Skin diseases in returned ESCMID eLibrary © by author
Transcript of Skin diseases in returned ESCMID eLibrary © by author
Skin diseases in returned
travelers
Pr. Eric CAUMES
Dept Maladies Infectieuses et Tropicales
Hop Pitié-Salpêtrière
Paris Sorbonne
University (ex Pierre & Marie Curie)
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Potential links of Interests
• In the past 5 years, I (or my department) have received
honoraria from BMS, Baxter, Galen, Codexial and
Takeda, for lectures on STDs and participation in
advisory boards (TBE vaccine, KS management,
permethrin, and dengue vaccine).
• Editor in Chief of the Journal of Travel Medicine
(submission wellcome) ESCMID eLibrary
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What is the part of tropical diseases
amongst skin diseases in returned
travelers seen in travel units?
• 1/ > 50%
• 2/ 35-50%
• 3/ 20-35%
• 4/ 5-20%
• 5/ < 5%5769
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10
20
30
40
50
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1995 2007 2008 2014
Tropical
Tropical skin diseases in returning
travelers : less and less common
1995- Caumes E. Clin Inf Dis 1995; 20:542-548
2007- Ansart S. Am J Trop Med Hyg 2007; 76:184-186
2008- GeoSentinel. Int J Inf Dis 2008 i:10.1016/j.ijd.2007.12.008
2015- Stevens MS et al. CMAJ open 2015; 0.9778/cmajo.20140082
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What is/are the leading skin disease(s)
diagnosed in returning travelers seen
in travel units?
• 1/ cutaneous larva migrans
• 2/ skin and soft tissue infections
• 3/ sexually transmitted diseases
• 4/ insect bites and stings
• 5/ skin related animal exposures5768
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0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
SSTI Insecte prurit Animal LMCa
Derm
Skin diseases in 8.227 ill travelers
(19%), GeoSentinel, 2007-2011
Rabies
PEP
Leder K et al. Ann Intern Med 2013; 158: 456-468
Sentinel
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Dermatoses Canadian Travellers, 2009-2012
• 1076 dermatoses/6639 consultations (16%)
• 5/6 Canadian Sites; 6 possible purpose for travel
• Sex: 41% M; 58%F; age (IQR): 39.7 y (26-52)
• Travel duration (IQR): 15 d (7-31d)
• Outpatient: 1049 (97%)
• Carribean: 242 (22%); Latin America: 197 (18%)
• Tropical Infections (16.4%): HrCLM (9.8%);
LCL (3.3%); myiasis (1.7%); leprosy (1.4%)
Stevens MS et al. CMAJ open 2015; 10.9778/cmajo.20140082 ESCMID eLibrary
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What is the leading animal to which
travelers are exposed?
• 1/ Bat
• 2/ Dog
• 3/ Cat
• 4/ Monkey
• 5/ Tiger
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20
40
60
80
100
120
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Insect bites (19%)
SSTI (14%)
HrCLM (9.8%)
Rash ukn (7.1%)
Prurit ukn (6%)
Animal (5.2%)
Skin problems in 1076 travellers Canada
Stevens MJ et al.
CMAJ open 2015
Sentinel
monkey (25), dog (18), other (10: bat
6, cat 3, tiger, stingray & leech 1)
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Skin diseases in returned travelers
(post travel and ID/travel unit biases)
• Epidemiological overview
• Skin and soft tissue Infections
• Hookworm related CLM,
creeping dermatitis
• Arthropodes exposure, pruritic
dermatoses ESCMID eLibrary
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What is the leading clinical form
of SSTI in returned travelers?
• 1/ cellulitis
• 2/ abscess
• 3/ impetigo
• 4/ furuncle
• 5/ folliculitis5771
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SSTI in 48 travelers, 1991 - 1993
• Impetigo : 19 (39%) - S aureus (40%)
[12 (63%) arthropod] - S.a + S.p (20%)
- S.pyogenes (20%)
- negative (20%)
• Erysipela : 9 (18%)
• Ecthyma : 8 (16%)
• Abscess: 4 (8%)
• Furoncle : 4 (8%)
• Intertrigo : 2 (4%)
• Folliculitis : 1 (2%)
• Necrotizing cellulitis : 1 (2%)
Caumes et al. Clin Inf Dis 1995;20:542-548 ESCMID eLibrary
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SSTI: from presentation to
treatment
Clinical form
Microbial agent
Presumptive treatment ESCMID eLibrary
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SSTI in 60 travelers, 01/2006 - 08/2007
Forms N (%) % culture + MS Sa GAS (Sp) Sa + Sp
Impetigo 21 (35%) 76% 31% 38% 31%
Abscess 14 (23%) 57% 100% 0 0
Ecthyma 11 (19%) 91% 10% 60% 30%
Cellulitis 11 (19%) 0 NA NA NA
Folliculitis 3 (5%) 33% 100% 0 0
Hochedez P et al. Am J Trop Med Hyg 2009; 80: 431-4
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M, 37 yo
D3 after bite
1. Furuncle
2.Folliculitis
3.Impetigo
4.Prurigo
5.Anthrax5772
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M, 43 yo, D2 after return
1.Furuncle; 2.Anthrax;
3.Impetigo; 4.Abscess; 5.Cellulitis
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M, 32 yo
D3 after bite
1. Furuncle
2.Ecthyma
3.Impetigo
4.Anthrax
5.Cellulitis5774
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Traveling
MRSA
M, 37 yo
D3 > return
1. Furuncle
2.Anthrax
3.Impetigo
4.Cellulitis
5.Abscess5775
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Abscess management
« Ubi pus, Ibi evacuata »
Still true since
Hippocrate
Am J Med 1876; 6: 226 ESCMID eLibrary
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D 1 : arthropod bite
D 4 : lesion onset
D 6 : return;
D 7 : 1st consultation
F, 35 yo, D1
> Ivory Coast
D3 > onset
1. Furuncle
2.Folliculitis
3.Impetigo
4.Cellulitis
5.Abscess5776
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Cutaneous lesion appeared 6
days after N°1 went back
M, 41 yo
D3 > onset
1. Furuncle
2.Abscess
3.Impetigo
4.Cellulitis
5.Anthrax5777
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Mrs fistulized abscess Mr cellulitis
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Mr Abscess
& Mrs
fistulized abscess
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What is the bacteria most likely
involved in the SSTI of both
couples?
• 1/ Streptococcus pyogenes
• 2/ Staphylococcus aureus PVL +
• 3/ Streptococcus agalactiae
• 4/ Staphylococcus aureus PVL -
• 5/ Staphylococcus epidermidis
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Import and spread of PVL+
S.aureus in travelers with SSTI• 38 travelers with S.aureus + SSTI vs 124 control with
other trav-dis; genotyping
• S.aureus SSTI were associated with travel duration and location (Africa: OR =4.2)
• Pts with PVL+ S.aureus SSTI were also colonized in the nares (73% vs 25%)
• SSTI due to PVL+ S.aureus were more likely to be complicated, have reduced antibiotic susceptibility and lead to 2ry spread (5 clusters)
Zanger P et al. Clin Inf Dis 2012; 54: 483-92
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S.aureus related SSTI in travelers
• Transmission in the household then in
the community
• Antibiotic resistance
• Recurrences
• Portage
Zhou YP, et al. J Travel Med. 2014; 21: 272-81
Zanger P (editorial). J Travel Med 2014; 21: 225-7 ESCMID eLibrary
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Palais des Papes
Avignon, France ESCMID eLibrary
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All these five patients presented
with creeping dermatitis, where
is the patient with loiasis ?
• 1/ Center
• 2/ Upper right
• 3/ Upper left
• 4/ Lower right
• 5/ Lower left
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Creeping eruption and CLMCreeping eruption
Not related to
parasitic
disease : lichen
striatus,
thrombophlebitis,
pili migrans,…
Related to the
migration of
parasite’s
larvae (incl
CLM):
animal
hookworm,
gnathostomiasis,
larva currens
Related to the
migration of
parasite :
scabies,
dracunculiasis,
loiasis, myiasis
Caumes E. Lancet Infect Dis
2004; 4: 659-660
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What is the most common cause
of creeping dermatitis in
returned travelers?
• 1/ Loiasis (nematode)
• 2/ Gnathostomiasis (nematode’s larvae)
• 3/ Hookworm related CLM (nematode’s larvae)
• 4/ Pyemotes ventricosus (arthropod)
• 5/ Larva currens (strongyloidiasis)(nematode)
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70 pts with creeping dermatitis, 2008-2012
Disease Number of cases (%)
HrCLM including
Hookworm folliculitis
66 (94%) including
7 HF /66 (11%)
Gnathostomiasis 2 (3%)
Loiasis 1 (1.5%)
Creeping (dog) hair 1 (1.5%)
Migratory myiasis,
dirofilariasis, larva currens,
Pyemotes ventricosus, scabies
0
Van Haecke C et al. Br J Dermatol 2014; 170: 1166-1169
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Boracay, Philippines ESCMID eLibrary
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What is the disease causing
creeping dermatitis with such a
parasitic cycle?
• 1/ Loiasis
• 2/ Gnathostomiasis
• 3/ Hookworm related CLM
• 4/ Pyemotes ventricosus
• 5/ Larva currens (strongyloidiasis)5783
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Folliculitis (HrCLM)
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Diagnosis of HrCLM relies on
1. Epidemiological data : typical exposure
2. Clinical appearance : creeping dermatitis (but also pruritic folliculitis)
3. Course of the disease : appearance less than one month after return, chronic
4. Biopsy of local lesion useless (except in folliculitis)
5. Stool examination : no interest except in ……dogs ESCMID eLibrary
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Hr Cut larva migrans in travellers
Ref (1) (2) (3)
Patients 60 67 64
Nationality Canada France France
After return 45 % 51 % 55 %
Lagtime 5d (0-30) 8d (0-28) 16d (1-120)
(1) Davies et al. Arch Dermatol 1993;129:588-591
(2) Caumes et al. Clin Infect Dis 1995;20:542-548
(3) Bouchaud et al. Clin Infect Dis 2000;31:493-498
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Identification of Ancylostoma braziliense in
HrCLM (Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5)
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Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5
Living hookworm larva recovered
from a skin scraping of folliculitis
Lesion (optical micro, x10)
hookworm larva
recovered
from a skin scraping
of folliculitis
lesion (optical
micro, x40)
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You can treat HrCLM patient
with…
• 1/ Ivermectine single or double dose
according to clinical presentation
• 2/ Albendazole 400 mg/d, 5 days
• 3/ Albendazole 800 mg/d, 3 days
• 4/ Albendazole 10% ointment
• 5/ Praziquantel5784
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Albendazole in HrCLM
Ref N= Dosage Cure rate
Coulaud, 1987 18 400 mg/d x 5 d 100%
Veraldi, 2011 78 400 mg/d x 7d 100%
Kaba, 2012 77 200-400 mg/d x 3 d 89%
Ref N= Dosage Cure rate
Jones, 1990 2 800 mg/d x 3 d 100%
Williams, 1989 4 800 mg/d x 3 d 100% ESCMID eLibrary
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HrCLM : efficacy of a single dose ivermectin
varies with the clinical presentation.
• 62 travellers (35 F, 27 M, mean age 35) with HrCLM
treated with 200 g/kg dose of ivermectin, single dose.
• All pts had creeping dermatitis and 6 patients (10%)
also had hookworm folliculitis (HF).
• Overall CR = 59/62 pts (95%). CR = 98% in the 56
pts presenting with only creeping dermatitis and
66% in the 6 patients also presenting with HF
Vanhaecke C et al. J Eur Acad Dermatol Venereol 2014; 28: 655-657 ESCMID eLibrary
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Topical albendazole in CLM : 2 pts
• 2 children, 10 kgs, 2 years old
• Return from Senegal, Dominican Republic
• 1 cutaneous lesion/pt
• ivermectin and albendazole contra indicated
• thiabendazole no more marketed
• albendazole ointment 10% (3 tablets, i.e. 1200 mg,
mixed with 12 gr crotamiton) twice a day during
10 days
Caumes E ; Clin Inf Dis 2004; 38: 1647-1648
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A traveler wants to know how to
avoid HrCLM on his next
vacation. Your advice to him is :
1. Use insect repellent
2. Sleep under bednets
3. Protect skin against direct sand/soil
exposure
4. Make dogs wearing sun glasses
5. Make dogs clean their shit5785
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Beppu, Japan
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Tokyo, Japan
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Borracay, Philippines
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Larva currens
Strongyloidiasis ESCMID eLibrary
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Creeping
Dermatitis
Loiasis
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Creeping dermatitis, loiasis
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Pruritic skin lesions
Pruritus
Localized Generalized
sine materia with skin
lesionsArthropod related
exposure
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What is the main cause of
generalized pruritus in a
returned traveler?
• 1/ Ciguatera
• 2/ HIV infection
• 3/ Onchocerciasis
• 4/ Scabies
• 5/ Marine dermatitis5786
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Generalized pruritus in
travelers (onset during travel)• Scabies
• Skin dryness (aged African migrants VFRs)
• HIV infection,
• Filariasis (onchocerciasis, loiasis), invasive phase of helminthic disease, African trypanosomiasis
• Ciguatera
• Cercarial dermatitis, Marine dermatitis ESCMID eLibrary
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What are the main itchy body
areas in a returned traveler w
scabies ?• 1/ Genitalia
• 2/ Breast
• 3/ Hands
• 4/ Head
• 5/ Back
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Courtesy Antoine Mahé
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Scabies = 1st cause of pruritus
• Occurs within one month after exposure (1st
episode) and within a few days (history of previous
scabies)
• Generalized itching, worsen at night, sparing head
• Specific findings : 5 to 10 mm burrows,
vesiculopustules and papulonodular genital lesions.
Classic distribution : interdigital web spaces, flexor
surfaces of the wrists, elbows, axillae, buttocks,
genitalia and breast. ESCMID eLibrary
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Itching in the marital bed
is scabies …..before
……….. bedbugs
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Common scabies = treatment
• Varies according to the country
• Topical: either permethrin OR benzyl benzoate
• Oral : ivermectin
• To be repeated :
– D 2 for BB,
– D 7 for permethrin,
– D 7 for ivermectin
• Also include persons sharing the same household (sex/bed partners, children) and environment (clothes, bedsheets,…) ESCMID eLibrary
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Imported Tropical skin
infections• Seen according to the place of exposure :
HrCLM, LCL, tungiasis, myiasis,
• Uncommon : tuberculosis, leprosy,
gnathostomiasis, loiasis,
• Rare : M.ulcerans infection (Buruli ulcer),
anthrax, C.diphteriae, onchocerciasis, lymphatic
filariasis, cutaneous forms of schistosomiasis,
trypanosomiasis and amebiasis. ESCMID eLibrary
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Cutaneous diseases in
returned travellers
• Acquisition: arthropods bites
• SSTI are the most common
• Tropical diseases: less and less common
• Dg of skin disease oriented by epidemiologal data (visited country, time return/appearance, at-risk exposure), and clinical signs
• Dg confirmed by specific tests ESCMID eLibrary
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Thank you for your
attention and kind
invitation
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