Diagnostic Considerations

Conditions to consider in the differential diagnosis of tungiasis include the following:

Cercarial dermatitis
Creeping eruption due to Ancylostoma species
Scabies
Tick bite
Flea bites
Myiasis (Dermatobia hominis)
Fire ant bites
Ingrown toenails
Viral warts

Workup

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Media Gallery

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. Compiled and designed by Fausto Bustos and Lucas Manfield.
Histopathologic findings in tungiasis.
Life cycle of the chigoe flea, Tunga penetrans. Courtesy of the CDC.
Complicated Tungiasis infection. Courtesy of Dermatology Atlas (http://www.atlasdermatologico.com.br/index.jsf) and Samuel Freire da Silva, MD.
Tungiasis lesion under toenail. Courtesy of Dermatology Atlas (http://www.atlasdermatologico.com.br/index.jsf) and Samuel Freire da Silva, MD.
Example of complicated infection with multiple tungiasis lesions and possible secondary infection. Courtesy of Wikimedia Commons [author R Schuster, https://commons.wikimedia.org/wiki/File:Jigger_infested_foot_(2).jpg].
Illustration of Tunga penetrans (sand flea) in its enlarged state. Courtesy of Wikimedia Commons [https://commons.wikimedia.org/wiki/File:ChiggerBMNH.jpg].
Removed parasite shown with needle. Courtesy of Wikimedia Commons [https://commons.wikimedia.org/wiki/File:Puce_chique_(Tonga_penetrans).jpg].
Tunga penetrans flea. Courtesy of Wikimedia Commons [author Philipp Weigell, https://commons.wikimedia.org/wiki/File:Tunga_penetrans_%281%29.JPG].
Image of Tungiasis infection on both feet. Courtesy of PLOS [Miller H, Ocampo J, Ayala A, Trujillo J, Feldmeier H. Very severe tungiasis in Amerindians in the Amazon lowland of Colombia: A case series. PLOS Neglected Tropical Diseases. 2019 Feb 7. Online at: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007068.].
Graphical abstract of predicted tungiasis occurrence within sub-Saharan Africa. Courtesy of MDPI [Deka MA. Mapping the Geographic Distribution of Tungiasis in Sub-Saharan Africa. Tropical Medicine and Infectious Disease. 2020 Jul 24;5(3):122. Online at: https://www.mdpi.com/2414-6366/5/3/122#.].

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Table 1. Medication Summary

Table 1. Medication Summary

Medication Name	Dosage/Application	Contraindications	Availability	Notes
Dimethicone ^{[59, 60, 61]}	Apply directly to the affected area once or twice daily. If legion numbers are under 40 or legions are in clusters: Apply 3 drops of NYDA® (approximately 50 μL each) to the exposed posterior side of the flea. Repeat the procedure 3x over 10 minutes. If fleas are in excessive hyper-keratotic skin and located on top of each other: NDYA® must be used to wet the skin intensely and repeatedly.	No known contraindications. Shown to be safe for extended use.	Available under the brand name NYDA®. But not available in all tungiasis endemic areas.
Topical Antibiotic Lotions ^{[64, 58, 61]}	0.8% ivermectin, 0.2% metrifonate and 5% thiabendazole lotions, applied 2 consecutive days.	No contraindications reported.	All are readily available except for metrifonate, which is no longer commercially available.
Zanzarin ^{[63, 8]}	Apply to all infected areas and areas at risk for tungiasis infection twice daily.	No known contraindications.	No longer commercially available, but made of ingredients that could be locally manufactured in areas where tungiasis is common.
Neem Seed Oil and Coconut Oil ^{[61, 69]}	One drop (approximately 0.05 ml) of a mixture of 20% cold-pressed virgin neem seed oil and 80% virgin coconut oil applied to the embedded flea’s abdominal tip on days 1 and 3.	Actives in cold-pressed neem oil are not toxic following oral, inhalation, or dermal exposure.	May be locally available where both neem trees and coconut palms grow.	The mixture requires proper storage as azadirachtin has a high sensitivity to ultraviolet light, pH, and temperature.

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Author

Darvin Scott Smith, MD, MSc, DTM&H, FIDSA Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Permanente Medical Group

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

Disclosure: Nothing to disclose.

Coauthor(s)

Lisa Manzanete, BS MD Candidate, Loma Linda University School of Medicine

Disclosure: Nothing to disclose.

Lily Amaturo BS Candidate, Stanford University

Disclosure: Nothing to disclose.

Nadia Hemmat BA Candidate, Stanford University

Disclosure: Nothing to disclose.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Zachary S Wettstein Stanford University

Disclosure: Nothing to disclose.

Stephanie A Nevins Research Assistant, Department of Genetics, Snyder Lab, Stanford University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

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