Answer to last month's Clinical Quiz

Question:

A 30 years old executive complained of an intensive itchy eruption on the back and trunk after a leisure sight-seeing and pleasure trip to Thailand. He denied any history of sexual activities during the trip but had admitted to sunbathing and lying nude on the beach whilst receiving body massage. The massage was very comfortable and he fell asleep for two hours on the beach. The itch was noted in the body immediately after he woke up from sunbathing but it became more intense and persistent for two weeks after returning to Hong Kong. He noted that there was some curious rash developing on his body recently as shown in the picture.

Answer:
C. Cutaneous larva migrans

Cutaneous larva migrans or creeping eruption is a description of a classic clinical picture of wandering, advancing, snake-like zig-zag pattern and itchy skin lesions caused by hookworms of various animals (usually dog hookworm). Adult hookworms live in the intestines of dogs and cats and their ova are left with the animal's faeces. The ova may hatch into infective larvae that will penetrate human skin by chance. Sandy beach with warm, moist and shaded areas are favourable to induce the process. The condition is common in South-east Asia. The larva will cause a non-specific dermatitis at the site of penetration and then produces exceedingly itchy and slightly raised erythematous bizarre tracks in the skin when the larva begins creeping activity. Although the disease is self-limiting, it can be accompanied by Loeffler's syndrome of pulmonary eosinophilia in severe infestations. However, the intense itchiness usually urges the sufferer to seek quick relief. Apart from symptomatic relief from oral anti-histamines, oral albendazole 400mg per day (if available) for three days is effective. Topical 10% albendazole preparations are also effective. Oral thiabendazole is less effective. Secondary syphilis is a great imitator of other cutaneous skin conditions but it seldom itches. Acute sunburn will be obvious when the patient presents as diffuse painful erythema (with or without vesicles) with colour looking like a boiled lobster. Only in the recovering stage, the patient finds extensive peeling of skin and severe itchiness. Burrows and excoriated papules or nodules in scabies are usually found in peri-umbilical area, inner wrist, finger-webs, instep of feet and genitals. Burrows are relatively short, tortuous linear lesions.