CPC07 Occupational cutaneous larva migrans presenting as diffuse folliculitis with concurrent helminthiasis

Cutaneous larva migrans (CLM) occurs following human skin contact with the larvae of animal hookworms, including the dog hookworm Ancylostoma caninum. To date, these hookworms cannot complete their life cycle in humans. The condition is mostly seen in the tropics or subtropics or in returning travellers; however, cases following local exposure to animal hookworms have been identified. Less than 5% of cases of CLM reported in the literature present as folliculitis. Strongyloidiasis is caused by infection with the soil-transmitted roundworm Strongyloides stercoralis and is seen in areas of poor sanitation. It can complete its life cycle within the human host, and infection can persist asymptomatically for decades. Toxocariasis is infection caused by the larvae of the dog or cat Toxocara spp. roundworm. Human infection occurs through ingestion of eggs, but these roundworms do not complete their life cycle in humans. Infection can be subclinical or present as visceral or ocular larva migrans. A 62-year-old man was admitted to hospital with an un­usual rash and significant metabolic derangement. He had a 4-week history of a diffuse, pruritic, erythematous, papulonodular rash extending from his flanks to his thighs with florid pustular areas on examination. He had no pre-existing medical conditions and denied sexual contact or foreign travel for over a decade. He worked as a cleaner in a large governmental organization with regular exposure to human and animal excrement, although he reported adequate personal protective equipment. Laboratory results revealed a new diagnosis of type 2 diabetes and eosinophils of 0.1 × 109 L−1, and blood culture grew multiple gastrointestinal bacteria. A skin biopsy demonstrated purulent folliculitis, abundant eosinophil infiltration, and multiple rhabditiform larvae within dilated and ruptured follicles. Slides were sent for specialist opinion, and filiform larvae with the characteristic double lateral alae of Ancylostoma spp. were identified. Given the patient’s occupational exposure, the findings were deemed to be compatible with CLM caused by the dog hookworm, A. caninum. Serology also revealed weak-positive Strongyloides, and positive Toxocara antibodies, although two faecal samples were negative for helminths. The patient was treated with a one-off dose of ivermectin and a 7-day course of albendazole. This is a highly unusual case of CLM presenting as fulminant folliculitis secondary to A. caninum, in the absence of foreign travel, and likely contracted through occupational exposure. The possible coinfection with S. stercoralis and Toxocara canis prompts discussion of the transmission, life cycle, diagnostic testing and management of all three helminths.