Embed Size (px)
Citation preview
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
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
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
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
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
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
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)
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
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?
