CUTANEOUS GNATHOSTOMIASIS: A CASE REPORT IN
Le Dinh Vinh Phuc, Lu Hoang Vu, Nguyen Trung Ngon
Abstract. A 33 year-old tourist guide man living in
Chi Minh City, Vietnam
came to Medic Medical
Center in with swellings at two forearms for 10 days. Lesions were gradually moving downward
and sometimes he got feeling like
something crawling under the skin with
itching, pain, and redness. We suspected larvae migrans syndrome and appointed
a number of tests. The eosinophil increased and the serology was positive for Gnathostoma IgG. We performed a skin
biopsy from his right forearm lesion and caught a
larva of Gnathostoma spinigerum. He was treated with a single dose of ivermectin (200 μg/kg/day). Re-examination after 3 weeks,
clinical symptoms resolved very well and eosinophil returned to normal. Ho Chi Minh City
Correspondence: Le Dinh Vinh Phuc, Medic Medical Center, 254 Hoa Hao Street, Ward 4, District 10, Ho Chi Minh City, Vietnam.Tel: 84.8.39270284 ; Fax: 39272543
Gnathostomiasis is a parasitic infection caused by the third-stage larvae of the helminths Gnathostoma spp., which are seen mostly in tropical and subtropical regions .
In Vietnam, G. spinigerum, G. hispidum, G. doloresi, and G. vietnamicum have been documented in the literature . However, only G. spinigerum is known to be responsible for human cases . The first human case was due to G. spinigerum, described in 1965, in a boy from Tay Ninh province, with a migrating tumor on his head . More than 20 years later, no more human cases have been reported. Until 1998, 3 human cases due to G. spinigerum were documented, with worms found in skin lesions .
The clinical features can be divided into immediate symptoms, a cutaneous form, and a visceral form. The triad of eosinophilia, migratory lesions, and obvious exposure risk are highly suggestive of the diagnosis of gnathostomiasis. Exposure risk must include residence in or travel to an area of endemicity and consumption of food that potentially contains the larval form of the parasite (raw or undercooked fish [in particular swamp eels, catfish, sleeper perch, bream, Nile tilapia, butterfish, loaches, or snake-headed fish], frogs, chickens, cats, or dogs) .
We report a case of cutaneous gnathostomiasis diagnosed by creeping eruption in both 2 arms and a caught larva from cutaneous lesion of the forearm.
On June 26, 2012, a 33 year-old man came to
with swellings at two forearms. He is a tourist guide in a domestic company. He was healthy without
a significant medical history. About
10 days now, he emerged
swollen lesions from the skin and prominent zigzag in one third of the forearm between
the two sides together with itching, pain, redness,
and hot to the touch. Lesions gradually moving downward and
sometimes he got feeling like something
crawling under the skin (Figure 1). Ho Chi Minh City
Figure 1. Larvae migrate under the skin on the right and left forearms.
During physical examination and exploitation epidemiological factors we noted he occasionally eat frogs grill in restaurant. We think about illness larvae migrate to the skin and do some tests.
The red blood cell counts of 5,060,000/mm3 and a white blood cell counts of 8,830/mm3 (50.7% neutrophil, 35.3% lymphocyte, and 10.7% eosinophil, absolute eosinophil count = 940/mm3). The serology was positive for Gnathostoma IgG. He was sent to the operating room for a small incision of his forearm to catch the larva to identify. In the specimen we found out a larva of Gnathostoma spinigerum (Figure 2).
Figure 2. Specimen of head of third-stage larvae of Gnathostoma spinigerum with four rows of spines.
Cutaneous gnathostomiasis is the most common manifestation of infection. It typically presents with intermittent migratory swellings, (nodular migratory panniculitis), usually affecting the trunk or upper limbs. These nonpitting edematous swellings vary in size and may be pruritic, painful, or erythematous . The criteria for a diagnosis of cutaneous gnathostomiasis were based on 1) presence of migratory swelling lasting at least two days; 2) absolute eosinophil counts >500/mm3; 3) stool examination results negative for other parasites; 4) presence of antibodies against a specific 24-kD antigen for Gnathostoma spinigerum by Western blot analysis; 5) a history of eating raw freshwater fish, crab, snake, bird, or chicken; and 6) a positive skin test result for G. spinigerum. A person was diagnosed with cutaneous gnathostomiasis if he or she satisfied criteria 1, 2, 3, and 4, plus criteria 5 or 6 .
Our case includes typical clinical symptoms, epidemiological factor, eosinophil increasing, positive serology and a caught larva from skin lesion.
Detection of the worm in the skin, although rarely found, is important to confirm the diagnosis of cutaneous gnathostomiasis. During 1986-1990, 127 patients were diagnosed with cutaneous gnathostomiasis but only 17 patients (13.39%) were found to have cutaneous worms (Kraivichian P, Yingyaud P, unpublished data). Thus, in most cases, only a presumptive diagnosis is made based on the clinical ground alone when the worm cannot be identified. Surgical removal of the worm is considered the best treatment for cutaneous gnathostomiasis. However, it is rather difficult to obtain the parasite .
Vietnam, more than 600 cases
from different cities of south Vietnam
have been diagnosed based on clinical symptoms and signs, eosinophilia and
ELISA at the Department of Parasitology, School
and Medicine. Cutaneous gnathostomiasis accounted for 63.8%. In 10
parasitologically confirmed cases, larvae were found from the skin: 7 with
spontaneously exiting larvae, 3 by skin biopsy. All 10 causative agents found
were G. spinigerum . University of Pharmacy
We think finding the third-stage larvae to identify will be difficult because of its very small size compared to the lesions under the skin where it causes, and depend on the experience of the surgeon.
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