Edward C. Keystone MD

Skin problems in returned travellers; what’s eating U? Jay S. Keystone/Edward C. Keystone MD Thursday, 19 April, 12 Skin problems in returned trave...
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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 Disorder pyoderma

lederman Caumes n=4,594 ’08 n=269 ’95

Herbinger n=4,158 ’11

16 10

18 25

22 8

Insect bite

8

10

17

allergic reaction leishmaniasis

5 3

6 3

5 2.4

myiasis

3

9

cutaneous larva migrans

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2

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 5

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6 Thursday, 19 April, 12

Fire ant bite 6 Thursday, 19 April, 12

Bed bug bite

Fire ant bite 6

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Flea bite

Bed bug bite

Fire ant bite 6

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Ivermectin Thursday, 19 April, 12

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 10mites Thursday, 19 April, 12

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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 18 Thursday, 19 April, 12

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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 31 Thursday, 19 April, 12

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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 33 Thursday, 19 April, 12

Lymphocutaneous disease • Sporotrichosis • M.marimum • Leishmaniasis • Nocardiosis • Bartonellosis • Tularemia 34 Thursday, 19 April, 12

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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 40 Thursday, 19 April, 12

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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 43 Thursday, 19 April, 12

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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 45 Thursday, 19 April, 12

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Leishmaniasis: immunological spectrum Normal Low High

Thursday, 19 April, 12

Leishmaniasis: immunological spectrum Normal Low High MCL

Thursday, 19 April, 12

Leishmaniasis: immunological spectrum Normal Low High MCL

Thursday, 19 April, 12

LR

Leishmaniasis: immunological spectrum Normal Low High MCL

Thursday, 19 April, 12

LR

CL

Leishmaniasis: immunological spectrum Normal Low High MCL

Thursday, 19 April, 12

LR

CL

DCL

Chronic ulcers or nodules

• leishmaniasis • TB • atypical mycobacteria • fungus 58 Thursday, 19 April, 12

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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 60 Thursday, 19 April, 12

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! Thursday, 19 April, 12

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