This paper presents a case of tungiasis in a man who had been on an expedition in South America. This is the first case of an imported arthropodic infection reported in Lithuania.
On September 12, 2005 a 28-year-old man reported to the Baltic American Clinic with swelling of the small toe on his right foot.
Consultation with surgeon: On examination, the patient had a nodule 0.7x 0.7 cm in size with a central black dot. He had no intensive itch or fever. The nodule that consisted of a yellow grey mass with a central black dot and white oval eggs was excised (Figure 1, 2). The material was send to the National Public Health Surveillance Laboratory, Parasitology Department, in Vilnius. Diagnosis of surgeon: arthropod bite.
Figure 1. The material from the lesion
Figure 2. The eggs of Tunga penetrans
Consultation with infectologist on 14 September 2005:
On examination, the patient did not have a rash similar to that associated with Leishmania ulcers. An open 0.5 cm nodule with surrounding inflammation was seen on the distal surface of his right foot. The serous discharge exuded.
During an expedition in South America from July 8 to August 18, 2005 the patient waded in Amazon river and slept outdoors in a tent. He noticed a distinguishable hard “insect” bite. The patient reported that the other expedition participants had similar skin lesions but they did not seek medical attention.
Primary (presumptive, preliminary) diagnosis: probable subcutaneous myiasis. Exclusion of Leishmania ulcer. Differential diagnosis: myiasis syndrome, cutaneous larva migrans.
Results of laboratory testing
Тotal blood count (CBC), IgE, Giemsa stained smears from an inflamed lesion for exclusion of leishmaniasis (Fig. 3), identification of surgical material. Prescribed treatment: local antimicrobial and good hygiene.
Figure 3. The Giemsa stained smear. Stained eggs of Tunga penetrans are seen
Tunga penetrans eggs were found in a direct smear (ocular×10, objective×10) at the Parasitology Laboratory on October 15, 2005. The pictures (Fig. 1-5) were sent to Centers for Disease Control (Atlanta, USA) Division of Parasitic Diseases. The tungiasis diagnosis was confirmed.
Figure 4. The eggs of Tunga penetrans in a direct smear (ocular×10, objective×10), in various stages of development
Figure 5. The egg of Tunga penetrans in a direct smear (ocular×10, objective×10). Size of egg 650 µm in length
Consultation with infectologist on September 21, 2005
The sore was not infected and the patient had no complaints. Laboratory testing results: eosinophilia, total IgE was not increased, Giemsa stained smears were negative for Leishmania amastigotes.
Tungiasis is an ectoparasitic disease caused by the penetration of the female sand flea (also called jigger) Tunga penetrans into the epidermis of its host (1-4). Tungiasis is a zoonosis and affects a broad range of domestic and peridomestic animals. It is endemic in many countries in Latin America, the Caribbean and sub-Saharan Africa (1-4).
Within 24 hours after penetration, the penetration site becomes irritated and painful 2 or 3 days later. Erythema and oedema develop around the lesion. The flea needs 8 to 12 days to reach maturity. During this process, its abdomen enlarges considerably and eventually reaches a diameter of 1 cm containing up to 200 ova. The inevitable pruritus causes the host to scratch the lesion, which in turn helps to expel the eggs. Fleas can live in their host and expel eggs for several weeks. After the eggs have been released, the flea dies. Thereafter, the lesion desiccates in situ and eventually the remains of the ectoparasite are expelled (3).
The diagnosis is made clinically taking into consideration the dynamic nature of the morphology of the lesion (4). Observation of eggs being expelled or attached to the skin around the rear cone and the release of brownish threads of faeces are pathognomic signs (4). Biopsy of the lesion for diagnosis or treatment is not indicated. Histological sections demonstrate the presence of the ectoparasite, chitinous fragments and often eggs (3, 4). The differential diagnosis of tungiasis includes myiasis, verrucae vulgaris, cutaneous larva migrans, dracunculosis, foreign body and arthropod bites (3).
Therapy consists of removing the flea with a sterile needle and topical application of an antibiotic in case of secondary infection (3). Without appropriate treatment secondary infections are common (3). In non-vaccinated individuals tungiasis may be complicated by tetanus (1,2). Prevention consists of using closed shoes whenever the feet are in contact with contaminated soil (3).
Cases of imported tungiasis occur in Europe. In a study in Italy, during the period 1991-2006, 19 patients with imported tungiasis were observed at the Institute of Dermatological Sciences, University of Milan (6). A prospective study of 269 consecutive patients in Paris who had travel-associated dermatosis found tungiasis in 6% of all diagnoses (5).
The infrequency of tungiasis and consequential unfamiliarity of physicians with this infestation in non-endemic areas may lead to diagnostic problems and incorrect case management.
1. Heukelbach J, Wilcke T, Eisele M and Feldmeier H. Ectopic localization of tungiasis. Am. J. Trop. Med. Hyg., 67(2), 2002, pp. 214–216.
2. Feldmeier H, Eisele M, Sabóia-Moura R. C, and Heukelbach J. Severe Tungiasis in Underprivileged Communities: Case Series from Brazil. Emerging Infectious Diseases. Vol. 9, No. 8, August 2003.
3. Heukelbach J et al. Tungiasis: a neglected health problem of poor communities. Tropical Medicine and International Health. Volume 6 no 4 pp 267-272 April 2001.
4. Tungiasis. Orphanet Encyclopedia. September 2004. http://www.orpha.net/data/patho/GB/uk-Tungiasis.pdf
5. Caumes E; Carriere J; Guermonprez G; Bricaire F; Danis M; Gentilini. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Mm Clin Infect Dis 1995 Mar; 20(3):542-8.
6. Veraldi S. Valsecchi M. Imported tungiasis: a report of 19 cases and review of the literature. International journal of dermatology. Vol 46; No 10, pages 1061-1066, October 2007 .