Divisions of Dermatology (GLD, JSF) and Infectious Diseases (GLD); Department of Pediatrics; Children's Hospital and Regional Medical CenterDivision of Dermatology; Department of Medicine (GLD)University of Washington School of Medicine Seattle, WA
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Tungiasis is an inflammatory infestation caused by burrowing of the female flea, Tunga penetrans, into the skin. Although tungiasis is rarely diagnosed in the United States, it is likely to be seen more frequently than in the past among those entering the United States from endemic areas because of increases in the volume and speed of international travel and migration. We present the first report of tungiasis diagnosed in a child in the United States.Case report. A 15-month-old girl was seen in hospital with a 1-month history of a red, swollen, asymptomatic distal right fifth toe. One month before her presentation the patient was adopted from a foster home in Paraguay. When the child arrived in the United States, her adoptive parents noted redness and swelling of the right fifth toe. The swelling increased during the next 2 weeks, and the lesion appeared to blister, prompting a visit to a community physician who prescribed cephalexin. When no improvement was noted 1 week later and purulent-appearing material was expressed from the edge of the lesion, she was referred to us for evaluation.She had no fever or other constitutional symptoms, has no other skin problems and had a normal gait. The right fifth toe was swollen and erythematous distal to the metatarsophalangeal joint. On the distal dorsal surface, extending under the distal nail plate, was a 7-mm pale, firm, hyperkeratotic papule with a black central core. A roentgenogram of the toe showed no foreign body, no gas in the tissue and no periosteal elevation.The distal nail was clipped back and the papule was unroofed under sterile conditions with a scalpel. Whitish material with a pasty consistency and the appearance of fine tapioca was expressed. The wound was debrided of all devitalized tissue, irrigated with normal saline and dressed with bacitracin ointment. The wound healed uneventfully.Microscopic examination of the exudate in the microbiology laboratory revealed numerous eggs (Fig. 1) and insect parts which were consistent with T. penetrans.Discussion.History. Tungiasis was first described in 1526 by Oveido among members of Columbus' crew from the Santa Maria who were left in Haiti after being shipwrecked.1 It appears to have originated in the region of the West Indies and became widespread in Africa after 1872 when the flea was transported there in the sand ballast of an English ship. The first case reported in the United States was in 1930 in a man who had lived his entire life in New Orleans but had probably contracted the infestation from a hemp pile which had come from Mexico.2 The first imported case in the United States occurred in 1966 in a traveler returning from Gabon, Africa.3 Only 22 reported cases of tungiasis, including our patient, have been diagnosed in the United States; all except the first case2 occurred in individuals who had been in Africa or South America a few days to weeks before presentation.3-13 Ours is the first report of tungiasis diagnosed in a pediatric patient in the United States and the first in an international adoptee, expanding the list of potential illnesses in these children.Prevalence. Tungiasis is now prevalent in Central and South America, the Caribbean Islands, tropical Africa, the Seychelles, Pakistan and the west coast of India. Reappearance of the infestation was reported recently in Mexico, where no cases had been seen since 1948.14 Prevalence of tungiasis was 15 to 40% among children in Nigeria15-18 and Trinidad.