Cases for Diagnosis
Hyperpigmented Plaque on the Foot of a Kenyan Patient
Placa hiperpigmentada en el pie de un paciente keniata
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Sendagorta, C. Vidaurrázaga, R. Mulekyo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Sendagorta" "email" => array:1 [ 0 => "elenasendagorta@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Vidaurrázaga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Mulekyo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Pediátrico Pablo Horstmann de Anidan, Lamu, Kenia" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa hiperpigmentada en el pie de un paciente keniata" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 767 "Ancho" => 700 "Tamanyo" => 84719 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy shows a brown ring around a central pore, surrounded by a whitish halo.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a black male, 38 years old, who was seen for a lesion that had been developing for 15 days on the external aspect of the ankle of the left foot. The lesion was painful and made walking difficult. Of interest, the patient lives in Kenya, in an area of extreme poverty where going barefoot is common.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination showed a hyperpigmented plaque, 4×4 cm, with poorly defined borders. The plaque consisted of several confluent papules, each of which had a dark brown spot at its centre, surrounded by a white halo with a hyperkeratotic surface (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dermoscopy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) showed that this spot was in fact a brown pigmented ring around a central pore (white arrow), surrounded by a whitish area bounded by a faint pigmented peripheral ring (black arrow).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical and dermoscopic characteristics of the lesion allowed us to establish a diagnosis of tungiasis. Once extracted, the dermoscopic image of the flea showed the presence of eggs in the abdominal cavity, as well as the posterior opening of the exoskeleton (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course</span><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was used to completely extract the parasites, which were 5 in number. Antibiotic prophylaxis and a tetanus booster dose were administered. The patient's subsequent clinical course was satisfactory.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tungiasis is an ectoparasitic infestation by the pregnant sand flea <span class="elsevierStyleItalic">Tunga penetrans</span>. The flea is endemic to Sub-Saharan Africa, South America, the Caribbean, and parts of Asia, where it is a serious health problem.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The flea is transmitted by direct contact of the skin with soil contaminated by pig or cow feces. It is typically a result of walking barefoot and lesions therefore often appear in the skin of the feet, particularly in the periungal area, although they can be seen in any region of the body.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical manifestations are highly variable, with isolated or multiple hyperpigmented papules being typical. It may present with pruritus or mild pain, but intense pain may also develop and walking may become impossible. Bacterial superinfection is the most common complication.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Diagnosis is based on the clinical characteristics of the lesion, although histological study is sometimes needed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In 2004, Bauer et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> used dermoscopy as an effective diagnostic aid for tungiasis. The dermoscopic characteristics they described included the presence of a brown ring around a central pore, which is the pigmented chitin surrounding the posterior opening of the sand flea's exoskeleton (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, white arrow). Subsequently, a peripheral pigmented ring or halo was described, which is the posterior part of the abdomen of the parasite.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Dermoscopy has also led to the description of additional tungiasis characteristics that are more variable and are not present in all patients, such as blue-gray spots, whitish chainlike structures, and the recently described radial crown sign.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> It should be noted that some of these signs have been described in white patients and that they are difficult to observe in black patients, as in the case we present.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis of tungiasis includes myiasis, cutaneous larva migrans, scabies, bacterial infections, tumors, warts, and foreign-body reactions.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most effective treatment involves surgical extraction of the flea, the administration of antibiotics, and tetanus vaccination; the role of other treatments, such as the use of ivermectin or thiabendazole, remains unclear. The use of adequate footwear is recommended as a preventative measure.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Immigration has produced a significant increase in the incidence of tungiasis outside of areas where it is endemic, leading inevitably to diagnostic difficulties.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As occurs in other parasitic infestations,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> dermoscopy can be helpful in patients in whom the diagnosis cannot easily be established on the basis of clinical findings.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Sendagorta E, Vidaurrázaga C, Raphael Mulekyo. Placa hiperpigmentada en el pie de un paciente keniata. Actas Dermosifiliogr.2012;103:633-634.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 599 "Ancho" => 800 "Tamanyo" => 101547 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic plaque consisting of confluent papules that have a central brown spot.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 767 "Ancho" => 700 "Tamanyo" => 84719 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy shows a brown ring around a central pore, surrounded by a whitish halo.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 641 "Ancho" => 800 "Tamanyo" => 69145 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Image of the flea following extraction. Dermoscopy shows a large number of eggs in the abdominal cavity of the flea.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "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. 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Röcken" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.140.6.761" "Revista" => array:7 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2004" "volumen" => "140" "paginaInicial" => "761" "paginaFinal" => "763" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15210479" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673602117673" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An additional dermoscopic feature of tungiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Di Stefani" 1 => "C.M. Rudolph" 2 => "R. Hoffmann-Wellenhof" 3 => "R.R. Müllegger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.141.8.1045" "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2005" "volumen" => "141" "paginaInicial" => "1045" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16103343" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Entodermoscopy: a new tool for diagnosing skin infections and infestations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Zalaudek" 1 => "J. Giacomel" 2 => "H. Cabo" 3 => "A. Di Stefani" 4 => "G. Ferrara" 5 => "R. Hofmann-Wellenhof" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000109353" "Revista" => array:7 [ "tituloSerie" => "Dermatology" "fecha" => "2008" "volumen" => "216" "paginaInicial" => "14" "paginaFinal" => "23" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18032894" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028209036929" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tunga penetrans: description of a new dermoscopic sign-the radial crown" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Marazza" 1 => "A. Campanelli" 2 => "G. Kaya" 3 => "R.P. Braun" 4 => "J.H. Saurat" 5 => "V. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 8 | 17 |
| 2024 October | 57 | 30 | 87 |
| 2024 September | 75 | 26 | 101 |
| 2024 August | 88 | 60 | 148 |
| 2024 July | 77 | 26 | 103 |
| 2024 June | 80 | 31 | 111 |
| 2024 May | 91 | 28 | 119 |
| 2024 April | 67 | 31 | 98 |
| 2024 March | 73 | 28 | 101 |
| 2024 February | 66 | 36 | 102 |
| 2024 January | 44 | 33 | 77 |
| 2023 December | 48 | 16 | 64 |
| 2023 November | 61 | 23 | 84 |
| 2023 October | 84 | 21 | 105 |
| 2023 September | 105 | 26 | 131 |
| 2023 August | 46 | 22 | 68 |
| 2023 July | 62 | 31 | 93 |
| 2023 June | 66 | 25 | 91 |
| 2023 May | 66 | 26 | 92 |
| 2023 April | 58 | 17 | 75 |
| 2023 March | 44 | 27 | 71 |
| 2023 February | 77 | 27 | 104 |
| 2023 January | 56 | 36 | 92 |
| 2022 December | 74 | 33 | 107 |
| 2022 November | 45 | 28 | 73 |
| 2022 October | 34 | 29 | 63 |
| 2022 September | 32 | 39 | 71 |
| 2022 August | 33 | 38 | 71 |
| 2022 July | 24 | 29 | 53 |
| 2022 June | 20 | 23 | 43 |
| 2022 May | 45 | 41 | 86 |
| 2022 April | 55 | 31 | 86 |
| 2022 March | 60 | 62 | 122 |
| 2022 February | 63 | 30 | 93 |
| 2022 January | 45 | 39 | 84 |
| 2021 December | 46 | 46 | 92 |
| 2021 November | 50 | 42 | 92 |
| 2021 October | 42 | 51 | 93 |
| 2021 September | 48 | 47 | 95 |
| 2021 August | 48 | 26 | 74 |
| 2021 July | 44 | 27 | 71 |
| 2021 June | 52 | 28 | 80 |
| 2021 May | 42 | 29 | 71 |
| 2021 April | 78 | 33 | 111 |
| 2021 March | 96 | 42 | 138 |
| 2021 February | 54 | 30 | 84 |
| 2021 January | 39 | 13 | 52 |
| 2020 December | 68 | 17 | 85 |
| 2020 November | 43 | 14 | 57 |
| 2020 October | 39 | 7 | 46 |
| 2020 September | 61 | 8 | 69 |
| 2020 August | 40 | 26 | 66 |
| 2020 July | 39 | 11 | 50 |
| 2020 June | 36 | 31 | 67 |
| 2020 May | 28 | 15 | 43 |
| 2020 April | 35 | 16 | 51 |
| 2020 March | 35 | 27 | 62 |
| 2020 February | 1 | 5 | 6 |
| 2020 January | 4 | 2 | 6 |
| 2019 December | 8 | 1 | 9 |
| 2019 November | 4 | 1 | 5 |
| 2019 September | 0 | 1 | 1 |
| 2019 August | 3 | 5 | 8 |
| 2019 July | 8 | 6 | 14 |
| 2019 June | 4 | 15 | 19 |
| 2019 May | 6 | 38 | 44 |
| 2019 April | 4 | 15 | 19 |
| 2019 March | 2 | 9 | 11 |
| 2019 February | 2 | 5 | 7 |
| 2019 January | 2 | 0 | 2 |
| 2018 November | 5 | 0 | 5 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 7 | 0 | 7 |
| 2018 March | 4 | 0 | 4 |
| 2018 February | 34 | 5 | 39 |
| 2018 January | 43 | 6 | 49 |
| 2017 December | 49 | 11 | 60 |
| 2017 November | 44 | 1 | 45 |
| 2017 October | 38 | 5 | 43 |
| 2017 September | 66 | 15 | 81 |
| 2017 August | 109 | 4 | 113 |
| 2017 July | 80 | 14 | 94 |
| 2017 June | 115 | 11 | 126 |
| 2017 May | 71 | 7 | 78 |
| 2017 April | 84 | 7 | 91 |
| 2017 March | 66 | 13 | 79 |
| 2017 February | 47 | 10 | 57 |
| 2017 January | 38 | 16 | 54 |
| 2016 December | 96 | 17 | 113 |
| 2016 November | 79 | 13 | 92 |
| 2016 October | 91 | 9 | 100 |
| 2016 September | 78 | 20 | 98 |
| 2016 August | 67 | 33 | 100 |
| 2016 July | 53 | 8 | 61 |
| 2016 June | 13 | 13 | 26 |
| 2016 May | 5 | 10 | 15 |
| 2016 April | 3 | 4 | 7 |
| 2016 March | 10 | 7 | 17 |
| 2016 February | 6 | 3 | 9 |
| 2016 January | 5 | 1 | 6 |
| 2015 December | 8 | 1 | 9 |
| 2015 November | 15 | 5 | 20 |
| 2015 October | 13 | 10 | 23 |
| 2015 September | 6 | 1 | 7 |
| 2015 August | 9 | 7 | 16 |
| 2015 July | 114 | 22 | 136 |
| 2015 June | 53 | 6 | 59 |
| 2015 May | 79 | 5 | 84 |
| 2015 April | 88 | 15 | 103 |
| 2015 March | 61 | 15 | 76 |
| 2015 February | 63 | 14 | 77 |
| 2015 January | 101 | 21 | 122 |
| 2014 December | 61 | 8 | 69 |
| 2014 November | 63 | 12 | 75 |
| 2014 October | 112 | 23 | 135 |
| 2014 September | 90 | 15 | 105 |
| 2014 August | 29 | 7 | 36 |
| 2014 July | 23 | 5 | 28 |
| 2014 June | 49 | 9 | 58 |
| 2014 May | 45 | 5 | 50 |
| 2014 April | 34 | 3 | 37 |
| 2014 March | 32 | 12 | 44 |
| 2014 February | 28 | 8 | 36 |
| 2014 January | 37 | 5 | 42 |
| 2013 December | 44 | 12 | 56 |
| 2013 November | 31 | 7 | 38 |
| 2013 October | 25 | 7 | 32 |
| 2013 September | 23 | 5 | 28 |
| 2013 August | 16 | 13 | 29 |
| 2013 July | 17 | 16 | 33 |
| 2013 June | 9 | 15 | 24 |
| 2013 May | 13 | 12 | 25 |
| 2013 April | 19 | 10 | 29 |
| 2013 March | 18 | 11 | 29 |
| 2013 February | 32 | 4 | 36 |
| 2013 January | 27 | 6 | 33 |
| 2012 December | 16 | 4 | 20 |
| 2012 October | 0 | 2 | 2 |
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