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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
 ~  Article Figures
 ~  Article Tables

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  Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 356-358
 

A rare case of cutaneous larva migrans due to Gnathostoma sp


Department of Microbiology, All India Institute of Medical Sciences, New Delhi-110029, India

Date of Submission05-Feb-2012
Date of Acceptance01-Apr-2012
Date of Web Publication8-Aug-2012

Correspondence Address:
J C Samantaray
Department of Microbiology, All India Institute of Medical Sciences, New Delhi-110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.99505

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 ~ Abstract 

A 28-year-old lady presented with recurrent erythematous skin lesions in different parts of the body for 3 months. There were several episodes of worm coming out of the lesions. Examination of the worms in the parasitology laboratory revealed it to be a larva of Gnathostoma sp. She was advised treatment with Albendazole for 21 days, and there was no recurrence of lesions.


Keywords: Gnathostoma, cutaneous larva migrans, eosinophilia


How to cite this article:
Mukherjee A, Ahmed N H, Samantaray J C, Mirdha B R. A rare case of cutaneous larva migrans due to Gnathostoma sp. Indian J Med Microbiol 2012;30:356-8

How to cite this URL:
Mukherjee A, Ahmed N H, Samantaray J C, Mirdha B R. A rare case of cutaneous larva migrans due to Gnathostoma sp. Indian J Med Microbiol [serial online] 2012 [cited 2019 Sep 22];30:356-8. Available from: http://www.ijmm.org/text.asp?2012/30/3/356/99505



 ~ Introduction Top


Gnathostoma is a tissue nematode, the larva of which is capable of causing varied symptoms in humans. The cutaneous symptoms are often mild, but recurrence is a major problem while diagnostic dilemma adds to the trouble. Visceral involvement (especially ocular and central nervous system) can be dangerous. We present a case of cutaneous gnathostomiasis with atypical presentation that was managed adequately.


 ~ Case Report Top


Ms. R, a 28-year-old lady from Imphal, Manipur, a state in North-Eastern India presented to the Dermatology outpatient department with complaints of recurrent appearance of small, dot-like itchy skin lesions in different parts of the body since last 3 months. The initial lesions appeared in the left upper arm, and subsequent lesions were observed in the back, lower abdomen and thigh [Figure 1]. These lesions were characterized by gradual increase in size accompanied by surrounding area of erythema and were intensely pruritic. Subsequently, the patient noticed a worm-like structure peeping through the centre of the lesion on application of pressure. After each episode of such observation and manual removal of the worm, the erythema and itching used to subside. In all, 5 such episodes of worm extrusion were reported by the patient. In case of lesions, where worm extrusion was not possible, swelling reappeared in a different area close to the previous one after 4-5 days of subsidence of the initial lesion. She also had an episode of diarrhoea and vomiting a few days prior to the development of skin lesions for the first time. There were non-specific complaints of muscular pain, malaise, cough (occasional) and tingling sensation in her legs. There were complaints of blurring of vision. However, an ophthalmological examination revealed no abnormalities. She was a housewife, non-vegetarian, but not used to have semi-cooked/smoked fish or meat products. Her family consumed drinking water from the local municipal supply only. She never had any pets, nor had a history of intimate exposure to stray cats, dogs or other domestic animals.
Figure 1: Photograph of skin lesion showing erythema

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Her laboratory investigations are shown in [Table 1]
Table 1: Details of initial reports of routine hemogram and two subsequent followups

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Other investigations like LFT, KFT, CXR and USG revealed no abnormality.

Based on patient's symptoms and eosinophilia, she was prescribed a course of diethyl Carbamazine (DEC) and also topical antimicrobial, antifungal and steroid ointments elsewhere. However, there was no significant symptomatic improvement (although there was significant fall in percentage and absolute eosinophil count), necessitating her visit to our tertiary care referral centre.

The worm extracted during the present episode was brought by the patient and was examined and identified [Figure 2], [Figure 3] and [Figure 4]
Figure 2: DPX mount of whole worm (10)

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Figure 3: Photograph showing four rows of hooklets and the oral opening on head bulb under microscope (40)

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Figure 4: Photograph showing tail end of the worm (40)

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The worm measured 2.2 mm in length under light microscope (100X). The breadth was variable, with a maximum of 0.3 cm. The head end was expanded containing 4 rows of hooklets, of which the last row appeared to be smaller. Internal structures like salivary glands, oesophagus or gut could not be appreciated. Ill- developed cuticular spines could be seen near the head end.

Based on the morphology, the worm was identified as a larva of Gnathostoma sp. and the patient was diagnosed as a case of cutaneous gnathostomiasis. She was started on a prolonged course of Albendazole 400 mg once daily for 21 days. There was no recurrence of symptoms accompanied by remission of non-specific symptoms.


 ~ Discussion Top


The genus Gnathostoma belongs to the Order spirurida and family Gnathostomadiae. Out of all the species, the 4 medically important species are G.spinigerum (most common and important) G.hispidum, G. doloresi and G.nipponicum. [1] Speciation can be made under microscope by observation of the distribution and shape of the cuticular spines over the body. [2]

It is a nematode, which is an important agent of zoonotic infection in countries like Indonesia, Malaysia, Burma, and Bangladesh. In Thailand and China, it is known as 'tua-chid' (painful tumour) and Changchiang Oedema, respectively. It has been reported from some states of India, mostly from the North-East. [3]

The definitive host for this organism belongs to the cat and dog family, in whom it resides within a pseudotumor formed in the gastric mucosa. In fact, the organism was first reported in 1836 by Owen in the gastric mucosa of a tiger that died in a London zoo. There are two intermediate hosts--- the first being copepods like Cyclops, mesocyclops and eucyclops (harbouring the immature larva) while aquatic lower animals like frog, snakes and fishes are the second intermediate host [harbouring the mature, third stage (L3) larval form]. Although the exact route of human infection is not clearly known, the accidental ingestion of infected cyclops with drinking water or consumption of raw meat of contaminated animals appears to be the likely causes. Hence, the role of human beings in its lifecycle is that of an accidental, paratenic host.

Gnathostoma is an aetiological agent of both cutaneous larva migrans (CLM) and visceral larva migrans (VLM). However, in contrast to the CLM caused by hookworm, it is usually deeper, may involve muscles and appear as an intermittent migratory swelling. Visceral gnathostomiasis is more dangerous. It may affect any organ-eyes, CNS, lungs and the gastro-intestinal tract. Laryngeal involvement may lead to dyspnoea and stridor. CNS involvement causes eosinophilic myeloencephalitis and may lead to severe complications.

The first case of ocular gnathostomiasis in India was reported in 1945 [4] and till date, there are only isolated reports of ocular gnathostomiasis from India. [3],[5],[6],[7],[8],[9],[10] Although cutaneous manifestations appear to be relatively common worldwide, there appears to be very little information regarding the situation in India. A Pubmed search with the keywords "gnathostomiasis cutaneous India" yielded no results. To our knowledge, this is the first case of isolated cutaneous manifestation of Gnathostoma reported from India.

 
 ~ References Top

1.Garcia LS. Diagnostic Medical Parasitology. 5th ed. Washington D.C.: ASM press; 2007.  Back to cited text no. 1
    
2.Miyazaki I. An Illustrated Book of Helminthic Zoonoses. Tokyo: International Medical Foundation of Japan; 1991.  Back to cited text no. 2
    
3.Barua P, Hazarika NK, Barua N, Barua CK, Choudhury B. Gnathostomiasis of the anterior chamber. Indian J Med Microbiol 2007;25:276-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Sen K, Ghosh N. Ocular Gnathostomiasis. Br J Ophthalmol 1945;29:618-26.  Back to cited text no. 4
    
5.Basak SK, Sinha TK, Bhattacharya D, Hazra TK, Parikh S. Intravitreal live Gnathostoma spinigerum. Indian J Ophthalmol 2004;52:57-8.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Bhattacharjee H, Das D, Medhi J. Intravitreal gnathostomiasis and review of literature. Retina 2007;27:67-73.  Back to cited text no. 6
[PUBMED]    
7.Bhende M, Biswas J, Gopal L. Ultrasound biomicroscopy in the diagnosis and management of intraocular gnathostomiasis. Am J Ophthalmol 2005;140:140-2.  Back to cited text no. 7
[PUBMED]    
8.Biswas J, Gopal L, Sharma T, Badrinath SS. Intraocular Gnathostoma spinigerum. Clinicopathologic study of two cases with review of literature. Retina 1994;14:438-44.  Back to cited text no. 8
[PUBMED]    
9.Kannan KA, Vasantha K, Venugopal M. Intraocular gnathostomiasis. Indian J Ophthalmol 1999;47:252-3.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Rao VA, Pravin T, Parija SC. Intracameral gnathostomiasins: A first case report from Pondicherry. J Commun Dis 1999;31:197-8.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]

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