Bullous Cutaneous Larva Migrans of the Foot

Ashton D. Hall Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio

Search for other papers by Ashton D. Hall in
Current site
Google Scholar
PubMed
Close
,
Keith M. Luckett
Search for other papers by Keith M. Luckett in
Current site
Google Scholar
PubMed
Close
, and
Kelli M. Williams Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio

Search for other papers by Kelli M. Williams in
Current site
Google Scholar
PubMed
Close

A 25-year-old man presented with a painful and pruritic rash on the right foot that had been present for several weeks. Examination revealed erythema and blistering of the toes without systemic symptoms (Figure 1). Travel history included a recent vacation to Jamaica, where the patient walked barefoot on the beach. He also reported a trip to Red River Gorge in eastern Kentucky, where he went hiking but denied getting his feet wet. He denied traumatic injury. An over-the-counter antifungal cream did not provide relief. On his initial presentation to the emergency department, he was diagnosed with atypical cellulitis, prescribed cephalexin and trimethoprim-sulfamethoxazole, and discharged. The patient returned 1 week later with worsening bullous lesions of the right foot, tenderness to palpation, and decreased capillary refill (Figure 2). Because of concern for Vibrio or Aeromonas soft-tissue infection, the patient was admitted and prescribed doxycycline and cefpodoxime. Radiographs showed a well-defined soft-tissue density projecting along the dorsal foot near the third and fourth metatarsophalangeal joint. Acid fast, anaerobic, and fungal cultures were negative after aspiration of the bullae. Magnetic resonance imaging ruled out osteomyelitis, and the patient was discharged on hospital day 3. At outpatient follow-up 1 week later, the patient’s rash had progressed to a red serpiginous lesion (Figure 3). Given epidemiologic risk factors and clinical history, the patient was diagnosed with cutaneous larva migrans (CLM) and treated with 200 mcg/kg of ivermectin for 2 days. His blistering lesions and pruritus resolved within 3 weeks (Figure 4).

Figure 1.
Figure 1.

Erythema and blistering of the third and fourth toes on initial presentation.

Citation: The American Journal of Tropical Medicine and Hygiene 110, 4; 10.4269/ajtmh.23-0750

Figure 2.
Figure 2.

Progressively worsening edema and blistering of the lesser toes despite antibiotic treatment. Picture was taken before and after aspiration of the bullae.

Citation: The American Journal of Tropical Medicine and Hygiene 110, 4; 10.4269/ajtmh.23-0750

Figure 3.
Figure 3.

Lateral view of the foot showing red serpiginous streaks from the lesser toes to the lateral midfoot and a dorsal serous blister, resulting in the diagnosis of cutaneous larva migrans.

Citation: The American Journal of Tropical Medicine and Hygiene 110, 4; 10.4269/ajtmh.23-0750

Figure 4.
Figure 4.

Resolution of bullae and serpiginous tracts following ivermectin. Picture was taken five weeks after the patient’s initial presentation.

Citation: The American Journal of Tropical Medicine and Hygiene 110, 4; 10.4269/ajtmh.23-0750

Cutaneous larva migrans, or creeping eruption, is one of the most common, albeit underrecognized, skin conditions reported in travelers returning from tropical and subtropical countries.1 This infection results from the penetration and migration of filariform larvae through the epidermis.1 Typical manifestations are intensely pruritic, slightly raised serpiginous rashes on the distal extremities, reflecting the path of the parasite.2 Bullae are atypical for CLM, accounting for only 3% of cases.24 Mechanisms responsible for bullae formation include the release of histolytic larval enzymes or a delayed hypersensitivity reaction to unknown larval antigens.2 Diagnosis is predominantly clinical and based on the patient’s travel to endemic regions, exposure to contaminated soil or sand, and a raised erythematous tract.1 Larva currens is the primary alternative diagnosis; however, it elicits severe urticaria owing to rapid larval migration at 5–15 cm per hour compared with 1–2 cm per day for CLM.5 First-line treatment includes oral albendazole or ivermectin, whereas antihistamines and corticosteroids may provide symptomatic relief.6

REFERENCES

  • 1.

    Leung AKC , Barankin B , Hon KLE , 2017. Cutaneous larva migrans. Recent Pat Inflamm Allergy Drug Discov 11: 211.

  • 2.

    Eksomtramage T , Aiempanakit K , 2018. Bullous and pustular cutaneous larva migrans: Two case reports and a literature review. IDCases 12: 130132.

  • 3.

    Veraldi S , Çuka E , Pontini P , Vaira F , 2017. Bullous cutaneous larva migrans: Case series and review of atypical clinical presentations. G Ital Dermatol Venereol 152: 516519.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Vijayasankar P , Subramaniam R , Karthikeyan K , 2022. Bullous cutaneous larva migrans of the palm. Am J Trop Med Hyg 106: 12981299.

  • 5.

    Greaves D , Coggle S , Pollard C , Aliyu SH , Moore EM , 2013. Strongyloides stercoralis infection. BMJ 347: f4610.

  • 6.

    Green R , Somayaji R , Chia JC , 2023. Bullous cutaneous larva migrans. CMAJ 195: E1040.

Author Notes

Authors’ addresses: Ashton D. Hall, Keith M. Luckett, and Kelli M. Williams, Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, E-mails: hall3ah@mail.uc.edu, lucketkm@ucmail.uc.edu, and mccaulki@ucmail.uc.edu.

Address correspondence to Ashton D. Hall, Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Ave., Cincinnati, OH 45267-0552. E-mail: hall3ah@mail.uc.edu
  • Figure 1.

    Erythema and blistering of the third and fourth toes on initial presentation.

  • Figure 2.

    Progressively worsening edema and blistering of the lesser toes despite antibiotic treatment. Picture was taken before and after aspiration of the bullae.

  • Figure 3.

    Lateral view of the foot showing red serpiginous streaks from the lesser toes to the lateral midfoot and a dorsal serous blister, resulting in the diagnosis of cutaneous larva migrans.

  • Figure 4.

    Resolution of bullae and serpiginous tracts following ivermectin. Picture was taken five weeks after the patient’s initial presentation.

  • 1.

    Leung AKC , Barankin B , Hon KLE , 2017. Cutaneous larva migrans. Recent Pat Inflamm Allergy Drug Discov 11: 211.

  • 2.

    Eksomtramage T , Aiempanakit K , 2018. Bullous and pustular cutaneous larva migrans: Two case reports and a literature review. IDCases 12: 130132.

  • 3.

    Veraldi S , Çuka E , Pontini P , Vaira F , 2017. Bullous cutaneous larva migrans: Case series and review of atypical clinical presentations. G Ital Dermatol Venereol 152: 516519.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Vijayasankar P , Subramaniam R , Karthikeyan K , 2022. Bullous cutaneous larva migrans of the palm. Am J Trop Med Hyg 106: 12981299.

  • 5.

    Greaves D , Coggle S , Pollard C , Aliyu SH , Moore EM , 2013. Strongyloides stercoralis infection. BMJ 347: f4610.

  • 6.

    Green R , Somayaji R , Chia JC , 2023. Bullous cutaneous larva migrans. CMAJ 195: E1040.

Past two years Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 606 606 225
PDF Downloads 320 320 173
 
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save