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Article type : Letter to Editor

Accepted Article

F. Peccerillo 1, F. Zambito Spadaro2, G. Fabrizi3, C. Feliciani2, C. Pagliarello4*, I. Stanganelli2*

* Both authors contributed equally to this work.

Department of Surgical, Medical, Dental and Morphological Sciences with Interest transplant,
Oncological and Regenerative Medicine; Dermatology Unit; University of Modena and Reggio
Emilia, Modena, Italy.
Department of Dermatology, University of Parma, via Gramsci 14, IT-43100 Parma, Italy.
Istituto Dermopatico dell'Immacolata, Fondazione Luigi Maria Monti IRCCS, Rome, Italy.
Division of Dermatology. UO Multizonale “Santa Chiara” Hospital, Trento. Italy.

Running head: A report of tungiasis

Corresponding author: Dr. Francesca Peccerillo

Department of Surgical, Medical, Dental and Morphological Sciences with Interest transplant,
Oncological and Regenerative Medicine. Dermatology Unit. University of Modena and Reggio
Emilia, via del Pozzo 71, 41124 Modena. Italy. Phone (+39) 059/4224264, fax (+39) 059/4224271,

E-mail: francescapeccerillo@gmail.com

Funding sources: None.

Conflict of interest: The authors have no conflicts of interest to disclose.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jdv.14595
This article is protected by copyright. All rights reserved.
Acknowledgments: Honorarium, grant, or other form of payment were not given to anyone of the

authors to produce the manuscript. All authors made substantive intellectual contributions to the
Accepted Article
published study and each author listed on the manuscript has seen and approved the submission of the



A 62-year-old Caucasian woman complained of a painful nodular lesion on her right heel that

restricted her walking. She had noticed the onset of the itching after approximately 3 weeks of travel

in Brazil. She was initially treated by her general practitioner with topical salicylic acid, suspecting a

plantar wart. After a week of increased itching and unbearable pain, the patient was referred to our

dermatological service. The lesion was roundish and approximately 1 cm in diameter, hard in

consistency (Fig. 1). After gentle curettage, dermoscopy was performed. We noticed a white halo of

hyperkeratosis with an incomplete, dark brownish ring, blue-black blotches, and a central orifice

surrounded by white ovoid structures (Fig. 2). After a few insightful questions, she was diagnosed

with tungiasis. We curetted out the eggs and fecal material and further performed spray cryotherapy,

instructing her to apply a topical antibiotic ointment for 2 weeks; this resulted in her full recovery.

The patient also received tetanus prophylaxis.

Tungiasis is a cutaneous parasitosis which is caused by a flea, Tunga penetrans. This infection is

widely distributed among mammals, affecting humans and small animals. It is endemic to South and

Central America, sub-Saharan Africa, and rarely, European countries1-2. The infestation cycle of the

flea lasts nearly 1 month. The female penetrates the skin of mammalian hosts and causes a

hypertrophic, rounded lesion with a central black dot. This represents the abdominal and genital

opening where the flea produces and expels its eggs3. In order to avoid severe complications such as

digit deformation, chronic lymphedema, tetanus, and sometimes sepsis, early diagnosis is decisive.

This holds especially in endemic areas where severe infestation often occurs4. Diagnosis in these areas

is usually straightforward; nevertheless, it can be tricky in nontropical areas, due to a low index of

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suspicion. Since skin lesions are one of the most common reasons for returning travelers to seek

medical evaluation, in case of a somewhat uncharacteristic plantar wart, we believe it is important to

Accepted Article
ask the patient if he or she recently visited a tropical area5.

“Zebra retreat” refers to the hesitation with which one considers a rare diagnosis (zebra) even though

it may be the most likely diagnosis. Gentle curettage followed by dermoscopy has the potential to

overcome this flaw in the reasoning process, avoiding missing a rare diagnosis.


1. Sachse MM, Guldbakke KK, Kachemoune A. Tunga penetrans: a stowaway from around the

world. J Eur Acad Dermatol Venereol. 2007; 21:11–16.

2. Palicelli A, Boldorini R, Campisi P, et al. Tungiasis in Italy: an imported case of Tunga penetrans

and review of the literature. Pathol Res Pract. 2016; 212: 475–483.

3. Maco V, Maco VP, Tantalean ME, Gotuzzo E. Histopathological features of tungiasis in Peru. Am

J Trop Med Hyg. 2013; 88: 1212–1216.

4. Mazingo HD, Behamana E, Zinga M, Heukelbach J. Tungiasis infestation in Tanzania. J Infect Dev

Ctries. 2010; 4: 187–189.

5. O’Brien BM. A practical approach to common skin problems in returning travelers. Travel Med

Infect Dis. 2009; 7: 125–146.

Figure legends:

Fig. 1: Nodular lesion on right heel.

Fig. 2: Dermoscopy of same lesion.

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Accepted Article

This article is protected by copyright. All rights reserved.

Accepted Article

This article is protected by copyright. All rights reserved.