Case for Diagnosis
Hyperkeratotic Yellow-Brown Papules on the Feet
Pápulas hiperqueratóticas de color amarillo-marrón en los pies
a Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte (CHULN), Lisbon, Portugal
b Faculty of Medicine, Dermatology Universitary Clinic, University of Lisbon, Lisbon, Portugal
c Dermatology Research Unit, Instituto de Medicina Molecular (IMM), University of Lisbon, Lisbon, Portugal
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A, Combined polypoid intradermal melanocytic proliferation with a peripheral melanocytic population consistent with a common nevus (arrow) and a second central spitzoid population (asterisks). Note the moderate lymphocytic inflammatory infiltrate (hematoxylin–eosin, original magnification 40). B, Common nevus at the periphery comprising nests of small clonal melanocytes (arrow). Central spitzoid population, with an abundant eosinophilic cytoplasm and discrete nuclear pleomorphism and no evidence of mitosis (hematoxylin–eosin, original magnification 100). C and D, Immunohistochemistry showing loss of BAP1 expression in the spitzoid (asterisks) but not common nevus component (arrow) of the lesion (BAP1, original magnification 100 and 200, respectively).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "X. Fustà-Novell, A. García-Herrera, O. Yélamos" "autores" => array:3 [ 0 => array:2 [ "nombre" => "X." "apellidos" => "Fustà-Novell" ] 1 => array:2 [ "nombre" => "A." 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Two weeks earlier, he had travelled to Saint Thomas and Prince Islands, where he played football without wearing shoes. He had been observed four days earlier in another hospital for a similar lesion on his left ankle.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed three hyperkeratotic yellow-brown and two small red papules with dark central dots distributed over the ankle, sole and toes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dermoscopy revealed a white halo of hyperkeratosis and a dark central orifice surrounded by a white ovoid structure (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Histopathology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Skin biopsy showed a collection of eggs at various maturation stages and sections of arthropod parasites, particularly reproductive and digestive portions and tracheal rings (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What is the diagnosis?</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical, dermoscopic and histopathological features allowed us to establish a diagnosis of tungiasis.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical course and treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Curettage of the lesions was performed along with secondary bacterial infection prophylaxis with topical and systemic antibiotics (topical fusidic acid and oral amoxicillin–clavulanic acid) and treatment with topical ivermectin. The patient had previously received all the recommended tetanus vaccinations. Clinical resolution was observed in three weeks, with no complications at follow-up.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tungiasis is a neglected ectoparasitosis caused by the penetration of the sand flea – <span class="elsevierStyleItalic">Tunga penetrans</span> or, less commonly, <span class="elsevierStyleItalic">Tunga trimamillata</span> – into the host's epidermis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–5</span></a> It is endemic in sub-Saharan Africa, India, Latin America and the Caribbean, occurring in travellers returning from these regions.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–5</span></a> It is usually acquired from walking barefoot or with open-toed shoes.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a> This parasite's primary habitat is sandy soils, but it can also be found in tropical forests and banana plantations.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> The patient usually complains of itch, pain and foreign body sensation.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Lesions predominantly affect the feet, especially the periungual area of the toes, heels and soles, but it can affect any part of the body contacting with the infested soil.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a> Skin findings differ, depending on the disease stage, and correlate with the embedded flea's life cycle.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> The female sand flea penetrates into the host's epidermis, leaving the posterior abdominal segment protruding, eliminating feces and laying eggs (100–200/week). This is followed by the development of a small red-brown macule, which evolves into the classic clinical presentation – a yellow papule with a dark central dot. The subsequent flea engorgement from egg production leads to swelling, erythema, pruritus and pain.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2,4</span></a> If untreated, the flea's life cycle ends in about four to six weeks and forms a black-crusted papule.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2,4</span></a> Although tungiasis diagnosis is clinical, dermoscopy can be a helpful tool, showing dark central pores, whitish oval structures, silver dendritic fibres and blue-black blotches in most cases.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The differential diagnosis includes arthropod bite, abscess, wart, pyogenic granuloma, leishmaniasis, myxoid cyst, myiasis or a foreign body.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Skin biopsy often reveals remnants of exoskeleton and egg shells.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The sterile removal of each flea with sterile needles, shave or punch biopsies is the treatment of choice. After extraction, the sore should be treated with a topical antibiotic, and both oral antibiotic prophylaxis and tetanus vaccine should be considered.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3,5</span></a> In patients with severe disease, topical ivermectin, topical dimethicone or oral thiabendazole may also be used.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a> The most considerable complication is secondary bacterial infection such as cellulitis, necrotizing skin, soft tissue infection and tetanus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Tungiasis is an emerging infection in travellers to endemic areas, whose best preventive measure is to wear closed-toe shoes. Thus, it is essential to instruct travellers with these recommendations so as to avoid infestation by this parasite.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Dermatologists must, therefore, be aware of it in order to promptly treat and prevent complications.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 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" => "Histopathology" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical course and treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 8 => array:2 [ "identificador" => "xack652795" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "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" => 499 "Ancho" => 1005 "Tamanyo" => 72053 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic yellow-brown (A) and small red papules (B) with dark central dots.</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" => 740 "Ancho" => 755 "Tamanyo" => 55268 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dermoscopy revealed a white halo of hyperkeratosis and a dark central orifice surrounded by a white ovoid structure.</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" => 614 "Ancho" => 755 "Tamanyo" => 113249 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin–eosin, original magnification ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tungiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G.V. 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Heukelbach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/s0036-46652005000600001" "Revista" => array:6 [ "tituloSerie" => "Rev Inst Med Trop Sao Paulo" "fecha" => "2005" "volumen" => "47" "paginaInicial" => "307" "paginaFinal" => "313" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16553319" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack652795" "titulo" => "Acknowledgments" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">To Professor Soares-de-Almeida and doctors Marta Lobo and Pablo Espinosa for histopathological examination.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000011400000002/v3_202302211823/S0001731022006299/v3_202302211823/en/main.assets" "Apartado" => array:4 [ "identificador" => "6161" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos para el diagnóstico" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000011400000002/v3_202302211823/S0001731022006299/v3_202302211823/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022006299?idApp=UINPBA000044" ]
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