the following:
    • Ancylostoma tubaeforme, Ancylostoma caninum, Ancylostoma ceylanicum, and Uncinaria stenocephala (ie, dog hookworms)
    • Bunostomum phlebotomum (ie, cattle hookworm)
    • Gnathostoma species (ie, cat, dog, and pig roundworms)
    • Capillaria species (ie, whipworms found in rodents, cats, dogs, and poultry)
    • Strongyloides myopotami, Strongyloides papillosus, and Strongyloides westeri (found in the small intestine of mammals)
    • Nematodes that use a human as a definitive host, such as Ancylostoma duodenale, Strongyloides stercoralis, and Necator americanus (rare causes of CLM)
      • A duodenale and N americanus usually cause ground itch.
      • S stercoralis is usually associated with larva currens.
  • CLM should not be confused with visceral larva migrans and ocular larva migrans, which are due to the ingestion of the eggs of the parasite Toxocara canis or Toxocara cati. Children with pica or people eating unwashed raw vegetables have the greatest risk of acquiring visceral and ocular larva migrans.
  • The following individuals are at risk of infection with CLM:
    • Sunbathers
    • Fishermen
    • Hunters
    • Gardeners
    • Construction workers
    • Pest exterminators
    • Children
    • Anyone with skin contact to sand or soil in warm areas

More on Cutaneous Larva Migrans

Overview: Cutaneous Larva Migrans
Differential Diagnoses & Workup: Cutaneous Larva Migrans
Treatment & Medication: Cutaneous Larva Migrans
Follow-up: Cutaneous Larva Migrans
Multimedia: Cutaneous Larva Migrans
References
Further Reading
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References

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Further Reading

See Image 33 at the McGill Faculty of Medicine Web site.

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Keywords

cutaneous larva migrans, CLM, Ancylostoma braziliense, Ancylostoma caninum, Ancylostoma ceylanicum, Ancylostoma duodenale, Ancylostoma tubaeforme, Bunostomum phlebotomum, Capillaria, creeping eruption, diarrhea, duck hunter itch, Gnathostoma, ground itch, hookworm, hypersensitivity reaction, malabsorption, Necator americanus, nematodes, ocular larva migrans, plumber itch, roundworm, sandworm disease, serpiginous pruritic lesions, Strongyloides myopotami, Strongyloides papillosus, Strongyloides stercoralis, Strongyloides westeri, Uncinaria stenocephala

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Jining Wang, MD, Department of Dermatology, Dean Health System
Jining Wang, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Kim Wang, MD, Staff Physician, Department of Pathology, Northwestern University Medical School
Kim Wang, MD is a member of the following medical societies: United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Medical Editor

Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital
Michael D Nissen, MBBS, BMedSc, FRACP, FRCPA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Pediatric Infectious Diseases Society, Royal Australasian College of Physicians, and Royal College of Pathologists of Australasia
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Martin Weisse, MD, Program Director, Associate Professor, Department of Pediatrics, West Virginia University
Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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