Case and Research Letters
Hookworm: An Uncommon Cause of Folliculitis in Travelers
Foliculitis por larvas de nematodo: una infrecuente causa de foliculitis en viajeros
A. Saenz Aguirre
, A. Martínez de Salinas Quintana, F.J. de la Torre Gomar, V. Fatsini Blanch
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Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain
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Saenz Aguirre, A. Martínez de Salinas Quintana, F.J. de la Torre Gomar, V. Fatsini Blanch" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Saenz Aguirre" "email" => array:1 [ 0 => "amaiasaenzagirre@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Martínez de Salinas Quintana" ] 2 => array:2 [ "nombre" => "F.J." "apellidos" => "de la Torre Gomar" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Fatsini Blanch" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Foliculitis por larvas de nematodo: una infrecuente causa de foliculitis en viajeros" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 543 "Ancho" => 905 "Tamanyo" => 50388 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous papular lesions on the buttocks with signs of excoriation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hookworm folliculitis is an atypical manifestation of cutaneous larva migrans (CLM) syndrome with which dermatologists should be familiar given the increase in travel to tropical and subtropical countries, where this entity is endemic. We present a case that was diagnosed in our hospital based on the patient’s clinical history and responded favorably to treatment after other more common potential etiologies were ruled out.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 33-year-old woman in good general health with no pre-existing lesions was seen for lesions on the buttocks with associated, predominantly nocturnal pruritus. The lesions had appeared 1 month earlier after a trip to Argentina and Brazil. She had received treatment at another care facility with oral corticosteroids, amoxicillin-clavulanic acid, and betamethasone-gentamicin cream, without improvement. Physical examination revealed multiple erythematous papular lesions on the buttocks, some of which were excoriated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The inguinal lymph nodes were not enlarged.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On suspicion of possible infectious folliculitis, a sample was taken for a herpes polymerase chain reaction test, biopsy, and laboratory tests, including serology for human immunodeficiency and hepatitis B and C viruses. The patient was prescribed valacyclovir (500 mg/12 h) for 5 days, fluconazole (50 mg/d), topical fusidic acid, and bilastine.</p><p id="par0020" class="elsevierStylePara elsevierViewall">After 5 days the lesions had worsened, and a new lesion, suggestive of a serpiginous track, had appeared. While this new lesion could have developed secondary to scratching, its appearance raised clinical suspicion of CLM (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Histological findings supported the clinical suspicion, showing dermal edema together with a perivascular and periadnexal inflammatory infiltrate with abundant eosinophils and perifolliculitis, without destruction of the follicular epithelium.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The results of a soft-tissue ultrasound, performed to attempt to visualize the parasite, were normal. However, given the prolonged clinical course of the condition and the clinical suspicion, the patient was prescribed oral albendazole (400 mg/d for 3 days). The lesions and the pruritus improved rapidly over the following weeks, resolving fully after 6 weeks without the need for additional treatment (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We present a case of hookworm folliculitis, an atypical presentation of CLM syndrome. Hookworm folliculitis is a rare entity (the largest series described in the literature consists of 7 patients),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and may be due to a hypersensitivity reaction to the presence of the nematode in the follicular canal.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">CLM syndrome is caused mainly by larvae of canine or feline nematodes (genus <span class="elsevierStyleItalic">Ancylostoma</span>),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–11</span></a> especially <span class="elsevierStyleItalic">Ancylostoma brasiliense</span>,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4–11</span></a><span class="elsevierStyleItalic">Ancylostoma ceylanicum</span>,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,11</span></a> and <span class="elsevierStyleItalic">Ancylostoma caninum</span>.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,8–11</span></a> Larvae are expelled in dog or cat feces, contaminate the soil, and subsequently infect the host by transcutaneous penetration.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5–8,11</span></a> This most often occurs on beaches in tropical and subtropical countries.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5–8,11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After an incubation period ranging from days to weeks,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,8,10</span></a> patients who develop hookworm folliculitis present with multiple pruritic follicular papules and pustules, located mainly on the feet<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> or buttocks.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5–9</span></a> Some patients may present small, characteristically short (<5 cm) furrows<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,6,8</span></a> that give rise to follicular lesions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Occasionally, vesicles and/or blisters may develop.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,6,7</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Diagnosis of this entity is based on the clinical presentation together with recent travel to a tropical or subtropical country, and does not require additional tests.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,11</span></a> The differential diagnosis should primarily include folliculitis of other, more common etiologies (e.g. bacterial folliculitis, which tends not to cause such intense pruritus<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7</span></a>), and scabies,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,11</span></a> which is associated with predominantly nocturnal pruritus. Laboratory analyses can reveal eosinophilia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Pathological analysis occasionally enables visualization of the parasites in the follicular ducts, although the most common finding is an eosinophilic infiltrate in the biopsy together with perifolliculitis,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5,8</span></a> as observed in the present case. In a series of 8 cases of CLM published in this journal, parasite remains were detected in only 1 biopsy, and diagnosis was oriented based on the secondary findings described above.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Ivermectin and albendazole are the first-line treatments.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,10,11</span></a> For the treatment of CLM syndrome ivermectin is usually administered in a single dose of 12 mg,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> while the albendazole dose is adjusted by weight (400–800 mg/d for 4 days).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Treatment of hookworm folliculitis may be less effective than that of CLM, <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5,7</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> and may require more doses of ivermectin or a combination of the 2 drugs.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a> Topical albendazole (10%) can be used to treat children or patients for whom oral treatment is contraindicated.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> One case that responded to topical ivermectin treatment has also been described.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Some cases can self-resolve without treatment within weeks or months.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5–8,11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, although hookworm folliculitis is very rare in Spain, the increase in travel to tropical and subtropical countries necessitates greater knowledge of tropical diseases<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in order to improve the quality of care of affected patients through rapid diagnosis and treatment, avoiding secondary infections and other complications.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The key to diagnosis of this condition is the presence of cutaneous folliculitis-like lesions with intense, predominantly nocturnal pruritus in individuals that recently travelled to a tropical country.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-28" "fechaAceptado" => "2018-09-18" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Saenz Aguirre A, Martínez de Salinas Quintana A, de la Torre Gomar FJ, Fatsini Blanch V. Foliculitis por larvas de nematodo: una infrecuente causa de foliculitis en viajeros. Actas Dermosifiliogr. 2020;111:275–276.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 543 "Ancho" => 905 "Tamanyo" => 50388 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous papular lesions on the buttocks with signs of excoriation.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 638 "Ancho" => 905 "Tamanyo" => 65962 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Worsening of the lesions on the buttocks with the appearance of raised serpiginous tracks (arrows).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 641 "Ancho" => 905 "Tamanyo" => 64578 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Improvement of skin lesions after treatment with albendazole.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hookworm-related cutaneous larva migrans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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