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Dermacademy Challenge - Clinical Case #4 - Dr. Stéphanie Leclerc-Mercier
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Clinical case shared by Dr. Stéphanie Leclerc-Mercier
Clinical Presentation
A 33-year-old female patient came in for insomnia-inducing pruritis on the buttocks evolving over a period of 10 days when she returned from holidays on Martinique. A clinical examination found she was in good general condition, with no fever.
Physical Examination
Skin lesions were made of small papules on the buttocks some of which were excoriated. The rest of her skin had no specific marks and there was no pruritis on surrounding areas. The patient remembers being bitten several times by mosquitoes.
Developments
The initial diagnosis was of prurigo following insect bites. Local corticotherapy was initiated.
The patient returned after 10 days because of aggravation of the pruritis and lesions that had very clearly changed as can be seen in the photos.
Diagnosis
The diagnosis retained was cutaneous larva migrans (CLM). When questioned, the patient said that she sat directly on the sand without a towel several times and had noticed that the lesions had been migrating for several days. Given the very evocative clinical picture and epidemiological data, a skin biopsy was not necessary.
Management and outcome
Full recovery was achieved after 15 days of taking 12 mg of ivermectin once daily.
Teaching points
Larva migrans is the most common skin condition affecting tourists (25%) according to a study of over 200 patients conducted by E. Caumes in 1995. In our patient, the clinical history of mosquito bites led to an initial misdiagnosis of post-insect bite prurigo. However, the context and very evocative serpiginous clinical aspect of the lesions necessarily raised the question of contact with sand on the beach, a classic and frequent contamination site (due to animal droppings). The diagnosis remains clinical and additional exams (biopsies or biological exams) are not needed given the very typical appearance. The 12 mg of ivermectin therapy was reported as effective in a NEJM publication in 1998 and a poster from the E. Caumes team in 2012.
Bibliography
- Caumes et al, Clin Inf Dis 1995;20:542-54.
- Van den Enden et al, NEJM 1998;339:1246-1247.
