|Year : 2014 | Volume
| Issue : 1 | Page : 32-34
Gnathostomiasis: A rare case of cutaneous creeping eruptions
Vaibhavi Subhedar1, Shirish Nandedkar2, Manish Jain3, Trupti Bajpai4
1 Department of Microbiology, Bombay Hospital, Indore, India
2 Department of Pathology, Sri Aurobindo Institute of Medical Sciences Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
3 Department of Medicine, Bombay Hospital, Indore, India
4 Department of Microbiology, Sri Aurobindo Institute of Medical Sciences Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India
|Date of Web Publication||24-Jun-2014|
Department of Microbiology, Sri Aurobindo Institute of Medical Sciences Medical College and Postgraduate Institute, MR-10 Crossing, Indore-Ujjain Road, Indore - 452 111, Madhya Pradesh,
Source of Support: None, Conflict of Interest: None
A 21-year-old vegetarian lady presenting with migratory erythema and pain in her right hand subsequently developed a blister on the palm. A worm-like structure came out of the wound and was identified as Gnathostoma spp. adult male worm. It is a very rare cause of creeping eruptions and so far only one case of cutaneous gnathostomiasis caused by a larva has been reported from India. This is the first case of cutaneous gnathostomiasis due to an adult Gnathostoma spp. in India.
Keywords: Creeping eruptions, gnathostoma, larva migrans, recurrent migratory edema
|How to cite this article:|
Subhedar V, Nandedkar S, Jain M, Bajpai T. Gnathostomiasis: A rare case of cutaneous creeping eruptions. Indian J Dermatopathol Diagn Dermatol 2014;1:32-4
|How to cite this URL:|
Subhedar V, Nandedkar S, Jain M, Bajpai T. Gnathostomiasis: A rare case of cutaneous creeping eruptions. Indian J Dermatopathol Diagn Dermatol [serial online] 2014 [cited 2019 May 23];1:32-4. Available from: http://www.ijdpdd.com/text.asp?2014/1/1/32/135195
| Introduction|| |
Gnathostomiasis, primarily a disease of felines, is a rare zoonotic infection of humans where man is the paratenic host. It is endemic in South-East Asia including India but very few cases have been reported in humans. Most of them are the cases of ocular gnathostomiasis. So far 72 cases of ocular gnathostomiasis have been reported in the world out of which 14 are from India.  Careful survey of literature revealed only one case of cutaneous gnathostomiasis caused by a larva, reported from India.  The present one, is the first case of cutaneous gnathostomiasis due to an adult male Gnathostoma spp. in a vegetarian lady, with successful management being reported.
| Case Report|| |
A 21-year-old lady presented to the outpatients department of our hospital with complaints of swelling and pain in her right hand for 2 months. It was migratory, starting from her right middle finger and proceeding to dorsum and then palm.
She gave past history of abdominal pain and cutaneous rash on abdomen and was admitted in some other hospital and treated. Her blood investigations repeatedly showed eosinophilia ranging from 16-21% (absolute eosinophil count 1390-2247/cu mm.), total white blood cell (WBC) count ranging from 8800-11,200/cu mm and erythrocyte sedimentation rate (ESR) from 18 to 21 mm at the end of 1 hour. Her other investigations like coagulation profile, hepatic and renal functions, rheumatoid arthritis factor, and uric acid level were within normal limits. Her stool was found to be negative for parasites, ova, or cysts as examined for three consecutive days. No microfilaria was detected in her nocturnal and diurnal blood samples. Magnetic resonance imaging (MRI) of her hand revealed cellulitis. She was a vegetarian and had no contact with pets or stray animals. She consumed water from the local water tank supplied by the municipal corporation. Her treatment started with antiallergics, analgesics, and antibiotics. The swelling subsided partially but reappeared again after 5-6 days, and she could feel some structure moving beneath the skin and subsequently developed a huge blister on her palm [Figure 1]. The blister was incised and contents were drained out. The patient was sent home after dressing the wound. Next day the patient returned with a live worm that came out when she was cleaning the wound [Figure 2].
|Figure 1: Photograph showing serpiginous skin eruptions on the palm of a patient|
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On macroscopic examination, the worm was orange-brown in color, motile, and measured 1.5 cm in length and 0.3-0.4 cm in breadth. Under light microscope, the head end was rounded having eight rows of hooklets and oral opening was also appreciated [Figure 3]. The anterior half of the body had leaf-like spines [Figure 4]. The tail end of the worm was coiled [Figure 5]. The internal structure of the worm could not be appreciated. Based on these findings, the worm was identified as an adult male of Gnathostoma spp., and the case was diagnosed as the first case of cutaneous gnathostomiasis caused due to an adult Gnathostoma spp. in India. The patient was treated with 400 mg bd albendezole for 21 days and was asked to visit again after 15 days. During the subsequent 15-days follow up, eosinophil count dropped from 2247/cu mm (i.e. 21%) to 1390/cu mm (i.e., 15.8%); total leukocyte count dropped from 11,200/cu mm to 8800/cu mm, whereas ESR was found to be raised (25 mm at the end of 1 h) as compared with earlier report. At present, she is free from her symptoms and on 6-months follow up.
|Figure 3: Photograph showing head bulb of Gnathostoma spp. adult male worm using light microscope (×10)|
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|Figure 4: Leaf-like spines on the body of adult male worm as seen through light microscope (×10)|
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|Figure 5: Photograph showing tail end of the adult male worm using light microscope (×10)|
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| Discussion|| |
Gnathostomiasis is caused by a spiruoid nematode. It is also known as consular disease, larva migrans profundus, nodular migratory eosinophilic panniculitis, panniculitis nodular migratoria eosinophilia, Shanghai's rheumatism, Yangtze River's edema, Chang-Chiang edema, Hoko-Fushu, or Tua-Chid.  The parasite nematode was first discovered by Owen in 1836 in the stomach wall of a tiger that died in London Zoo,  and it was first described in humans in 1889 in Thailand by Levinson.  Four species of Gnathostoma are known to infect human beings, but Gnathostoma spinigerum is commonly seen in south-east Asia including India.  The infective form is a third-stage larva (L3) that is responsible for the larva migrans syndrome that causes cutaneous, cerebrospinal, and ocular lesions. Humans acquire infection by eating raw, marinated, or poorly cooked parasitized fish. Because man is not a natural host, the parasite fails to mature and wanders through the tissue periodically causing symptoms of larva migrans. Diagnosis is mostly made by eosinophilia, migratory lesions, history of geographic and food exposure, and above all examination of the extracted worm. Creeping eruptions have been well documented because of filiform larvae of Ancylostoma spp., Necator americana, Strongyloides, and migratory maggots but rarely with Gnathostomiasis. Certain nematode larvae on entering into an unnatural host may not be able to complete this journey through the host's tissue to their normal abode. 
Gnathostoma infection occurs via oral route by ingestion of undercooked infected fish. Our report describes a woman with confirmed Gnathostomiasis. The accidental ingestion of infected Cyclops with drinking water is the likely cause in our case as the patient was vegetarian. 
In most cases of cutaneous gnathostomiasis, it is the third stage larva that is responsible for cutaneous lesion. However, cases have been reported from Japan indicating that several Japanese and tropical strains of Gnathostoma spp. may be able to develop into the adult stage in the human body.  In our case, the worm was identified as an adult male based on the features like color (orange-brown color), size (1.5 × 0.3-0.4 cm in length and breadth, respectively), presence of eight transverse rows of cephalic hooklets, leaf-like spines in the anterior half of the body, and presence of blunt coiled ends. 
To conclude, Gnathostoma should now be considered as an emerging pathogen for cutaneous creeping eruptions. With the newly emerging cases of cutaneous gnathostomiasis, it has become imperative that the clinicians become familiar with the disease.
| Acknowledgement|| |
The authors wish to thank the management, technical, and clinical staff of Bombay Hospital, Indore and Sri Aurobindo Institute of Medical Sciences (SAIMS) Medical College and Postgraduate (PG) Institute, Indore for their kind support.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]