J. Parasitol., 101(4), 2015, pp.

488489
American Society of Parasitologists 2015

Autochthonous Hookworm-Related Cutaneous Larva Migrans Disease in Northeastern Italy:

A Case Report
W. Akkouche*, S. A. Ahmed*, A. Sattin, S. Piaserico, A. Calistrijj, E. De Canale*, and C. Parolin*jj
* Microbiology and Virology Unit, Azienda Ospedaliera di Padova, Via Giustiniani, 2 - 35128 Padova, Italy. Correspondence should be sent to:
ettore.decanale@sanita.padova.it
After 3 days of treatment, due to a worsening of the situation the
patient decided to interrupt the corticosteroid therapy and arrived at the
rst-aid Unit of the Padua Hospital and from there went to the
Microbiology and Virology Unit. At the physical examination, no lesions
were appreciable in the thumb. However, serpiginous erythematous
lesions, slightly raised, were noticeable creeping from the wrist of the
right forearm up the arm to the right shoulder (Fig. 1AD). A similar
lesion of a smaller size (roughly 5 cm) was also present on the left forearm.
At the follow-up, 2 days later, the lesions progressed from the right
shoulder to the left one (Fig. 1D). The patient reported he lived with a dog
and a cat, he was not aware of a personal or familiar history of allergy,
and he did not present fever or trauma. Moreover, he denied travels
outside Italy.
Parasitological stool examination, including stool concentration
procedures for the detection of worm eggs and larvae, were negative for
the patient and for his pet animals. Blood tests of the patient were normal
except for a mild increase of the eosinophil absolute count (0.71 3 109/L).
Moreover, while the epidermis was spared, in the upper dermis the
cutaneous biopsy showed an inammatory inltrate, characterized by the
presence of lymphocytes, and neutrophil as well as eosinophil granulocytes. The rate of lesion progression on the right arm was up to 10 cm per
day while in the left forearm lesions progressed only a few millimeters per
day. Even thought the most-common anatomic locations of HrCLM
lesions are the feet, followed by buttocks and thighs (Hochedez and
Caumes, 2007; Heukelbach and Feldmeier, 2008), overall the anamnestic,
laboratory, and clinical data were suggestive of such a disease. Thus, the
patient was treated with systemic Albendazole (400 mg for 3 days), which
represents the treatment of choice in these cases (Caumes, 2000). After 1
day the itch stopped and, after 3 days, cutaneous lesions completely faded.
The resolution of symptoms conrmed the diagnosis.
HrCLM disease is caused by the lariform larvae of different
Ancylostomatidae nematodes that mainly affect dogs and cats, which
release the eggs in their feces (Capelli et al., 2003; Mehta and Shenoi, 2004;
Hochedez and Caumes, 2007; Heukelbach and Feldmeier, 2008; Vanhaecke et al., 2014). Humans are infected through accidental penetration
of their skin by free-living larvae at the lariform stage. The larvae burrow
through the intact skin upon contact with contaminated-soil beach sands
(Morrone et al., 2008). Moreover, larvae of hookworms are excellent
swimmers and can survive for weeks in humid environments. After being
trapped in the epidermis, the larvae can rapidly migrate, producing the
classical clinical picture with creeping spongiotic vesicles (Davies et al.,
1993). Neither larvae nor eggs are released in human stools.
Nematodes of signicance in veterinary medicine in Italy that can cause
HrCLM are mainly represented by Ancylostoma caninum and Uncinaria
stenocephala (Capelli et al., 2003; Traversa et al., 2014). In particular, the
latter is well adapted to temperate climates and is widespread in the red
fox (Vulpes vulpes) population in Italy. Human cases of HrCLM in Italy
have already been reported with an outbreak in Naples (Galanti et al.,
2002) and additional cases in Rome (Biolcati and Alabiso, 1997; Morrone
et al., 2008).
The uncommon presentation of the initial HrCLM lesions on the right
hand (Hochedez and Caumes, 2007) points to the animal samples
handled and collected by the patient, with bare hands during his daily
work, as a possible source of infection. Furthermore, as mentioned
above, he also reported direct contact with water drained from a pond

ABSTRACT:

Here we report the case of a 42-yr-old patient who presented

himself to us with a serpiginous erythematous lesion from the wrist of the
right forearm up the arm to the right shoulder A similar lesion of a smaller
size was also present in the left forearm. On the basis of clinical
manifestations and progression of the lesion, combined with previous
treatments and different diagnostic investigations, hookworm-related
cutaneous larva migrans (HrCLM) disease was hypothesized.
Albendazole was employed as treatment and the resolution of the
symptoms conrmed the diagnosis. The relevance of the reported case
relies on 3 main aspects: the acquisition of the disease in Italy, the initial
treatment with topical corticosteroids that sped up the progression of the
cutaneous trail, and the uncommon location of the lesions. Furthermore,
the anamnestic data and the laboratory/clinical investigations strongly
suggested an occupational exposure to the etiological agent. As illustrated
here, HrCLM might represent a challenge for Western physicians in terms
of diagnosis, treatment, and ways of acquisition. Describing the clinical
presentation and the treatment of cases of cutaneous larva migrans might
contribute to early and correct diagnosis, to an increase of our knowledge
on this disease, and to an update on its epidemiology.

In Western countries hookworm-related cutaneous larva migrans

(HrCLM) is one of the most-frequent dermatological disorders reported
in tourists returning from topical regions (Caumes et al., 1995; Boggild et
al., 2006; Hochedez and Caumes, 2007). Furthermore, although rare in
temperate areas, autochthonous cases of HrCLM have been reported in
New Zealand and the United States as well as in Europe (Davies et al.,
1993; Heukelbach and Feldmeier, 2008). Despite its frequency, this travelassociated skin disease represents a challenge for Western physicians.
Indeed, wrong or delayed diagnosis and inappropriate treatments are very
common events (Hochedez and Caumes, 2007).
A 42-yr-old Italian man, working as a zoology technician in different
intensive farms of the Venice province, presented himself at the rst-aid
unit of the Padova Hospital with a 1-wk history of itchy skin lesions on
both upper arms. The patient used to work with bare hands in handling
and collecting animal samples. Furthermore, in 1 of the farms located in a
rural area, he was in contact with an old water pipe that drained the water
used to knead the feed for the livestock from a natural, open-access pond.
During the anamnesis, he reported the initial development of several
itchy papules and vesicles in the right thumb. His condition remained
stable during the following 2 days. After a diagnosis of allergy by the
general practitioner, he treated the itchy part of his hand with topical
corticosteroids.
Parasitology Department, Suez Canal University, Ismailia, 45122,
Egypt.
Infectious and Tropical Diseases Unit, Azienda Ospedaliera di Padova,
Via Giustiniani, 2 - 35128 Padova, Italy.
Unit of Dermatology, Department of Medicine, University of Padova,
Via Cesare Battisti, 206-35128 Padova, Italy.
jj Department of Molecular Medicine, University of Padova, via A.
Gabelli, 63 - 35121 Padova, Italy.
DOI: 10.1645/15-725.1
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FIGURE 1. Photographs of different affected sites in the patient showing serpiginous lesions typical of the cutaneous larva migrans syndrome. (A)
Ventral aspect of the right forearm. (B) Ventral and medial aspects of the right arm. (C) Extension of lesion to the right shoulder. (D) Creeping of lesion
to the back and left shoulder. The photographs were taken at day 5 (AC) and day 7 (D), after the onset of symptoms upon written consent from the
patient.
accessible to wild animals. In 2003 in the Italian district of Lodi
(Lombardy), located at the same latitude with respect to Padova, a case
of HrCLM with lesions at the right wrist and calf was described in a
subject working with hydraulic pumps and suction pipes to irrigate elds
(Veraldi et al., 2003). All together these data, along with the lack of eggs
and larvae in stools of our patients pets and the absence of infestation
evidence among his family members, strongly suggest an occupational
exposure to the larvae. The possibility that autochthonous HrCLM in
temperate countries might represent an occupational disease deserves
further investigations with an accurate analysis of environmental/animal
samples collected at work.
Intriguingly in the reported case, the high rate of lesion progression in
his right arm appeared to be anomalous for HrCLM (Davies et al., 1993).
However, it has been previously reported by Morrone and coworkers
(Morrone et al., 2008) that the application of a topical steroid, which is
normally used to treat cutaneous dermatitis (Usatine and Riojas, 2010),
induces a faster progression of the lesions. Thus it is likely that, also in the
reported case, the corticosteroid which was administered in the right
forearm was responsible for the atypical presentation.
In conclusion, we report here a case of autochthonous HrCLM in
northeastern Italy potentially linked to occupational exposure to the
etiological agent. Currently, HrCLM represents a challenge to Western
physicians in terms of diagnosis, treatments, and ways of acquisition, all of
which might inuence the presentation as in the case described here. On
the other hand, the administration of incorrect drugs due to a wrong
diagnosis might have a negative impact on the disease course, as illustrated
by the effect of topical corticosteroids on the progression of the cutaneous
trail in our patient. Reports describing the clinical presentation and the
treatment of cases of HrCLM in Europe, as does the present one, might
contribute to an increase in our knowledge of this disease and an update to
its epidemiology.

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