RESEARCH LETTER

Severe Cutaneous Larva Migrans in a Traveler

to Jamaica, West Indies
Simone J. French and John F. Lindo

Pruritic skin conditions are not uncommon in
emergency departments. Most are noninfectious and they
are rarely serious, requiring only symptomatic treatment.
We describe a case of cutaneous larva migrans (CLM)
acquired during topless sunbathing on a tropical beach
that is unique in several ways.
Case Report
An 18-year-old female Swedish national was brought
to the Accident and Emergency Department of the
University Hospital of the West Indies (UHWI),Kingston,
Jamaica by a general practitioner, with a 3-day history
of a pruritic eruption on the skin affecting the chest,
breasts and back. She had sunbathed topless on several
occasions in the Negril resort area of western Jamaica.
Significant examination findings were confined to
the skin. There were multiple serpiginous tracks on the
chest, breasts and back, with associated areas of redness
(Figure). The lesions were recognized as those typical
of CLM. The lesions were atypical in location, since
normally they are most often found on the feet and legs.
The dramatic pattern resulted from what appeared to be
a heavy infection.
The patient was treated with oral thiabendazole
50 mg/kg per day for 3 days, and follow-up was arranged
with a dermatologist in the resort area where she was
staying. She was not examined again at the UHWI before
her return to Europe.
The dog and cat hookworms, Ancylostoma caninum
and A. braziliensis, most often cause CLM, although it
may also result from infection with other nematodes,
including Uncinaria stenophala, Bunostomum phlebotomum
and Dirofilaria sp.1
About two-thirds of lesions due to CLM occur on
the feet, with only 7% of lesions occurring on the trunk
and upper extremities.2 The lesions in the case reported
were found at unusual sites, namely the chest, breasts and
back. The case was also remarkable for the large number
of lesions, which must have resulted from a heavy in-
fection.Once in the skin,the larvae are unable to penetrate
the stratum germinativum of their unnatural human host
and migrate laterally, causing a localized nonspecific
dermatitis.1 The worms may remain stationary, but often
migrate 1 to 2 cm each day.1
Migration of the larvae is characterized by wander-
ing, serpiginous, raised tunnels in the skin that are clearly
visible to the naked eye.1 Lesions are usually few in
number, but the presence of multiple larvae may produce

Simone J. French, DM: Department of Accident and

Emergency Medicine, The University of the West Indies;
John F. Lindo, PhD: Department of Microbiology,
The University of the West Indies, Kingston, Jamaica.

The authors had no financial or other conflicts of interest to

disclose.

Correspondence: Dr John F. Lindo, PhD, Department

of Microbiology, The University of the West Indies,
Figure Creeping eruption on patient’s back comprising multiple
Kingston 7, Jamaica.
serpiginous tracks. Similar lesions were present on both breasts
J Travel Med 2003; 10:249–250. and the chest.

249
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bizarre patterns. Although the actual duration is variable,
the disease is often self-limiting, with between 25%
and 81% of cases resolving within 4 weeks of infection.2
Patients who seek medical attention most often present
within a few days of onset, due to the discomfort of the
pruritus.
CLM occurs in a sporadic manner and is therefore
not often encountered by physicians. In fact, the initial
diagnosis made by doctors is wrong in 55% of cases;
erroneous diagnoses include ant bites, scabies and linear
lichen planus.3 Misdiagnosis often leads to inappropriate
treatment, such as local application of steroids or cryo-
therapy, and delay in time to definitive therapy.3,4 Diagnosis
(as in this case) is made on the basis of the characteristic
clinical features.1 There is no role for the laboratory, since
eosinophilia occurs in a minority of cases, and total serum
IgE and other serologic markers for worm infection are
unhelpful.1
Rarely, the larvae gain access to the lungs and are
coughed up and swallowed. Pulmonary involvement
produces Loeffler’s syndrome, the hallmark of which is
persistent cough.1
Epidemiologic information for the Caribbean is
scant; however, a study conducted by Lee and Bishop
in 1998 in Montserrat estimated an incidence of 0.064%
among children.5 Several cases of CLM have been
reported among European and American tourists who
were infected while on holiday in Jamaica.3 Furthermore,
29 (48%) of 60 Canadians who contracted CLM while
on holiday in the Caribbean had visited Jamaica.6 Risk
factors for the development of CLM among holiday-
makers included younger age, infrequent use of protective
footwear, and increased time spent on the beach at night.5,6
Ninety percent of affected persons in one series reported
seeing stray animals on the beach where they were staying,
and cats were reported far more commonly than dogs.6
Most endemic areas are characterized by the absence of
laws and practices to prevent fouling of beaches and other
public areas by dogs and cats. The case reported is likely
to have come into contact with infective larvae while
sunbathing on the local beach. Currently, there are
intervention programs in the Caribbean to remove cats
and dogs from public beaches in light of the threat to the
region’s fragile tourism industry from CLM.
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 1 0 , N u m b e r 4
Eggs of Ancylostoma and Uncinaria species were present
in 23% and 22.7%, respectively; of the stools of well-cared-
for dogs in a residential area of Kingston, Jamaica, and
the rate of helminth infection is likely to be even higher
among strays.7 Strays represent a significant reservoir for
infection, as illustrated by the case.
Therapy for CLM includes cryotherapy with dry
ice or ethyl chloride and local application of a 10–15%
thiabendazole solution or ointment in early cases. Oral
thiabendazole, albendazole and ivermectin have also been
used with good effect.1,3 In the severe case described, it
is unlikely that topical thiabendazole would be effective,
because of the apparent heavy worm burden.
This case illustrates an uncommon, severe com-
plication of topless bathing. The diagnosis was made
rapidly, as the patient presented in an endemic area.
Physicians in industrialized areas should be aware of this
condition,which could be misdiagnosed if not considered.
References
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