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HELMINTH INFECTIONS& THEIR CUTANEOUS MANIFESTATIONS

Brittany Grady, DO

DISCLOSURES

I have no conflicts of interest to declare

LEARNING OBJECTIVES:

• Describe the cutaneous manifestations of helminth

infections

• Recognize recent developments and incidence of

helminth infections within the United States of America

• Evaluate, diagnose, and treat affected patients more

knowledgeably and effectively

WHAT IS A HELMINTH?

• Helminths (worms) are large, multicellular organisms

• Often visible to the naked eye

• Free-living or parasitic

• Belong to 2 different phyla:

• Roundworms (Nematodes)

• Flatworms (Platyhelminthes)

ROUNDWORMS (NEMATODES)

• Unsegmented

• Each species has 2 different sexes

• Contain a body cavity and digestive tract

FLATWORMS (PLATYHELMINTHES)

• Segmented or unsegmented

• Primarily hermaphroditic

• Do not have a body cavity

• Further subdivided into 2 different classes:

• Flukes (Trematodes)

• Tapeworms (Cestodes)

ROUNDWORM (NEMATODE) INFECTIONS

• Cutaneous Larva Migrans

• Onchocerciasis

• Filariasis

• Strongyloidiasis

• Trichinosis

• Toxocariasis

CUTANEOUS LARVA MIGRANS (CLM)

• AKA Creeping Eruption

• CLM primarily affects people in tropical and

subtropical climates, including the SE United States

• Caused by animal hookworms, most commonly

Ancylostoma braziliense and A. caninum

• Eggs are eliminated via animal (cat or dog) feces

and larvae mature in the sand/soil

• Larvae infiltrate exposed skin surfaces of humans (end

hosts)

• Confined to the epidermis (lack collagenase)

XX X

CLM

CUTANEOUS LARVA MIGRANS (CLM)

• Larval migration through the epidermis (1-2 cm/day)

• Clinical features:

• Localized, intense pruritus

• Linear or serpiginous raised erythematous “tracts”

• +/- vesiculation

• Most frequent location is distal lower extremities or

buttocks

• Diagnosis usually made clinically (biopsy rarely helpful)

W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed. Edinburgh:

ElsevierGrayson/Saunders; 2012: 761-895

Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd

ed. Edinburgh: Elsevier/Saunders; 2012: 1391-1421

www.visualdx.com

Grady BE, Baum B. A Classic Case of Cutaneous Larva Migrans. 2013.

http://www.consultantlive.com/skin-diseases/content/article/10162/2148906

CUTANEOUS LARVA MIGRANS (CLM)

• Self-limited, but patients typically seek medical treatment

• Treatment options:

• PO Albendazole 400-800mg/day (Peds: 10-15 mg/kg/day) x 3-5 days

• PO Ivermectin 12mg (Peds: 150 mcg/kg) x 1

• Topical 10-15% thiabendazole solution or ointment TID x 15 days

• Cryotherapy to leading edge of skin tract (often unreliable)

ONCHOCERCIASIS

• AKA River Blindness

• Onchocerciasis primarily affects people in tropical Africa

• Caused by Onchocerca volvulus

• Transmitted via blood meal of infected black fly (Simulium

spp.)

• Larvae mature into adult worms in the dermis and subcutis

• Mature adult female worms become encapsulated in

fibrous tissue (onchocercomas)

• Each worm produces hundreds of microfilariae which

migrate to the skin, connective tissue, eyes, and lymph

nodes

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of

the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed.

Edinburgh: Elsevier/Saunders; 2012: 761-895www.who.int/intestinal_worms/en

ONCHOCERCIASIS

• Clinical features:

• Onchocercomas- firm, freely mobile subQ nodules often

located over bony prominences

• Acute papular onchodermatitis chronic onchodermatitis

lichenification, atrophy, depigmentation

• “Hanging groin”- chronic lymphatic obstruction of inguinal

lymph nodes

• Progressive sclerosing keratitis can lead to blindness in severe

cases

• 2nd most common cause of infection-related blindness

• Accounts for 0.8% of overall blindness globally

www.visualdx.com

Nelson SA, Warschaw KE. Protozoa and Worms. In:

Dermatology 3rd ed. Edinburgh: Elsevier/Saunders; 2012:

1391-1421

www.visualdx.com

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of

the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895

Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology

3rd ed. Edinburgh: Elsevier/Saunders; 2012: 1391-1421

Grayson W. Infectious Diseases of the Skin. In:

McKee’s Pathology of the Skin 4th ed.

Edinburgh: Elsevier/Saunders; 2012: 761-895

ONCHOCERCIASIS

• Treatment options:

• DOC: PO Ivermectin 150 mcg/kg x 1 q3-12 months

• Treatment continued for worm’s lifetime (10-15 years)

• Adjunct: PO Doxycycline 100-200mg/day x 6 weeks

• Targets Wolbachia endobacteria that reside within the O.

volvulus nematodes

• Wolbachia is responsible for inflammation that leads to

subsequent protective fibrosis

• Nodulectomy: surgical removal of onchocercomas

from head/neck reduces the incidence of ocular

disease

FILARIASIS

• AKA Elephantiasis

• Filariasis primarily affects individuals in tropical or subtropical

regions, including the Caribbean Islands and South America

• Caused by Wucheria bancrofti (90% of cases)

• Transmitted via bite of infected mosquitoes

• Deposited larvae migrate to lymphatic system and develop into

adult worms

• Adult worms release microfilariae into the bloodstream

Cano J, Rebollo MP, Golding N, et al. The Global Distribution and Transmission Limits

of Lymphatic Filariasis: Past and Present. Parasites & Vectors. 2014 Oct; 7: 466

www.visualdx.com

FILARIASIS

• After 10-15 years of infection, the clinical features of

chronic disease become evident

• Leading cause of permanent disability worldwide

• Clinical features:

• Acute adenolymphangitis associated with fevers and chills

(recurrent)

• Chronic lymphedema hypertrophy of skin

(hyperkeratotic, verrucous, fibrotic) redundant folds

deformity

• Secondary bacterial and fungal infections common

• Most commonly affected sites: lower extremities and genitalia

www.visualdx.com

www.visualdx.com

James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and Bites. In: Andrews’ Diseases of the Skin: Clinical Dermatology 11th ed. Edinburgh: Elsevier/Saunders; 2011: 414-447

FILARIASIS

• Treatment options:

• DOC: PO Diethylcarbamazine 6 mg/kg/day x 12 days

• Active against microfilariae, limited effect on adult worms

• Adult worm lifespan in host approx. 5-10 years

• Adjunct: PO Doxycycline 200mg/day x 4-8 weeks

• Targets Wolbachia endobacteria

• Supportive care: limb elevation, compression stockings,

protection from trauma, NSAIDs

STRONGLYLOIDIASIS

• AKA Larva Currens

• Worldwide distribution, especially in tropical and subtropical regions, including SE United States and Appalachia

• Caused by the human parasite Strongyloidesstercoralis

• Transmitted via direct contact with free-living larvae, usually through contaminated soil

• Larvae penetrate skin migrate to intestine to mature into adult worms lay eggs develop into infective larvae in intestine

• Infective larvae migrate toward the perianal opening

• Penetrate skin

Puthiyakunnon S, Boddu S, Li Y, et al. Strongyloidiasis-An Insight into

Its Global Prevalence and Management. PLoS Negl Trop Dis. 2014

Aug; 8(8): e3018

www.cdc.gov/par

asites

STRONGLYLOIDIASIS

• Most patients with strongyloidiasis are asymptomatic

• Larval migration through skin (up to 10 cm/day)

• Clinical features:

• Urticarial serpiginous, raised, erythematous “tract” usually

located on the buttocks or trunk

• Autoinfection can cause the rash to recur for weeks to years

• Hyperinfection with Strongyloides- diffuse petechiael

“thumbprint purpura” eruption

• Seen in immunocompromised individuals

• Dermal invasion of a large number of larvae that migrate

through vessel walls

• High mortality

www.cdc.gov/parasi

tes

www.visualdx.com

STRONGLYLOIDIASIS

• Recommended to treat all known infected patients,

whether symptomatic or not

• Consider testing patients at risk prior to initiating

immunosuppressive drugs i.e. corticosteroids

• Microscopic stool examination

• Treatment options:

• DOC: PO Ivermectin 0.2 mg/kg/day x 2 days (consider

repeating in 2 weeks)

• PO Albendazole 400 mg BID x 7 days

• PO Thiabendazole 25 mg/kg BID x 2 days (7-10 days for

hyperinfection syndrome)

TRICHINOSIS

• Worldwide distribution, including the United States

• Caused by Trichinella spp. (most commonly Trichinella

spiralis)

• Transmission via ingestion of larva-containing cysts in raw or

undercooked meat

• Ingested larvae invade small bowel and mature into adult

worms

• Adult female worms release larvae that migrate to striated

muscle and encyst (may remain viable for several years)

• Disease severity categorized as light (1-10 ingested larvae),

moderate (50-500 ingested larvae), or severe (>1000

ingested larvae)

www.visualdx.com

TRICHINOSIS

• Pigs are the most common source of human infection

• Typically from consumption of home-prepared

sausage or undercooked wild game in the U.S.

• Worldwide incidence has declined dramatically in

past 2-3 decades

• Improved pig-raising practices

• Improved inspection processes

• Commercial and home freezing of pork

• Public awareness of danger of eating undercooked

meats

www.cdc.gov/para

sites

www.cdc.gov/parasites

TRICHINOSIS

• Nonspecific GI symptoms occur first (1-2 days post consumption)

• Classic symptoms occur within 2 weeks of eating contaminated meat

• Clinical features:

• Myalgias (approx. 90% cases)

• Periorbital edema

• Nonpruritic morbilliform exanthem (uncommon)

• Subungual splinter hemorrhages

• Rare, severe cases may affect CNS, heart, and/or lungsdeath

www.visualdx.com

www.visualdx.com

TRICHINOSIS

• Self-limited if mild disease

• Treatment options:

• PO Corticosteroids- Prednisone 40-60 mg/day until symptoms

resolve (followed by gradual taper)

• Highly recommended to address allergic-reaction related signs and

symptoms

• Especially if CNS, cardiac, or pulmonary involvement

• Caution: Corticosteroid monotherapy may decrease the number of adult worms expelled via GI tract increased number of larvae

produced

• PO Albendazole 400 mg BID x 8-14 days

• PO Mebendazole 200-400 mg TID x 3 days, then 400-500 mg TID x

10 days

TOXOCARIASIS

• Endemic in the United States

• Highest prevalence in hot, humid regions

• Caused by Toxocara canis and T. catis (dog and cat

roundworms, respectively)

• Transmission via accidental ingestion of eggs from the

environment or (more rarely) ingestion of undercooked meat

infected with Toxocara larvae

• Eggs hatch and travel hematogenously to various body tissues

including liver, heart, brain, lungs, muscles, or eyes

• Disease primarily affects children

• 13.9% of the U.S. population ≥ 6 years of age are seropositive for

toxocariasis

TOXOCARIASIS

• A U.S. study in 1996 showed that 30% of dogs younger

than 6 months deposit Toxocara eggs in their feces

• Studies have shown that almost all puppies are born

already infected with Toxocara canis

• Research suggests that 25% of all cats are infected

with Toxocara cati

• Via Centers for Disease Control and Prevention (CDC)

TOXOCARIASIS

• Most people who are infected do not have any symptoms

• Manifestations reflect the number of migrating larvae, where the larvae

have migrated in the body, and the degree of inflammation that

developed in response to the presence of the larvae

• Clinical features:

• Transient rash, chronic urticaria, eczematous dermatitis, cutaneous

nodules

• In 2 case control studies, 65% of patients with chronic urticaria and 38.1% of patients with chronic prurigo were found to be seropositive for Toxocara

• Anti-helminthic treatment cured the chronic urticaria in 50% of cases and

the chronic prurigo in 80% of cases

• Visceral toxocariasis

• Ocular toxocariasis- at least 70 people are blinded by this disease each

year in the U.S.

www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a2.htm

Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging

Infectious Diseases with Cutaneous Manifestations. J Am

Acad Dermatol. 2016 Jul; 75(1): 19-31

TOXOCARIASIS

• Treatment indicated for symptomatic visceral or

ocular disease

• Treatment options:

• PO Albendazole 400 mg BID x 5 days

• PO Mebendazole 100-200 mg BID x 5 days

• Systemic corticosteroids may be necessary to control

inflammatory response

FLATWORM (PLATYHELMINTH) INFECTIONS

• Fluke (Trematode) infections

• Schistosomiasis

• Tapeworm (Cestode) infections

• Cysticercosis

SCHISTOSOMIASIS

• AKA Bilharziasis, Cercarial Dermatitis, “Swimmer’s Itch”

• Worldwide distribution, especially tropical climates

• Caused by Schistosoma mansoni, S. haematobium,

and S. japonicum (human schistosomes- not seen in

U.S.)

• Caused by Trichobilharzia and Bilharziella spp. (avian

schistosomes- seen in Northern U.S. and California)

• Transmission via direct contact with free-living larvae

released by freshwater snails

SCHISTOSOMIASIS (HUMAN)

• Larvae penetrate skin within minutes of contact

dermis vascular system

• Larvae mature into adult worms within vascular

system (mesenteric venules)

• Adults deposit eggs in venules intestines (S.

mansoni, S. japonicum) or bladder (S. haematobium)

• Eggs eliminated via feces or urine

SCHISTOSOMIASIS (AVIAN)

• Larvae penetrate skin within minutes of contact

• Remain in stratum corneum

• Humans are accidental “dead end” hosts

• Larvae die shortly (within hours) after initial penetration

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the

Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895

www.cdc.gov/parasites

www.cdc.gov/parasites

SCHISTOSOMIASIS

• Skin manifestations begin within minutes to hours

• Represent a hypersensitivity reaction to larval penetration of skin

• Clinical features:

• Cercarial dermatitis “swimmer’s itch”- urticarial, pruritic erythematous

papular eruption

• Most commonly on lower legs/feet

• Seen with both human and avian schistosome larvae

• Katayama fever- fever, chills, diarrhea, headache

• Hypersensitivity reaction against migrating human schistosome larvae

• Bilharziasis cutanea tarda- papular, granulomatous, or verrucous lesions

• Seen in those with chronic, visceral disease

• Secondary to deposition of eggs in the dermis

• Genital and perineal regions most commonly affected

Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd ed. Edinburgh:

Elsevier/Saunders; 2012: 1391-1421

James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and

Bites. In: Andrews’ Diseases of the Skin: Clinical Dermatology 11th

ed. Edinburgh: Elsevier/Saunders; 2011: 414-447

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin

4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895

SCHISTOSOMIASIS

• Cercarial dermatitis (acute skin eruption) is self-limiting,

but may persist for several weeks

• Treatment options (human):

• DOC: PO Praziquantel 20 mg/kg BID-TID x 1

• Treatment options (avaian):

• No treatment required for cercarial dermatitis caused by

avian schistosomes

• Antihistamines and topical corticosteroids for symptomatic

relief

CYSTICERCOSIS

• Worldwide distribution, including the United States

(most commonly SW U.S.)

• Caused by Taenia solium (pork tapeworm)

• Transmission via fecal-oral ingestion of eggs via

contaminated food or water

• Ingested eggs hatch in the small bowel and penetrate

intestinal mucosa

• Spread hematogenously and encyst in various body

tissues including muscle, brain (neurocysticercosis),

heart, eyes, and skin

• Cysts remain viable for 3-5 years

CYSTICERCOSIS

• Cysticercosis versus Taeniasis

• You cannot acquire cysticercosis from ingestion of infected undercooked pork

• A quick word about Taeniasis…

• Ingestion of T. solium larval cysts in undercooked pork

• Leads to infestation of small bowel with adult tapeworms (compared to eggs ingested in cysticercosis)

• Tapeworm lives and grows (up to 30 feet!) within the intestine

• Gravid proglottids or eggs are shed and expelled via feces (individual now an infectious carrier of disease)

• Autoinfection not uncommon ingestion of eggs cysticercosis

www.cdc.gov/parasites

www.cdc.gov/p

arasites

CYSTICERCOSIS

• Incidence is rising in the United States, especially in

states with a large immigrant population (most

commonly from endemic Latin America)

• Cases are most frequently reported in New York,

California, Texas, Oregon, and Illinois

• There are an estimated 1,000 new hospitalizations for

neurocysticercosis in the United States each year

• Neurocysticercosis is a leading cause of adult onset

epilepsy worldwide

Sorvillo, FJ, DeGiorgio C, Waterman SH. Deaths from

Cysticercosis, United States. Emerg Infect Dis. 2007 Feb;

13(2): 230-235

CYSTICERCOSIS

• Clinical features:

• Multiple, asymptomatic, firm subQ or intramuscular

1-2 cm nodules

• Can resemble other common cutaneous lesions such as

lipomas or epidermoid cysts

• Muscle involvement often associated with myalgias and

fever

• Neurocysticercosis can present with seizures

• Intraocular cysticercosis may lead to vision loss

Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of

the Skin 4th ed. Edinburgh: Elsevier/Saunders; 2012: 761-895

Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging

Infectious Diseases with Cutaneous Manifestations. J Am

Acad Dermatol. 2016 Jul; 75(1): 19-31

CYSTICERCOSIS

• The natural history of the lesions of cysticercosis is spontaneous resolution (cysts degenerate after 3-5 years)

• Studies have indicated that treated patients with neurocysticercosis have fewer residual seizures than those not treated with an anti-helminthic medication

• Inactive lesions of cutaneous cysticercosis are treated surgically

• Treatment options:

• DOC: PO Albendazole 15 mg/kg/day x at least 8 days

• PO Praziquantel 50 mg/kg/day (in 3 divided doses) x 14 days

• Consider systemic corticosteroids prior to initiation of anti-helminthic therapy

FINAL THOUGHTS

• 21st century has brought increased international travel

for vacation, business, medical missions, and

immigration

Via U.S. Dept. of State

Via U.S. Dept. of

Commerce

Via U.S. Dept. of

Commerce

FINAL THOUGHTS

• Approx. 17% of travelers seek medical care because

of cutaneous disorders

• Helminth infections are important causes of morbidity

and mortality worldwide

• Although many helminth infections are uncommon in

the United States, it is important to be aware of these

conditions (they do exist!)

• Little research has been done to calculate the

burden of these diseases within the United States

REFERENCES• Cano J, Rebollo MP, Golding N, et al. The Global Distribution and Transmission Limits of Lymphatic Filariasis:

Past and Present. Parasites & Vectors. 2014 Oct; 7: 466

• Croker C, Reporter R, Redelings M, et al. Strongyloidiasis-Related Deaths in the United States, 1991-2006. Am

J Trop Med Hyg. 2010 Aug; 83(2): 422-426

• Gavignet B, Piarroux R, Aubin F, et al. Cutaneous Manifestations of Human Toxocariasis. Ja Am Acad

Dermatol. 2008 Dec; 59(6): 1031-1042

• Grady BE, Baum B. A Classic Case of Cutaneous Larva Migrans. 2013. http://www.consultantlive.com/skin-

diseases/content/article/10162/2148906

• Grayson W. Infectious Diseases of the Skin. In: McKee’s Pathology of the Skin 4th ed. Edinburgh:

Elsevier/Saunders; 2012: 761-895

• Hoerauf A, Mand S, Volkmann L, et al. Doxycycline in the Treatment of Human Onchocerciasis: Kinetics of

Wolbachia Endobacteria Reduction and of Inhibition of Embryogenesis in Female Onchocerca worms.

Microbes Infect. 2003 Apr; 5(4): 261-73

• Housholder AL. Parasites and Other Creatures. In: Review of Dermatology. Toronto: Elsevier; 2017: 312-319

• James WD, Berger TG, Elston DM. Parasitic Infestations, Stings, and Bites. In: Andrews’ Diseases of the Skin:

Clinical Dermatology 11th ed. Edinburgh: Elsevier/Saunders; 2011: 414-447

• Kollipara R, Peranteau AJ, Nawas ZY, et al. Emerging Infectious Diseases with Cutaneous Manifestations. J

Am Acad Dermatol. 2016 Jul; 75(1): 19-31

REFERENCES

• Lupi O, Downing C, Lee M, et al. Mucocutaneous Manifestations of Helminth Infections. J Am Acad

Dermatol. 2015 Dec; 73(6): 929-957

• Nelson SA, Warschaw KE. Protozoa and Worms. In: Dermatology 3rd ed. Edinburgh: Elsevier/Saunders; 2012:

1391-1421

• Puthiyakunnon S, Boddu S, Li Y, et al. Strongyloidiasis-An Insight into Its Global Prevalence and Management.

PLoS Negl Trop Dis. 2014 Aug; 8(8): e3018

• Sanprasert V, Sujariyakul A, Nuchprayoon S. A Single Dose of Doxycycline in Combination with

Diethylcarbamazine for Treatment of Bancroftian Filariasis. Southeast Asian J Trop Med Public Health. 2010

Jul; 41(4): 800-12

• Sorvillo, FJ, DeGiorgio C, Waterman SH. Deaths from Cysticercosis, United States. Emerg Infect Dis. 2007 Feb;

13(2): 230-235

• www.cdc.gov/parasites

• www.uptodate.com/contents/strongyloidiasis

• www.visualdx.com

• www.who.int/intestinal_worms/en

QUESTIONS?