Skin problems in returned travellers; what’s eating U? · 5 Case i. A 35 year old female returns from C. America with a pruritic rash ! over the next 6 months she complains of recurrence

Skin problems in returned travellers; what’s eating U?

Jay S. Keystone/Edward C. Keystone MD

Thursday, 19 April, 12

Skin problems in returned travellers

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Disorder ledermann=4,594 ’08

Caumesn=269 ’95

Herbingern=4,158 ’11

pyoderma 16 18 22cutaneous larva migrans

10 25 8

Insect bite 8 10 17allergic reaction 5 6 5leishmaniasis 3 3 2.4myiasis 3 9 0.8




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Case i. A 35 year old female returns from C. America with a pruritic rash ! over the next 6 months she complains of

recurrence of lesions, one or two at a time.

•  Insect bites: •  - pattern (clusters, linear) •  - fleas, bedbugs, mites, reduviid bugs •  - painful - tse tse, black fly, ants •  - recurrent, pruritic, papular urticaria •  - Rx: topical steroids, hydroxyzine


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Fire ants Thursday, 19 April, 12

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Fire ants

Fire ant bite


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Fire ants

Bed bug bite Fire ant bite


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Fire ants

Flea bite Bed bug bite Fire ant bite



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Ivermectin


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Case v. A 6 months old immigrant child from Honduras presents with a 3 week history of a papular, pustular rash.

Scabies •  mite infection from direct contact papular,

pustular, vesicular, very pruritic rash •  location: intertriginous, genitals, abdomen,

axillae, extensor surfaces •  dx; clinical, scrape burrow and examine

microscopically •  Rx: lindane (↑ resistance), 5% permethrin,

ivermectin •  Norweigen scabes: no pruritus, 1000�s mites







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Case vi. A 35 year old traveler returns from one month in rural Venezuela with a painful lesion on his great toe, present for two weeks

Tungiasis (chigoe, jigger, sand flea): • Africa, South and Central America,

India •  female flea burrows into foot •  painful nodule •  surgical: extract flea














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Case vii. A 50 year old man returns from two weeks in Belize, urban and rural travel, complaining of lesions on

his arms; sharp jabs of pain with a feeling that �something is moving inside�

Myiasis (Tumbu & Bot fly) •  egg deposition onto skin •  furunculoid lesion; central opening; usually

painful; �movement inside� ugh! •  Rx : �suffocate� with paraffin (vaseline, bacon

fat, crazy glue, nail polish) •  extraction by lateral pressure, rarely surgery



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Case viii. A 35 year old fisherman presents with nodular lesions on his hand which

move progressively up his arm.

Fish tank or swimming pool granuloma •  inoculation of Mycobacterium

marinum found in fresh or brackish water

•  Dx. Culture •  Tx: doxycycline; rifampin and

ethambutol


Lymphocutaneous disease

• Sporotrichosis• M.marimum• Leishmaniasis• Nocardiosis• Bartonellosis• Tularemia

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Case ix .A 30 year old man returns from Jamaica; one week after return complains of a severely pruritic, serpiginous,

linear, progressing rash with bullae on his foot.

Cutaneous larva migrans: •  very pruritic linear, serpigenous lesions;

occasionally bullous •  Rx: topical or oral thiabendazole, albendazole,

ivermectin •  suspect strongyloidiasis (larva currens);

- perianal larval track - rapid migration, up to 10 cm/hr - prolonged symptoms



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Case x An 18 year old woman returns from St. Lucia and notices (one the plane) a linear pigmented rash on her leg

which seems to be darkening. No pruritus or pain. Phytophotodermatitis: (Limes disease) •  psoralen containing compounds

(lime juice) which cause UVA •  photosensitization •  painless, erythematous, pigmented,

straight streaks or droplets



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Case Xii .A 23 year old Vietnamese man, recently arrived in the U.S. complains of fever for 3 days. On examination you note a rash on his back.

Indigenous medicine: •  �scratching the wind � or �coining� •  linear bruises from rubbing with a

coin to increase circulation and cure the fever •  common among Vietnamese of

Chinese origin







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Leishmaniasis: immunological spectrum

High LowNormal



High LowNormal

MCL



High LowNormal

MCL LR



High LowNormal

MCL LR CL



High LowNormal

MCL LR CL DCL


Chronic ulcers or nodules

• leishmaniasis• TB• atypical mycobacteria• fungus

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Case xxi. A 35 year old returns three days ago from four weeks in South Africa, both urban and rural stay,

complains of fever, inguinal discomfort and a lesion on his leg.

Eschar: •  Mediterranean, Indian, African tick typhus (R.

conorii) or S.E. Asian scrub (mites) typhus (R. tsutsugamushi)

•  febrile illness + rash •  DDx: anthrax, (edematous margins), spider bite

(Brown recluse; loxesceles, herpes zoster, trypanosoma chancre

•  Dx: serology •  Rx: tetracycline


Tropical Dermatology Summary

• Epidemiology is everything! (travel and exposure history, in particular)• When in doubt, cut it out..and

culture it!• chronic nodules,plaques or ulcers:

usually leishmaniasis,fungus or mycobacteria• If it moves ,it is probably alive…and

a parasite!






Documents

Skin problems in returned travellers; what’s eating U? · 5 Case i. A 35 year old female returns from C. America with a pruritic rash ! over the next 6 months she complains of recurrence