An unusual recurrence of pruritic creeping eruption after treatment of cutaneous larva migrans in an adult Ghanaian male: a case report with a brief review of literature

The hookworm related Cutaneous Larva Migrans is a common disease present in the tropic and subtropical areas of the world. The disease is self limiting and would naturally resolve within weeks. However, an unusual recurrence of the disease in a Ghanaian male after standard treatment was observed and is herein reported. A 52 year old Ghanaian male of Akan dissent was diagnosed with Cutaneous Larva Migrans in a clinic in Accra, Ghana. Symptoms of the disease persisted for three days after treatment with a 400mg single dose Albendazole and was only resolved after re-dosing with 400 mg daily of the same drug for three days. Two months post-treatment, the usual pruritic creeping eruption typical with the disease re-appeared even though the victim has not been re-exposed to any possible larva contaminated source. This could possibly be a case of hookworm- related larva resistance to a standard anti-helminthic therapy and host immunity.


Introduction
Cutaneous Larva Migrans (CLM) caused by infestation of either the dog or cat hookworm is not an unusual disease. However, the unusual recurrence of the disease in a Ghanaian male during treatment warrants discussion and wider dissemination of the experience. This is important in order to create the necessary awareness among health workers. This article therefore aims to reiterate the possibly existence in Ghana and elsewhere of the hookworm-related larva with reduced tolerance to albendazole and highlight on appropriate measures needed to enhance patient care. Serpentine or linear single-track lines later mark the course of the larvae as they migrate through the epidermis. The clinical features of CLM have been described [1]. The pruritic lesions may be attributed to an immune response to the larvae and their products [2]. The creeping eruption usually appears 1-5 days after skin penetration, but the incubation period may be up to a month. It is important to note that the location of the track does not necessarily relate to the location of the larva which is randomly moving ahead of the track formation and single tracks or multiple tracks may be present, depending on the severity of infection. Cutaneous larva migrans heals naturally within few weeks or months of infestation.
The disease could easily be misdiagnosed by a less informed doctor who has never had an encounter with it as the lesions may be mistaken for fungal infections or inflammatory skin disorders.
Indeed, data on CLM among travellers revealed that between 22% and 58% are misdiagnosed or inappropriately treated [3]. Again in Africa and some parts of the world where traditional beliefs are rife, CLM could easily be linked to unnatural or spiritual cause due to the nature of disease manifestation, thus orthodox treatment may not be sought. In this short article the interesting case involving a Ghanaian male adult is presented and discussed. In the light of these unusual occurrences, an informed consent was sought from the patient to publish his case for which he agreed. It must be emphasized that majority of people living in tropical countries are at high risk of infestation and the larva can attack any person who come into contact with it regardless of the social status.

Discussion
Since most of the reported CLM cases in literature are from tourist returning from visits to tropical countries, it is the responsibility of the authorities in tourist destinations such as Ghana to encourage periodic de-worming of pets by owners. Additionally, the waste products of dogs and cats must be properly disposed off. Stray dogs and cats must be removed for confinement and not allowed to roam the streets, beaches and other spots where people are likely to come into contact with their faeces. Shoes must be worn at all times in areas where dogs and cats roam. Residents and tourist to these areas must take the necessary precaution.
Various means have been employed to treat or manage CLM. In one of the method, liquid nitrogen was applied to the migrating eruption in order to destroy the larva [5]. However cryotherapy with liquid nitrogen under normal circumstance is not recommendable as the larva is usually located several centimeters beyond the visible end of the eruptions hence it is difficult to locate their exact position. It has also been demonstrated that the larvae are capable of surviving temperatures as low as -21°C for more than 5 minutes. Another reason for which cryotherapy is not favoured is that chronic ulcerations may occur if the procedure is not performed well.
Various regime of albendazole have been used with different outcomes. Careful analyses of the outcome of each regimen suggest that the 400mg for three days or more is the best. Oral albendazole 800 mg/daily for 3 days has also been suggested [6]. Ivermectin has been described as an alternative for the treatment of cutaneous larva migrans. In a study that compared the efficacy of single doses of oral ivermectin (12 mg) and oral albendazole (400 mg) in the treatment of cutaneous larva migrans, the cure rate was 100% and 46% for ivermectin and albendazole respectively [7]. Thiabendazole is another agent which can be applied either topically or orally in the treatment of CLM [8]. It is important to mention that because of high incidence of side effect, the use of oral Thiabendazole to treat CLM is being discouraged. Side effects recorded with the use of this drug include dizziness, nausea, vomiting and intestinal cramps.
In our experience, the initial 400 mg single dose was not able to kill the larva. When a three-day course of the drug was given, the symptom quickly resolved. The later regimen therefore appears to be the best regardless of the initial larva load. However of a big surprise and atypical was the reappearance of the creeping eruptions two months after treatment. This could not be a case of re-infestation as the victim had stop the routine gardening with his bare hands, a practice thought to have been responsible for the initial infestation. Again, it could not be due to delayed or prolonged immune response to the larval debris since it responded promptly to Page number not for citation purposes 4 treatment with antihelminth. The new eruptions were exactly around the same area of the waist where the initial observation was made. With some few considerations, the new creeping eruption observed was assumed to have been caused by "resurrected" larvae. Given the history of treatment, and the fact that the disease could have naturally been resolved within that period, it was obvious that this strain of the larvae has an increased tolerance for albendazole in addition to an ability to withstand the host immune system. If this is a case of larva resistance to a standard drug then the situation indeed calls for prompt attention in the management of

Conclusion
This case highlight the presence in Ghana of the larva of the dog's hook worm with apparent resistance to albendazole and an ability to with stand the host immunity. Presence of drug resistant larva could modulate the host immune response to other diseases. This case emphasizes the need to follow up patients with CLM after treatment to ensure they are completely cured.

Competing interests
The authors declare no competing interests.

Authors' contributions
ET was responsible for the overall clinical management of the patient and was also involved in writing of the manuscript. NBQ was involved in the conception and writing of the review. All authors have read and agreed to the final version of this manuscript and have equally contributed to its content and to the management of the case.