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Autochthonous Cutaneous Larva Migrans Infection in Guipúzcoa
Larva migrans cutánea de origen autóctono en Guipúzcoa
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Panés-Rodríguez, L. Piera-Tuneu, A. López-Pestaña, N. Ormaetxea-Pérez, P. Gutiérrez-Támara, S. Ibarbia-Oruezabal, A. Tuneu-Valls" "autores" => array:7 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Panés-Rodríguez" "email" => array:1 [ 0 => "adriapanes@gmail.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" => "L." "apellidos" => "Piera-Tuneu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "López-Pestaña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "N." "apellidos" => "Ormaetxea-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "P." "apellidos" => "Gutiérrez-Támara" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "S." "apellidos" => "Ibarbia-Oruezabal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Tuneu-Valls" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Clínica Veterinaria Anoeta, San Sebastián, Guipúzcoa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Larva migrans cutánea de origen autóctono en Guipúzcoa" ] ] "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" => 634 "Ancho" => 951 "Tamanyo" => 119359 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Multiple serpiginous tracts on the trunk.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term cutaneous larva migrans (LM) refers to an erythematous pruritic rash of serpiginous morphology that advances in the direction of one of its ends. It is caused by the migration of helminth nematode larvae through the epidermis,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1,2</span></a> and is the most commonly imported disease of tropical origin.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3,4</span></a> The diagnosis is clinical, based on observation of the characteristic skin lesions. Pathology study is unnecessary for its diagnosis; when biopsy is performed, it must be taken into account that the larva is found 1 to 2<span class="elsevierStyleHsp" style=""></span>cm in front of the advancing end of the serpiginous lesion, making parasitic structures unlikely to be found in the sample.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are numerous species of nematodes that can cause this infestation; the main one that affects humans is <span class="elsevierStyleItalic">Ancylostoma braziliense</span>.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> The majority of these species are found in regions with a hot climate and, in Spain, this is therefore an imported disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The adult forms of the species that cause LM colonize the digestive tract of cats and dogs, from where their eggs are excreted in the feces.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> These animals are the definitive hosts,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> as the larva can complete its life cycle in them. Under optimal environmental conditions of temperature and humidity,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> eggs excreted in the feces hatch to release larvae that mature until they reach the filariform (infective) stage. On reaching this phase, the larvae can penetrate the skin to infect a new animal and thus complete their life cycle, or else they can enter the skin of a human being. On penetration, the larva provokes the appearance of a small, pruritic erythematous papule or vesicle, and opens a path through the epidermis, advancing at a rate of approximately 2 to 3<span class="elsevierStyleHsp" style=""></span>cm a day<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a>; this is the cause of the characteristics lesions, which are serpiginous, erythematous, and intensely pruritic. Several serpiginous tracts can often be seen simultaneously in a single patient.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> As the larvae advance, the initial section of the lesion becomes dry and crusted. Lack of the enzyme necessary to cross the basement membrane of human skin (collagenase)<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> means that the larvae cannot reach the blood or lymph vessels, and they therefore migrate through the epidermis for an indeterminate time until they die without being able to complete their life cycle. Even so, a case of visceral LM due to <span class="elsevierStyleItalic">Ancylostoma caninum</span> has been published<span class="elsevierStyleItalic">.</span><a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical course is towards spontaneous resolution of the lesions over a period of 1 to 2 months due to the immune response that is triggered.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Cases of lesions that have persisted for 2 years have been reported.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Possible complications, such as bacterial superinfection and allergic reactions, and the intense pruritus make treatment recommendable.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to review cases of LM with no epidemiologic history of recent travel to endemic regions; it thus refers only to autochthonous cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This was a retrospective observational study of patients diagnosed with LM in the dermatology department of Hospital Universitario Donostia between August 2011 and June 2015. All patients lived in Gipuzkoa, Spain, and had no history of recent travel outside this province.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Variables analyzed included age, sex, date of onset of the condition, nature of possible contact with soil contaminated by larvae, site of the lesions on the body, findings on biopsy (if performed), and climatic conditions during the previous months that could have favored the onset of the disease.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Four patients, all men, were studied. The mean age was 60 years (range, 39-79 years). They denied recent foreign travel, but they did report recent contact with soil possibly contaminated by animal feces in the rural environment. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the main clinical and epidemiologic characteristics of each patient and the possible context in which contact with the larvae occurred.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The site of the skin lesions was on the lower limbs in 3 cases (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and on the trunk in 1 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This last patient described being stripped to the waist while working in his garden and repeatedly entering into contact with soil that could be contaminated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Biopsy and blood tests were performed in 2 patients, with similar findings in both cases. Histopathology revealed a superficial and deep perivascular dermatitis with a predominance of eosinophils (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The blood tests showed peripheral eosinophilia of 13% and 17%, respectively; other parameters were within normal limits.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis was made clinically, based on the characteristic skin lesions and the epidemiologic history of contact with soil possibly contaminated by animal feces.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The treatment prescribed in all 4 cases was albendazole 400<span class="elsevierStyleHsp" style=""></span>mg a day for 5 days, with a good clinical response in 3 of them. The fourth patient presented recurrence despite a good initial response to the antiparasitic treatment. We found that his sandals were dirty with soil. After changing the footwear and restarting systemic treatment, the lesions disappeared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Between 2011 and 2015, 4 cases of LM were diagnosed in our center in patients who did not report recent travel outside the province of Gipuzkoa; these were therefore autochthonous cases of LM. Both the medical history and the sites of the lesions indicated occupational exposure, as all 4 patients had been in contact with soil probably contaminated by parasite-infected animal feces.</p><p id="par0070" class="elsevierStylePara elsevierViewall">LM is observed predominantly in travelers arriving from hot and humid regions, particularly Sub-Saharan Africa, Latin America, the Caribbean, and Asia.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> In recent years, a total of 15 autochthonous cases have been detected in western European countries: Germany,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> England,<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13–16</span></a> France,<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17–19</span></a> Italy,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Spain,<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2,21</span></a> and Serbia.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> The main clinical and epidemiological characteristics of all cases of autochthonous LM in Europe are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. We bring 4 new cases (21% of the total) to add to those already reported in our continent. A total of 6 cases (32%) have been reported in Spain, making this the European country with the highest incidence of autochthonous LM in the last decade.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">These findings would suggest that the incidence of autochthonous cases of this condition is likely to increase in the future. The presence of skin lesions compatible with LM must therefore lead to inclusion of this disease in the differential diagnosis even if the patient reports no recent travel outside Europe.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The etiologic agents of LM are numerous. The possible hosts and the geographic distribution of each of them are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2,6,7</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The intestinal nematodes <span class="elsevierStyleItalic">Ancylostoma</span> spp. and <span class="elsevierStyleItalic">Uncinaria</span> spp. are the most prevalent groups of parasites in household pets worldwide; pets are among the most important sources of spread of the disease and of risk to human and animal health.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> This is due above all to their life cycle, their route of transmission, and the large number of eggs produced by each female. In animals, the skin lesions are typically interdigital and are hidden by the hair.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> After penetrating the skin, the parasite reaches the bloodstream and migrates to the lungs, from where it is swallowed and reaches the intestine, the site where it matures to the adult phase. In the intestine, the parasite feeds on the animal's blood, producing anemia, blood-stained diarrhea, and even death in young animals.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> The females produce enormous numbers of eggs (around 20<span class="elsevierStyleHsp" style=""></span>000 eggs a day), which are excreted with the host's feces. In the environment, under suitable climatic conditions of warmth and humidity (optimal temperatures vary between 25<span class="elsevierStyleHsp" style=""></span>°C and 30<span class="elsevierStyleHsp" style=""></span>°C; moist, sandy, shady, and well-oxygenated soil), the eggs hatch to produce larvae that pass through 2 stages to reach the L3 stage. The L3 larva is filariform, measures about 660<span class="elsevierStyleHsp" style=""></span>μm in length and 2<span class="elsevierStyleHsp" style=""></span>μm in diameter, and is infective for dogs and humans, as it is able to penetrate the skin.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In humans, the infection is typically acquired on walking barefoot or sitting on soil contaminated with L3 larvae derived from infected animal feces; LM lesions are therefore usually observed on the lower limbs and buttocks.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2,5</span></a> Lesions can also appear in other regions, such as the trunk or scalp.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis should include larva currens, caused by <span class="elsevierStyleItalic">Strongyloides stercoralis</span>, in tropical and subtropical regions.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Clinically, these diseases are differentiated mainly by the greater speed of migration through the epidermis; the lesions in larva currens progress at 5 to 15<span class="elsevierStyleHsp" style=""></span>cm per hour<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> and the path is relatively straight, whereas LM advances at 2 to 3<span class="elsevierStyleHsp" style=""></span>cm a day in a more serpiginous path. Humans can be the definitive host of <span class="elsevierStyleItalic">Strongyloides stercoralis</span>, as this parasite has the potential to cross the basement membrane of the skin to reach blood and lymph vessels, thus completing its life cycle. Migration through the human body can provoke iron-deficiency anemia, gastrointestinal symptoms, and Loeffler syndrome. This syndrome is characterized by peripheral eosinophilia and migratory pulmonary infiltrates caused by passage of the larvae through the lungs. Cases of Loeffler syndrome caused by LM have also been reported.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Climate change is altering the ecology of a number of helminth species with zoonotic potential. The increase in temperatures is particularly important for those parasite species that complete part of their life cycle in the soil, 1 of the main routes of transmission of this zoonosis. All the months in which a diagnosis of LM was made at our center had similar meteorological characteristics. In August 2011, air from the Sahara reached the north coast of Spain, producing unusually high temperatures. In addition, the climatic instability associated with that low pressure produced stormy showers on several days, with rain recorded on 14 days. In September 2013, it rained on 15 days, with heavy storms on 4 of them. And there were 2 clear episodes of entry of tropical air at the beginning and end of the month, with maximum temperatures of 36<span class="elsevierStyleHsp" style=""></span>°C in the west of Gipuzkoa. August 2014 had a particularly high rainfall, with rain present on 19 days. The number of hours of sun was below average (by about 20%), with only 1 cloudless day. In June 2015, it rained for a total of 16 days, mainly in the east of Gipuzkoa. It was a very warm month, with maximum temperatures of 38<span class="elsevierStyleHsp" style=""></span>°C on the Gipuzkoan coast.</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is likely that the increasing temperatures and high humidity in the north of the Iberian Peninsula, and the low levels of solar radiation compared with other areas of Spain, will create an ideal environment for eggs of parasites that cause LM to hatch in our soil and for the larvae to develop, especially in the warmer summer months.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Although current veterinary guidelines recommend parasite prevention for dogs and cats every 3 months, these periodic controls may not be carried out in rural environments or animals may become reinfested within this period, or feral animals (especially cats) may be involved. This will facilitate the spread of the parasite and the appearance of new cases.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Several systemic treatment options exist. Oral treatment can be given as a single dose of albendazole 400<span class="elsevierStyleHsp" style=""></span>mg by mouth. A 3- or 5-day course of treatment with doses of 400 or 800<span class="elsevierStyleHsp" style=""></span>mg a day is more effective,<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> with a complete response in 99% of cases. Thiabendazole is also effective at doses of 1.25-2.5<span class="elsevierStyleHsp" style=""></span>g a day,<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> but this drug is not as well tolerated as ivermectin or albendazole, as it can cause nausea, vomiting, and headache. A single dose of 12<span class="elsevierStyleHsp" style=""></span>mg of ivermectin is effective and is well tolerated.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">If topical therapy is used, the application of thiabendazole at concentrations of 15% or 6.25% twice a day achieves resolution of the disease with 2 to 8 days of treatment.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Cryotherapy is not recommended as it is highly traumatic and the larvae are found some centimeters in front of the advancing end of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8,26</span></a> Cure has also been observed after skin biopsy.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Clinical resolution is usually seen a week after starting treatment. Preventive measures must be adopted to prevent greater spread of this disease. Veterinary controls to deparasitize dogs and cats should be performed every 3 months, with special insistence in rural areas. Another factor to be taken into account is the involvement of wild and feral animals, such as foxes and cats, which can also spread these larvae and are more difficult to control. Health staff should be trained to recognize this disease so that it can be quickly identified.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Patients will then receive early treatment and epidemiologic information can be gathered about possible sources of contact to prevent further contagion. To this end, it would be very interesting to know the species of larvae implicated in each case in order to be able to direct treatment to the parasitized animals or against the mechanism of transmission. It is important to insist on barrier methods, such as the use of closed footwear and appropriate clothing to avoid contact with soil contaminated by animal feces. Cleaning or changing footwear must be included as part of the treatment of this disease; this is important to prevent reinfestation in the same individual and contamination of urban areas. The possibility of short-term dissemination in the urban setting must also be taken into account, as contaminated footwear and other fomites can infest carpets,<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> where the eggs can live for several days. Town parks, which can be moist shady areas, could be a suitable setting for the hatching of eggs excreted in the feces of parasitized household pets. Identification of the parasite in the 4 cases reported would provide data on the prevalence, life cycle, and hosts of these larvae, and this information could be used to prevent further spread of the species that cause this condition in our setting.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0125" class="elsevierStylePara elsevierViewall">LM is an easily recognized condition that is usually associated with a history of travel to areas in which this dermatosis is endemic. However, autochthonous cases occur in Europe, and our series is the largest published to date. We should expect an increase in the incidence of this disease in both rural and urban areas in the warmer months (June through September) and in moist environments. The rapid identification of this dermatosis, the initiation of an effective treatment, knowledge of the sources of contagion, and preventive measures can be effective in preventing greater spread of LM of autochthonous origin.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this research.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital's regulations regarding the publication of patient information.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres822696" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec819501" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres822695" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec819502" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-28" "fechaAceptado" => "2016-01-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec819501" "palabras" => array:5 [ 0 => "Cutaneous larva migrans" 1 => "Spain" 2 => "Europe" 3 => "Climate" 4 => "Nematode infections" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec819502" "palabras" => array:5 [ 0 => "Larva migrans cutánea" 1 => "España" 2 => "Europa" 3 => "Meteorología" 4 => "Nematodo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous larva migrans (LM) infection forms a serpiginous eruption caused by the migration of nematode helminths through the epidermis. The parasites are acquired when the skin comes into contact with soil contaminated by the feces of infected animals. Until now, infections have been believed to be imported from tropical and subtropical regions. Our aim was to study cases of cutaneous LM diagnosed in residents of the Spanish province of Guipúzcoa who had not recently traveled to such regions.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional observational study of LM cases diagnosed in Hospital Universitario Donostia from 2011 to 2015 in patients who had not visited a region where this nematode infection is endemic. Clinical diagnoses were based on characteristic lesions. We studied the following variables: age, sex, site of lesions, date of onset of symptoms, possible source of contagion, pathologic findings, treatment, and clinical course.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We found 4 cases, all in men (mean age, 60 years). Lesions were on the lower extremities in 3 patients and on the trunk in 1 patient. All had been in contact with soil that could have been contaminated by feces and was the most likely source of the parasite. The lesions disappeared after treatment with oral albendazole.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The appearance of cases of autochthonous LM in Europe requires investigation of the culprit species, a review of the epidemiology of this infection, which was once considered imported, and the planning of public health measures to prevent it from becoming endemic.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Larva migrans cutánea (LM) es una erupción serpiginosa causada por helmintos nematodos que circulan por la epidermis. Se adquiere cuando la piel entra en contacto con tierra contaminada por heces de animales infestados por estos nematodos. Hasta ahora se consideraba como enfermedad importada de zonas tropicales y subtropicales. El objetivo fue estudiar los casos de LM diagnosticados como autóctonos por no haber salido de la provincia de Guipúzcoa recientemente.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional transversal retrospectivo de los casos diagnosticados de LM en el Hospital Universitario Donostia de 2011 a 2015, sin viaje previo a ninguna zona endémica de este cuadro. El diagnóstico fue clínico ante las lesiones características. Las variables estudiadas fueron: edad, género, localización de las lesiones, fecha de inicio de los síntomas, posible fuente de contagio, datos anatomo-patológicos, tratamiento y evolución.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se han recogido 4 casos, todos varones, con una media de edad de 60 años. Tres casos presentaron lesiones en las extremidades inferiores, mientras que uno lo hizo en el tronco. Todos nuestros pacientes habían estado en contacto con tierra que pudiera estar contaminada por heces, siendo este el mecanismo de transmisión más probable. Se instauró tratamiento con albendazol oral, con resolución de las lesiones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La aparición de nuevos casos de LM de origen autóctono en Europa obliga al estudio de la/s especie/s causal/es, a una revisión epidemiológica de esta infestación y a planificar qué medidas se deberían tomar para evitar que una enfermedad considerada hasta ahora como importada, se convierta en autóctona.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Panés-Rodríguez A, Piera-Tuneu L, López-Pestaña A, Ormaetxea-Pérez N, Gutiérrez-Támara P, Ibarbia-Oruezabal S, et al. Larva migrans cutánea de origen autóctono en Guipúzcoa. Actas Dermosifiliogr. 2016;107:407–413.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1304 "Ancho" => 800 "Tamanyo" => 167813 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Multiple serpiginous tracts on the dorsum foot.</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" => 634 "Ancho" => 951 "Tamanyo" => 119359 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Multiple serpiginous tracts on the trunk.</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" => 1266 "Ancho" => 950 "Tamanyo" => 280063 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A predominantly perivascular inflammatory infiltrate formed mainly of eosinophils can be observed in the superficial and deep dermis. Hematoxylin and eosin, original magnification ×40.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site Affected \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Onset \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Possible Contact \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biopsy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Course \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dorsum of the foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">August 2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trekking using sandals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good initial clinical course<br>Subsequent reinfestation<br>Resolved by changing footwear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trunk, arms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">September 2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gardening<br>without a shirt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes. Perivascular<br>dermatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution after<br>treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lower leg, dorsum of the foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">August 2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gardening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes. Perivascular<br>dermatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution after<br>treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lower leg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">June 2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trekking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution after<br>treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1383288.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Clinical and Epidemiological Characteristics of the Patients in the Series.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Cases \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site Affected \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period of the Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Related<br>Activity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clothing \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time Without Travelling to the Tropics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beattie et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United<br>Kingdom<br>(Scotland) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><br>– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left buttock and flank \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><br>– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trekking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Short trousers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral ivermectin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diba et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United<br>Kingdom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left arm<br>Abdomen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">October \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paint-ball \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paint-ball clothing in contact with dog<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Roest et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United<br>Kingdom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right buttock \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">September \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sitting on the beach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patterson et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United<br>Kingdom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Winter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contact with dog feces \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Barefoot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Never \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical thiabendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klose et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7, 38, and 44 y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Feet (2) and right hand (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">August \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Banks of a river and of a lake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Never \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical thiabendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ropars et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France (Brittany) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left flank \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hiking around a lake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral ivermectin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tamminga et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France (Brittany) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Left foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">September \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Walking on a beach<br>Camping \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Never \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral ivermectin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zimmermann et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right leg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Flooding of patient's house \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical and oral thiabendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Akkouche et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Upper<br>limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Veterinary paramedic<br>Contact with stagnant water \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gloves not used when working with animals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Never \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Santiago et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain<br>(Pyrenees) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Buttocks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Riverbank \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bathing suit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sábat et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thumb \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contact<br>with dogs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thiabendazole oral \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tomović et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Serbia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 and 70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Trunk (1)<br>Back (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">August (1)<br>June (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fall in sand (1)<br>Repairing a car \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not wearing a<br>shirt (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Never \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral albendazole (1)<br>Oral ivermectin (2)<br> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1383287.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical and Epidemiological Characteristics of Cases of Larva Migrans Arising in Europe With no History of Travel.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Host \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Distribution \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ancylostoma braziliense</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dogs<br>Cats \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tropical and subtropical regions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ancylostoma caninum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dogs<br>Occasionally cats \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Worldwide distribution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ancylostoma tubaeforme</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cats<br>Other felines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Worldwide distribution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ancylostoma ceylanicum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Canines<br>Felines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Africa, Australia, and Asia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Uncinaria stenocephala</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dogs<br>Occasionally cats \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Temperate regions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Bunostomun phlebotomum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cattle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Temperate regions \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1383289.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Hosts and Geographic Distribution of the Causative Species of Cutaneous Larva Migrans.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Illness after international travel" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 13 | 27 |
| 2024 October | 97 | 30 | 127 |
| 2024 September | 104 | 26 | 130 |
| 2024 August | 116 | 55 | 171 |
| 2024 July | 102 | 37 | 139 |
| 2024 June | 101 | 40 | 141 |
| 2024 May | 95 | 36 | 131 |
| 2024 April | 96 | 25 | 121 |
| 2024 March | 85 | 34 | 119 |
| 2024 February | 63 | 33 | 96 |
| 2024 January | 57 | 37 | 94 |
| 2023 December | 50 | 17 | 67 |
| 2023 November | 78 | 29 | 107 |
| 2023 October | 67 | 22 | 89 |
| 2023 September | 89 | 31 | 120 |
| 2023 August | 59 | 9 | 68 |
| 2023 July | 89 | 32 | 121 |
| 2023 June | 92 | 24 | 116 |
| 2023 May | 97 | 26 | 123 |
| 2023 April | 120 | 17 | 137 |
| 2023 March | 93 | 23 | 116 |
| 2023 February | 82 | 29 | 111 |
| 2023 January | 72 | 28 | 100 |
| 2022 December | 69 | 39 | 108 |
| 2022 November | 34 | 21 | 55 |
| 2022 October | 32 | 46 | 78 |
| 2022 September | 35 | 44 | 79 |
| 2022 August | 19 | 38 | 57 |
| 2022 July | 31 | 34 | 65 |
| 2022 June | 21 | 22 | 43 |
| 2022 May | 36 | 36 | 72 |
| 2022 April | 63 | 29 | 92 |
| 2022 March | 47 | 47 | 94 |
| 2022 February | 76 | 30 | 106 |
| 2022 January | 69 | 33 | 102 |
| 2021 December | 54 | 39 | 93 |
| 2021 November | 68 | 33 | 101 |
| 2021 October | 60 | 43 | 103 |
| 2021 September | 45 | 32 | 77 |
| 2021 August | 46 | 39 | 85 |
| 2021 July | 51 | 37 | 88 |
| 2021 June | 24 | 23 | 47 |
| 2021 May | 36 | 50 | 86 |
| 2021 April | 219 | 35 | 254 |
| 2021 March | 134 | 32 | 166 |
| 2021 February | 58 | 32 | 90 |
| 2021 January | 47 | 19 | 66 |
| 2020 December | 60 | 12 | 72 |
| 2020 November | 42 | 27 | 69 |
| 2020 October | 71 | 14 | 85 |
| 2020 September | 51 | 10 | 61 |
| 2020 August | 40 | 18 | 58 |
| 2020 July | 41 | 13 | 54 |
| 2020 June | 48 | 27 | 75 |
| 2020 May | 58 | 16 | 74 |
| 2020 April | 41 | 21 | 62 |
| 2020 March | 32 | 20 | 52 |
| 2020 February | 2 | 1 | 3 |
| 2019 December | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 May | 3 | 2 | 5 |
| 2019 April | 0 | 2 | 2 |
| 2019 March | 0 | 4 | 4 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 7 | 0 | 7 |
| 2018 February | 31 | 5 | 36 |
| 2018 January | 40 | 9 | 49 |
| 2017 December | 40 | 9 | 49 |
| 2017 November | 36 | 11 | 47 |
| 2017 October | 38 | 7 | 45 |
| 2017 September | 20 | 8 | 28 |
| 2017 August | 29 | 8 | 37 |
| 2017 July | 17 | 6 | 23 |
| 2017 June | 30 | 8 | 38 |
| 2017 May | 26 | 10 | 36 |
| 2017 April | 20 | 6 | 26 |
| 2017 March | 24 | 11 | 35 |
| 2017 February | 16 | 8 | 24 |
| 2017 January | 18 | 6 | 24 |
| 2016 December | 34 | 10 | 44 |
| 2016 November | 21 | 16 | 37 |
| 2016 October | 36 | 26 | 62 |
| 2016 June | 0 | 2 | 2 |
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