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Case presentation 1CUTANEOUS LARVA
MIGRANS
Shinta dewi / Sawitri
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BACKGROUND
• creeping verminous dermatitis, sandworm eruption,plumber’s itch, duck hunter’s itch
Cutaneous Larva Migrans
• animal hookworms ( Ancylostoma braziliense, A.
caninum , Uncinaria stenocephala,Bustonum phlebotonum)
Most common cause
• (Carribean, Africa, Central and South America, India, Southeast Asia)
Most common areas
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BACKGROUND
Whois atrisk
Barefoot beachcombers and sunbathers
Children in sandpits
FarmersGardeners
Plumbers
Hunters
Electricians
Carpenters
Pest exterminators
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Related Physical Findings:
Wheezing, dry cough andurticaria
Time fromexposure to onset
of symptomsusually 1 to 6 days
Skin changes is themost prominent
findings
The most commonanatomic sites isfeet and buttocks
The eruption lastbetween
2 and 8 weeks
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BACKGROUND
CLM
• condition in which larvae of any animal nematodes
infect humans, and the infected human is a dead endhost.
Creeping Eruption• the clinical findings of a migratory serpiginous lesion.
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Case Identity • Name : Ms. Y
• Sex : Female
• Age : 45 y.o
• Occupation : housewife
• Address : Sidoarjo
• Reg No : 12198383
• Outpatient clinic : 12 Agustus2013
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• Itchy red linear lesion at the left breast
since 5 days before she came to
outpatient clinic
• At first the lesion was small, like an acne
then increase in length and became curvy
• She never take oral or applied topical
medication
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• She loves gardening, history of last
gardening 1 weeks ago, in which she never
wore gloves
• No history of having the same disease
before
• No history of family or surrounding people
having the same disease as patient.
• No history of having pet in her home
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PHYSICAL EXAMINATION
VITAL SIGN
BP 120/80, PR : 80, RR : 20, BT : 36.5 oC
GENERAL STATUS Compos mentis, look well Head/Neck : anemia-, icterus-,cyanosis-,dyspnea- Thorax : Cor and pulmo within normal limit Abdomen : Soepel, liver and spleen not palpable Extremity : Warm, no edema
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DERMATOLOGICAL STATUS
12 August 2013
• Regio mamae
sinistra : Curvy
erythematous linear
papule and pustule
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ASSESSMENT
CUTANEOUS LARVA MIGRANS + SECUNDER INFECTION
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DIAGNOSIS
• -
TERAPI
• Natrium Fusidat u.e for 4
days
Planning
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• Patient complain
• Progression of the lesion
• Control to outpatient clinic Monitoring
• Do not manipulate thelesion
• Wear protection, such as
gloves, when come incontact with soilEducation
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12-08-13
16-08-13
23-08-13
02-09-13
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FOLLOW UP 2013 2013 2013
Subjective :
-Itchy
-Burn sensation-pustule
++
+++
++
+-
+
--
-
--
Objective:
-Curvy
erythematous
linear papule
-Scale
-Erosion
-Hiperpigmentation
-Pustule
+ +
++
++
-
+
++
++
-
-
-
+
-
-
-
-
-
-
-
-
+
-
Theraphy -Natrium
Fusidat
2%
-
Loratadin
e 10 mgtab
-chlorethyl
spray
-Albendazole
1x1tab, 3 days
-loratadine 10
mg tab
- Chlorethyl
spray
- Loratadin
10 mg tab
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About CLM
• Cutaneous larva migrant is a parasitic skin
disease caused by the migration of animal
hookworm larvae in the epidermis
• most common hookworm species being
A.braziliense n A.caninum.
•
Contact with sand or soil contaminated withanimal feces is required for infection to occur.
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• Larvae penetrate the human skin and migrate
up to several cm a day, usually between
stratum germinativum and stratum corneum.
• Induces localized eosinophilic inflammatory
reaction.
• Cannot penetrate through basal membrane-
Self limiting.
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Differential Diagnose
• Scabies
• Contact dermatitis
•
Dermatophytosis
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CLINICAL MANIFESTATION
THEORY
Subjective
• itching
• burning
• Contact with
contaminated sand or
soil skin lesion 1-5 days
after exposure• Movement up to
several cm per day
My patient
• Subjective
• Itching (+)
• Burning (+)
• Contact with Last soil, last7
days (+)
• Increase in length (+)
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Theory
Physical examination
• Erythematous, raised,vesicular, linear orserpentine cutaneoustrail
• Vesicular or bullouslesions at the site of
penetration• predilection: buttocks,
feet
My Patient
Physical examination
• Erythematous, raised,
vesicular, linear +,serpentine cutaneous trail
• Mamae sinistra
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Diagnosis
* Clinical findings
- Skin biopsy, skin scraping
Diagnosis* Clinical findings (+)
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THEORY THERAPY
- Albendazole 400mg p.o daily for 3days
- Ivermectin 200ug/kg daily for 1-2
days
- Topical tiabendazole oralbendazole 10%
- Chlorethyl spray along lesion
- Surgical excision or cryotherapy notrecommended
My Patient
- Albendaxole 400 mg p.o daily for3 days
- Chlorethyl spray along lesion
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Histophatology
orthokeratosis, multiple intraepidermal bullae, spongiosis,
dilated vascular channels, lymphocytic exocytosis, and
numerous eosinophils
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Mechanism of action Albendazole
1. Inhibit the polymerization of the parasite
tubulin into microtubules
• (There is a higher affinity of albendazole to
the parasite tubulin, so the activity is
mediated mainly againts the parasite rather
than on the host)
2. Inhibition of the enzyme fumarate reductase
which is helminth specific
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MECHANISM OF ACTION
INVERMECTINE
• Ivermectin kills the larval Onchocerca volvulusworms – microfilariae – that live in thesubcutaneous tissue of an infected person.
• Ivermectin does not kill the adult worms butsuppresses the production of microfilariae byadult female worms for a few monthsfollowing treatment, so reduces transmission,As the adult worms can continue to producemicrofilariae until they die naturally