Tungiasis in a returning traveler from the tropics

Redero Cascón, Mar; Hernando Real, Susana

doi:10.1016/j.medcle.2019.03.044

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A whitish-transparent mass of ovoid shapes, 4× magnification (A); eggs, 200× magnification (B), and newly hatched larva, 200× magnification (C)." ] ] ] "textoCompleto" => "Tungiasis is a skin infestation caused by a small insect, the Tunga penetrans flea, after contact with the foot on sandy soil containing pregnant females. Over the past few decades, tungiasis, along with cutaneous larva migrans, has become the most common parasitic skin disease acquired by tourists frequenting tropical beaches.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Even so, there are few cases described in the literature. The following is a clinical case of tungiasis imported from the tropics.A 37-year-old woman, with no pathological history of interest, who, after a trip to Mozambique, in which she reported having walked with flip-flops on the beach, went to her podiatrist's office for pain in the left great toe. On examination, the podiatrist extracted material from the subungual area, with which the patient went to the Emergency Department of our hospital to be evaluated, where she was diagnosed with a parasitic nail infection. Said material was sent to the Microbiology Service for a definitive diagnosis.A whitish conglomerate of approximately 40 ovoid structures was observed on examination with magnifying glass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Eggs were visualized in the microscopic examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and a larva was observed inside the mass (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The visualized structures, together with the clinical symptoms and epidemiological history in Mozambique, allowed the definitive diagnosis of tungiasis.The patient's progression was favourable after correct debridement and cleaning of the subungual bed and subsequent application of topical antibiotic.Tungiasis is an exclusively tropical ectoparasitic infestation, currently present in southern and central America, in the West Indies, in sub-Saharan Africa and the Indian Ocean. The prevalence of tungiasis can reach more than 50% of the population in some hyperendemic areas, sometimes massive parasitic infestations, responsible for superinfections and disabilities, which is a serious health problem in developing countries.<a class="elsevierStyleCrossRefs" href="#bib0030">1,2</a>T. penetrans, also known as “nigua”, “jigger”, “chigoe flea” or “sand flea” is a blood-sucking insect, 1mm long, and it is one of the smallest fleas in the world.The infection is carried out by direct contact with the sandy soil in which the fleas jump. Only fertilized females are those that have the ability to enter the epidermis with their jaws, where they cause nodular inflammation, leaving the back of their abdomen visible. This distends and acquires a whitish spherical shape of about 5–7mm in diameter. This structure is easily visible on the fifth day. Females expel around 100 eggs (ovoid, 300×600μm) for a period of 2 weeks, after which they die and detach from the host's skin. The eggs develop into larvae, pupae, and adult fleas. The life cycle lasts about 15 days.<a class="elsevierStyleCrossRef" href="#bib0040">3</a>Clinically, tungiasis appears on the feet in 99% of the cases reported, specifically in the subungual sulcus or in interdigital spaces. Epidermal penetration goes unnoticed or creates itching and irritation. After 4 or 5 days, one or more few-millimeter long whitish papules or nodules appear, with a black dot in the center to lay eggs. When the flea increases in volume (up to 1cm), pain, inflammation and ulceration occur, which can cause difficulty walking. At this stage, the female expels the eggs. The lesion is then covered by a black scab that disappears in a few days. Secondary bacterial infections are common.<a class="elsevierStyleCrossRefs" href="#bib0045">4,5</a>Diagnosis is made based on clinical findings. It is easy to recognize in endemic areas, but in traveling patients the differential diagnosis may include a common wart, myiasis, another arthropod sting or bite, or an inflammatory reaction to a foreign body.The treatment of tungiasis in the traveling patient consists of the complete extraction of the flea or its eggs to avoid inflammatory reactions, and local disinfection. It is recommended to apply topical antibiotic for a few days to avoid bacterial superinfections.<a class="elsevierStyleCrossRef" href="#bib0045">4</a>There are very few reported cases of tungiasis in traveling patients.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> It is an infection with a benign course and not well known by health personnel, reason why it is often underdiagnosed, since few cases require medical assistance and even less a specialist in infectious and tropical diseases.In the case reported, the diagnosis of tungiasis was not clinical, but microbiological, since the health personnel who provided care to our patient were not familiar with this type of imported disease. Even so, the approach was correct, and progression was favourable.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Redero Cascón M, Hernando Real S. Tungiasis en paciente viajera procedente del trópico. Med Clin (Barc). 2020;154:376–377." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 543 "Ancho" => 1750 "Tamanyo" => 134486 ] ] "descripcion" => array:1 [ "en" => "Content extracted from the subungual bed lesion. A whitish-transparent mass of ovoid shapes, 4× magnification (A); eggs, 200× magnification (B), and newly hatched larva, 200× magnification (C)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tunga penetrans: a stowaway from around the world" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Sachse" 1 => "K.K. Guldbakke" 2 => "A. Khachemoune" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1468-3083.2006.01888.x" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2007" "volumen" => "21" "paginaInicial" => "11" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17207161" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early references to the occurrence of Tunga penetrans in tropical Africa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Hoeppli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Trop" "fecha" => "1963" "volumen" => "20" "paginaInicial" => "143" "paginaFinal" => "153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13963854" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Eisele" 1 => "J. Heukelbach" 2 => "E. van Marck" 3 => "H. Mehlhorn" 4 => "O. Meckes" 5 => "S. Franck" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00436-002-0817-y" "Revista" => array:6 [ "tituloSerie" => "Parasitol Res" "fecha" => "2003" "volumen" => "90" "paginaInicial" => "87" "paginaFinal" => "99" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12756541" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Images in clinical medicine periungual tungiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Muehlstaedt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMicm074290" "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "359" "paginaInicial" => "e30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19073971" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and histopathologic study of 39 patients with imported tungiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Nazaaro" 1 => "G. Genovesse" 2 => "S. Veraldi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cup.13410" "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "2019" "volumen" => "46" "paginaInicial" => "251" "paginaFinal" => "255" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30632189" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015400000009/v2_202005120646/S2387020620301224/v2_202005120646/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015400000009/v2_202005120646/S2387020620301224/v2_202005120646/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620301224?idApp=UINPBA00004N"]

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Vol. 154. Issue 9.

Pages 376-377 (May 2020)

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