Tropical Objectives Cutaneousand Subcutaneous Disorders

While many different skin conditionscould be considered tropical, this arti-cle will focus only on a few of themore common and challenging cuta-neous and subcutaneous disordersthat podiatric physicians are likely toencounter in their patients fromThird World Countries and duringmedical outreach activities.

Cultural Sensitivity andAwareness.

It is imperative for the podiatricphysician to demonstrate sensitivityto the different cultural backgroundsfrom which patients with cutaneousdisorders may present. Different reli-gious beliefs, unusual healing prac-

Continued on page 190

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $149 (you

save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In thenear future, you may be able to submit via the Internet.If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will

also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A listof states currently honoring CPME approved credits is listed on pg. 196. Other than those entities currently accepting CPME-approvedcredit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man-aged care organization or other entity. PMwill, however, use its best efforts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts bynoted authors and researchers. If you have any questions or comments about this program, you can write or call us at: PodiatryManagement, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected] this article, an answer sheet and full set of instructions are provided (p. 196).—Editor

FEBRUARY 2011 • PODIATRY MANAGEMENTwww.podiatrym.com 189

of the world with more temperateclimates. In addition, business trav-el and tourism to endemic zonescan result in an unwelcome micro-bial hitchhiker of an otherwise pro-ductive trip and dream vacation.1

Many of the conditions that willbe discussed here are also encoun-tered more frequently in populationsof a lower socioeconomic status.Adding to these encounters withtropical cutaneous disorders is the in-creasing number of podiatric physi-cians who are participating in medi-cal outreach programs or missions toMexico, Central America, SouthAmerica, Africa, India, and the FarEast—areas with a higher incidenceof superficial infectious diseases.

Tropical cutaneous and sub-cutaneous disorders are en-demic to climates with high-

er temperatures and increased hu-midity such as the southern part ofthe United States and certain tropi-cal regions of Latin America. Sowhy should podiatric physicianspracticing in an area with a colderclimate care about tropical diseases?The expanding immigrant popula-tions in places like the UnitedStates, Canada, England, and Eu-rope have increased the frequencywith which such disorders presentto physician offices in many parts

ObjectivesAfter completing this CME,

the reader will be able to

1) Articulate the need for un-derstanding tropical cutaneousand subcutaneous diseases

2) Describe the clinical presen-tation of common tropical cuta-neous and subcutaneous diseases

3) Discuss the diagnostic testsand tools required to confirm thediagnosis of common tropicalcutaneous and subcutaneousdiseases

4) Prescribe an effective treat-ment regimen for common tropi-cal cutaneous and subcutaneousdiseases

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Medical Education

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

By Jeffrey C. Page, DPM and LauritzJensen, DA

These diseases are no longerlimited to the tropics.

TropicalCutaneous andSubcutaneousDisorders

and periungual infections; however,other candidal species are potentialagents (e.g., C. kursei, C. tropicalis),and may occasionally be involved inhuman disease. Typical manifesta-tions, especially in older patients, in-clude cheilitis—especially at the cor-ners of the mouth— inframammaryand other cutaneous rashes (Figure1), periungual discolorations, andnail deformities (Figure 2). Vulvo-vaginitis, balanitis, oral candidiasis,and rashes associated with inconti-nence and geriatric diaper use arealso fairly common, especially in thepoorly served areas of Latin Americaand assisted living facilities in theUnited States. Although C. albicansis described as a constituent memberof the normal microbiota of hu-mans—especially the mucocutanousareas—the species is usually only atransient microbe of cutaneous andnail regions of the body.

Nevertheless, candidal yeast iscapable of adhering to many sur-faces, especially when the growthof normal bacterial flora species isdisrupted by an extended course ofbroad-spectrum antibiotics, whennutritional deficiencies are present,or when elderly patients are inca-pable of maintaining a state ofgood personal hygiene. Reduceddefenses that are linked to deficien-cies in the immune status of the pa-tient are also significant contribut-

ing factors and frequently result inunforgettably aggravated and dra-matic presentations.

Not surprising, a yeasty smell isfrequently quite noticeable; however,culture on Sabouraud agar—especiallywhen the isolated colony counts arehigh—is more definitive is makingthe diagnosis. Corrective measures,such as regular bathing and washingof clothing, daily application of topi-cal azoles, and the implementation ofother therapeutic interventions usual-ly control yeast infections.2

ScabiesScabies is a common, highly

pruritic infestation of the skin thatis caused by the mite Sarcoptes sca-biei. Infestation by the Sarcoptesscabiei leads to an intensely pruriticrash. It is markedly inflammatory innature and, as a result, almost al-ways produces an intense itching atthe site of the lesion. The itching ismost intense at night. The femalemite is the chief offender and bur-rows directly into the epidermis.Scabies is highly contagious, and itis likely that multiple members ofthe same family will be afflicted. Be-cause of the intense itching, pa-tients often present with inflamma-tion and extensive excoriation, andit may prove difficult to locate a pri-mary lesion (Figure 3). The clinicianshould search for burrows in areassuch as finger webs, wrists, axillaryfolds, the abdomen, buttocks, infra-mammary folds, and the genitaliain men. Infants, more frequentlythan adults, may have widespreadinvolvement (Figure 4). Burrowsmay be 2–15 mm long. Additionalnonspecific lesions may includepinpoint erosions, papules, vesicles,scaling erythema, and eczematousinflammation. Rarely, nodules maybe found. The rash may be present


190 www.podiatrym.comPODIATRY MANAGEMENT • FEBRUARY 2011

Tropical...

tices involving shamanism,strange herbal remedies, and ma-

ternal traditions are part of the pa-tient’s character. Openly discountingunwarranted or seemingly irrelevanttherapeutic modalities is oftencounter-productive and may notshow respect for what the patient be-lieves to be true. Furthermore, formaleducation may be limited, and thelack of fluency in language may also

prove to be a formidable barrier tocommunicating with the patient.Sensitivity to cultural difference istherefore paramount, and avoidingthe temptation to summarily dismissan alternative treatment is perhaps amore productive approach which willgain the confidence of the patient.

A man examined by one of usduring a medical mission to LatinAmerica presented with a chronicfoot rash. Of note was a profuse apol-ogy for the discoloration and smell ofhis feet caused by his daily applica-tion of a salve made primarily of avo-cado, probably a traditional maternalremedy. Patterns of daily living andemployment activities may place dif-ferent demands on the feet in foreignlands. For example, the farm workeroften has his feet in moist soil all daylong which may promote fissuring,while a weaver of hand-made textileswill often sit for hours, day after day,on a reed mat with weight borne onthe dorsum of the foot, leading tothe development of hyperkeratoticlesions on the dorsal foot. The fol-lowing is a concise introduction tocutaneous and subcutaneous condi-tions found in the tropics.

Superficial Candidiasis(Cutaneous and Periungual)Candida albicans is the typical

yeast agent isolated from cutaneous

Continuing

MedicalEducation

Figure 1: Candida albicans infection inan elderly Mexican patient.

Figure 2: Candida krusei nail infection inan agricultural worker fromGuatemala.

Figure 4: Scabies infestation on the foot ofan infant.Photo taken by Dr. James Cabeen.

Figure 3: Scabies infestation in an infant.


marked but localized irritation (e.g.,pruritis, skin excoriation from exces-sive scratching). The eggs, which areappropriately referred to as nits, arefirmly cemented to the hair shaft. Nits(Figure 6) are more visible than livinglice and are considered reliable for apositive diagnosis.The female louselays approximatelysix eggs per day upto one month andthen dies. Thelouse hatches in8–10 days and ma-tures in 18 days.Most adults carryapproximately 20lice.

Lice are trans-mitted by closepersonal contact. This includes sex-ual activity, the sharing of combs,hats, clothing, and sleeping in thebed of an infected person. Treat-ment is similar to scabies in that atopical cream or shampoo must beemployed. Permethrin 1% sham-poo or pyrethin shampoo are effec-tive remedies. The medication isleft on the hair and scalp for atleast five minutes before beingwashed off. Malathione is alsorapidly effective and is useful forlice resistant to pyrethins and per-methrin. It should not be used forinfants and neonates.

A single oral dose of ivermectinrepeated in ten days is also effective.After the affected area is treated, thehair is combed with a fine toothedcomb to remove nits, and the areatreated again a sec-ond time. Close con-tacts may also needtreatment, and cloth-ing and bed linensmust be laundered or

on any part of the body, includingthe palms and soles.3,4

The diagnosis is made when themite itself, its eggs, or fecal pelletsare observed under light microscopy.A small amount of mineral or micro-scopic immersion oil is placed onvisible lesions prior to scrapingwhich, among other things, pro-motes adherence of the skin cellsand mite parts to adhere to thescalpel blade. Figure 5 is a compositeimage of a mite, an egg, and sybala(fecal material) from a single patient.

Lindane was formerly the mostcommonly used insecticide for eradi-

cation of the infestation, but now,primarily due to the availability ofless toxic agents, has limited use. Thescabies infestation may be complete-ly eradicated by the use of 5% perme-thrin, which is applied from the neckdown and allowed to remain on theskin overnight.5 Permethrin has lowinherent toxicity and limited percu-taneous absorption. It may be appro-priate to treat family members andintimate contacts simultaneously. Al-ternatively, a single oral dose of iver-mectin has efficacy at a dose of 200micrograms/kg. Many clinicians pre-fer repeating the dose after one week,especially in immune-compromised hosts andthose living in crowdedconditions.6

PediculosisInfestation of lice by

Pediculus humanus is typ-ically a scalp problem(pediculosis capitus),whereas the crab louseor Phthirus pubis in-volves the pubic region.These lice feed on theskin and often produce

Tropical... placed in a sealed plasticbag for 24-48 hours.

Cutaneous LeishmaniasisCutaneous leishmaniasis is en-

demic to a number of parts of theworld, including the Middle East

and Latin Ameri-ca.7 It is consid-ered one of themost serious skindiseases in manydeveloping coun-tries8 and oftenproduces long-term chronic con-ditions. Duringour medical out-reach activities toCentral America,L e i s h m a n i a

braziliensis and L. mexicana werethe most frequent species encoun-tered, specifically in the Peten De-partment of Guatemala. In this re-gion “chicleros” or men who maketheir living working under thedense tropical canopy harvestingthe tree gum are at particular risk.The biological vector is the Lut-zomyia, a blood-sucking sand fly.Initially, an ulcer forms at the bitesite, and will become quite conspic-uous and develop into impressive,purulent lesions (Figures 7 and 8).

A confirmed diagnosis may beobtained by scraping the open le-sion or biopsy and examining thematerial microscopically. The ob-served amastigotes (the tissue tissuestage or trypanosomal form thatlacks a flagellum) will conclusively

confirm the clinical diag-nosis. In medical out-reach clinics this maynot be possible and thephysician will be forcedto rely on empiric rea-sons for treatment. And,unless the patient isproperly treated, dissemi-nation of the parasitemay occur. Even if theulcer spontaneouslyheals as evidenced by theformation of a large cica-trix on the leg or foot,dissemination and an in-sidious recurrence is areal possibility. Mucosalinvolvement of the naresand mouth is also possi-


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Figure 5: Composite slide of the scabiessybala, mite, and egg.

Figure 7: Cutaneous leishmaniasis onthe ankle of a child from Guatemala as-sociated with cellulitis.

Figure 8: Discoid ulcerationsof cutaneous leishmaniasis ina youngmale.

Figure 6: Nits on the hair of a child fromGuatemala.

the Cochrane database9 demon-strated that in American cutaneousleishmaniasis, intramuscular meg-lumine antimoniate was betterthan oral allopurinol, but that thetwo in combination were superiorto either alone. Furthermore, intra-venous meglumine antimoniate ad-ministered for 20 days was superiorto shorter dosing regimens, even

when the latter werecombined with topi-cal agents. Patientssuffering from leish-maniasis recidivansare often resistant tothe usual treatments.

In an Iranianstudy of 32 patients, acombination of allop-urinol and intramus-cular injection ofmeglumine antimoni-ate was used success-fully with minimalside-effects.7 A studyin Pakistan of 200 pa-tients with leishmani-

asis compared itraconazole 100 mgtwice daily with intramuscular meg-lumine antimoniate and determinedthat itraconazole is more effective,economical, and has fewer side-ef-fects than meglumine antimoniate.10

Side-effects of systemic antimonialsinclude both minor (fever, rash, pru-ritis, erythema, arthralgia, abdomi-nal pain) and serious (chest pain, hy-peramylasemia, increased liver en-zymes, pancytopenia, renal and hep-atic failure) adverse effects.11

Cutaneous Larva Migrans(CLM)

Also known as creeping erup-tion, cutaneous larva migrans CLMis most commonly caused by an in-vading filariform larva of a dog orcat hookworm (e.g., Ancylostoma

caninum, Braziliense) (Figure 10). Itis the most common tropically ac-quired dermatosis in the world.Other manifestations include neu-roretinitis, eosinophilic pneumoni-tis, myositis, folliculitis, erythemamultiforme, or ophthalmologicalmanifestations.12 Parasites are foundin moist dirt contaminated with petfecal material. The filariform larva isthe infective stage and directly pen-etrates into the cutaneous tissue.

Common in the Caribbean, aperson who walks barefoot on con-taminated soil is at risk. In fact, thelarvae penetrate any exposed cuta-neous area.13 The clinical appear-ance is distinctive with a progres-sive linear, or serpiginous, raised,erythematous border occurringmost commonly in the foot. It fre-quently stings or causes intenseitching. The infestation can occurin both children and adults.14

Albendazole, a benzimidazolederivative, has proven efficacyagainst cutaneous hookworm dis-ease and is perhaps the most widelyavailable and most inexpensive an-tihelminth agent sold in develop-ing countries. Thiabendazole topi-cal paste preparations are also valu-able and rapidly absorbed, eradicat-ing the worm. A. caninum and A.braziliense are basically dog para-sites, and the human is an acciden-tal, dead-end host. Consequentlythe invading juvenile worms willeventually die, even without treat-ment. Albendazole or thiabenda-zole simply hastens the process andprovides quicker relief.

Actinomycetoma andEumycetoma

This condition is also known asMadura foot, being first described inthe Madura area of India in the



Tropical...

ble and may result in an un-wanted “plastic surgery” sculpted

by the microbial invader. The pa-tient in Figure 9 presented with dis-figuring lesions and scars in manyareas of the body. He was subse-quently referred and appropriatelytreated at a regional medical center.

Systemic treat-ment with antimoni-als, readily availablethrough endemiczones in Latin Amer-ica, is effective anderadicates the infec-tion quickly. Anti-monial sodium sti-bogluconate is com-monly given in adosage of 20 mg/kgover 20 days. Someauthors have advo-cated the addition ofallopurinol or theuse of fluconazole.Local heating, curet-tage, and topical meglumine anti-moniate or imiquimod may hastenresolution.

In a systematic review conductedfor the Cochrane Database,8 the au-thors assessed 49 trials involving5,559 participants. Some of the con-clusions reached included a signifi-cant benefit of cure for Leishmaniamajor infections with the use of 200mg of oral fluconazole, topical 15%paromomycin plus 12% methylben-zethonium chloride, and photody-namic therapy. In this study, oralpentoxifylline was a good adjuvanttherapy to intramuscular meglumineantimoniate. Oral Itraconazole wasuseful for Leishmania tropica infec-tions as well as intralesional sodiumstibogluconate and thermotherapy.

A second systematic review for

Continuing

MedicalEducation

Figure 9: Severe scarring of thetorso resulting from recurrentleishmaniasis, not initially treat-ed for the cutaneous form.

Figure 10: Filariform larva or the in-fective stage of cutaneous larvamigrans.

Figure 11: Micrograph of Fusariumoxysporum. Note the banana shapedmacroconidium.

Figure 12: Mycetoma Fusarium culture.Note the characteristic violet color.


complete laboratory diagnosis maybe established through Gram stain-ing, periodic acid-Schiff (PAS), andculture (Figure 15).16

Although it may not be possibleto reverse the chronic effects of thedisease, management of eumyce-toma or actinomycetoma is appro-priately first directed at the infect-ing organism through the systemicadministration of an antifungal oran antibacterial agent respectively.Two drugs administered in fiveweek cycles are recommended foractinomycetoma and this regimenmay be repeated once or twice.Trimethoprim sulfamethoxazole,dapsone, and Rifampin have been

1880’s. It has subsequently been de-scribed from many tropical areas ofthe world and is endemic in Africaand portions of Latin America. Ingeneral, mycetomas are linked towound contamination or possiblytraumatic inoculation (e.g., thornpenetration, insect bite) of an envi-ronmental bacterial or fungal mi-crobe. The foot is often the site in-fected. Actino-mycetoma is causedby an actinomyces bacterial agent,which usually responds well to an-tibiotic treatment. Fungal agents aremuch more insidious and difficult totreat. Consequently, it is essentialthat the clinician identify thecausative agent as quickly as possi-ble. During a medical mission, thiscan be accomplished by examiningthe expressed exudates, Gramstained, and observing the bacterialcells under the oil immersion lens.Interestingly, many different fungalagents have been linked to eumyce-tomas, including Madurella myce-tomatis, M. grisea, Pseudallescheriaboydii, Fusarium oxysporum (Figure11), F. solani, etc. Laboratory diagno-sis of fungal involvement is possibleby culturing the agent or observingthe mycelia mass in a histologicalsection or from exudates (Figure 12).

There is no racial predilectionbut men are more than twice aslikely as women to acquire the in-fection. The most common age ofonset is between 20 and 50 years.Thought to be associated with localtrauma, mycetoma is most com-monly found in the foot and leg,the hand, or the torso. The diseasemay penetrate to deeper structures,causing disfigurement, but it israrely fatal. Pulmonary and cranialextension has been reported.15

The initial clinical presentationis often nothing more than painlesssubcutaneous swelling along with ahistory of a puncture wound at thesite. This is followed by the develop-ment of subcutaneous noduleswhich are then followed by muchmore swelling and induration (Fig-ures 13 and 14). The classic manifes-tation of mycetoma is the develop-ment of draining sinuses productiveof small grains containing clumps ofcausative organisms. The color ofthe grains may be characteristic ofcertain pathogens, although a more

Tropical... effective. Ketoconazole,voriconazole, Itraconazole,and Amphotericin B havebeen used effectively in thetreatment of eumycetoma. Extend-ed treatment (up to 10 months) forfungal agents is obligatory, howev-er, and resistance has been docu-mented.17 Surgical intervention hasbeen employed through excision oflocalized lesions, drainage of sinus-es, and amputation. Unfortunately,because of the need for long-termsystemic azole therapy, fungalmycetomas are extremely difficultto treat in primitive conditions inThird World Countries because ofthe necessity of long-term systemicazole therapy. The expense and po-tential for adverse toxicity reactionare overwhelming to the patient.Over-the-counter pain medicationmay give some palliative relief andallow the patient to sleep better.

Lymphedema (Filarial andPodoconiosis)

Some principal causes of lym-phedema of the lower extremitiesinclude infectious (e.g., filarial par-asites) and non-infectious (e.g.,podoconiosis, obesity, malignancy)entities. In essence, the conditionoccurs when the lymphatic vesselsare damaged and the flow of thelymph is significantly impeded. Tosay the least, it is an insidious andprogressive disease that can onlyminimally be treated in an out-reach clinic. Virtually all the casesof lymphedema should be referredto a community treatment centerfor long-term management.

In the Americas, filariasis (ele-phantiasis or the mosquito-trans-mitted parasiteWuchereria bancrofti)is most common to Brazil, and en-demic cases would not be expectedin most other Latin Americancountries. Podoconiosis, as indicat-ed by the word’s etymology, refersto dust or mineral particles that in-vade and afflict the barefoot farm-ers who work in silica-rich volcanicsoil. It seems to occur most often inAfrican and Central and SouthAmerican regions.

Spectacular cases of lymphede-ma are seen in clinic stations, par-ticularly in remote localities.Marked swelling, infected nodules,and mossy lesions of the feet and


Continuing

Medical EducationFigure 13: En-la rgementand indura-tion from un-treated Fusar-ium myce-toma in aGuatemalanfisherman.

Figure 14: Fusarium mycetoma. Thewhite granulomas are positive for fun-gal colonies.

Figure 15: Probable co-infection of acti-nomycetoma and eumycetoma withdraining sinuses in a woman from thejungles of the Yucatan Peninsula.

Dr. Page is Associ-ate Dean, Collegeof Health Sciencesand Professor andDirector of the Ari-zona School of Po-diatric Medicine atMidwestern Uni-versity-Glendale,Arizona. He isImmediate PastChair, Board of Directors, American Asso-ciation of Colleges of Podiatric Medicineand a Fellow of the American College ofFoot and Ankle Surgeons, American Pro-fessional Wound Care Association, Ameri-can College of Foot and Ankle Orthope-dics and Medicine, and American Societyof Podiatric Dermatology.

Dr. Jensenearned a Bachelorof Science andMaster of Sciencefrom BrighamYoung University(Parasitology) anda Doctor of Arts(Microbiology)from the Universi-ty of Northern Col-orado. His post-doctorate was completedat Brigham Young University, where heserved as the Co-principal Investigator onthe Epidemiology of Echinococcosis grant(NIHAl 10588). He hasmore than 25 yearsof teaching experience in the biologicalsciences, specializing in microbiology. Hecurrently serves as the Chair of the Depart-ment of Microbiology at Midwestern Uni-versity, Glendale Campus, and has servedas the Executive Director and the Presi-dent for DOCARE International (12 yearsof experience organizing medical out-reach programs in Mexico and Centraland South America). His research inter-ests are tropical diseases, with special at-tention given to the epidemiology ofcampylobacteriosis.

Hernandez MI. Diagnosis and treatment ofscabies: a practical guide. Am J Clin Dermatol.2002; 3 (1):9-18.

5 Mumcuoglu KY, Gilead L. Treatmentof scabies infestations. Parasite. 2008 Sep;15(3):248-51.

6 Currie BJ, McCarthy JS. Permethrinand ivermectin for scabies. N Engl J Med.2010 Feb 25;362 (8):717-25.

7 Esfandiarpour I, Dabiri SH. Treatmentof cutaneous leishmaniasis recidivans with acombination of allopurinol and meglumineantimoniate: a clinical and histologic study.Int JDermatol 2007Aug; 46(8):848-52.

8 Gonzalez U, Pinart M, Reveiz L, Alvar J.Interventions for Old World cutaneous leish-maniasis. Cochrane Database Syst Rev. 2008Oct. 8; (4):CD005067.

9 Gonzalez U, Pinart M, Rengifo-PardoM, Macxaya A, Alvar J, Tweed JA. Iinterven-tions for American cutaneous and mucocuta-neous leishmaniasis. Cochrane Database SystRev. 2009Apr 15; (2):CD004834.

10 Saleem K, Rahman A. Comparison oforal itraconazole and intramuscular meglu-mine antimoniate in the treatmenht of cuta-neous leishmaniasis. J Coll Physicians SurgPak. 2007Dec;17 (12):713-6.

11 Ezazine SN, Mrabet N, Khaled A, et al.Side effects of meglumine antimoniate in cu-taneous leishmaniasis: 15 cases. Tunis Med.2010 Jan;88 (1):9-11.

12 Bowman DD, Montgomery SP, ZajacAM, et al. Hookworms of dogs and cats asagents of cutaneous larva migrans. Trends Pr-asitol. 2010Apr;26 (4):162-7.

13 Brenner MA, Patel MB. Cutaneouslarva migrans: the creeping eruption. Cutis.2003Aug;72 (2):111-5.

14 Mattone-Volpe F. CDutaneous larvamigrans infection in the pediatric foot. A re-view and two case reports. J Am Podiatr MedAssoc. 1998May;88 (5):228-31.

15 Maheshwari S, Figueiredo A, NarurkarS, Goel A. Madurella mycetoma—a rare casewith cranial extension. World Neurosurg.2010 Jan; 73 (1):69-71.

16 Hemalata M, Prasad S, Venkatesh K, etal., Cytological diagnosis of actinomycosisand eumycetoma: A report of two cases.Diagn Cytopathol. 2010 Mar (Epub ahead ofprint).

17 Van de Sande WW, Fahal AH,Bakker-Woudenberg, IA, van Belkum A.Madurella mycetomatis is not susceptibleto the echincandin class of antifungalagents. Antimicrob Agents Chemother.2010 Jun; 54 (6):2738-40

18 Dreyer G, Addiss D, Dreyer P, andNorões J. Basic Lymphoedema Management.Treatment and Preventiion of Problems Asso-ciated with Lymphatic Filariasis. Hollis Pub-lishing Company: Hollis, NH: Hollis Publish-ingCompany; 2002.

Additional ReferencesBarrera MG, Leonardi D, Bolmaro RE, et

al., In vivo evaluation of albendazole micro-spheres for the treatment of Toxocara canis

larva migrans. Eur J Pharm Biopharm. 2010Mar 27. [Epub ahead of print]

Petithory JC. Visceral and cutaneouslarva migrans. Rev Prat. 2007 Nov 30;57(18):1977-83.

Leonardi D, Echenique C, Lamas MC,Salomon CJ. High efficacy of albendazole-PEG 6000 in the treatmente of Toxocaracanis larva migrans infection. J AntimicrobChemother. 2009 Aug;64 (2):375-8.

Magalhaes GM, Oliveira SC, Soares AC,et al., Mycetoma caused by Nocardia caviaein the first Brazilian patient. Int J Dermatol.2010 Jan; 49 (1):56-8.

Fukuda H, Saotome A, Usami N, et al.,Lymphocutaneous type of nocardiosiscaused by Nocardia brasiliensis: a case reportand review of primary cutaneous nocardio-sis caused by N. brasiliensis reported inJapan. J Dermatol 2008 Jun; 35 (6):346-53.


Tropical...

toes (Figure 16) are character-istic manifestations, and invad-

ing microbes only add to the in-flammatory reactions and furtherpromote gross deformities.18

Effective management requires

manual lymph drainage and shortstretch bandaging applied by askilled lymphedema specialist.

ConclusionThe cutaneous and subcuta-

neous disorders described above aremost frequently encountered intropical climates but are appearingwith increasing frequency in tem-perate climates. For some of thesetropical disorders, such as scabiesand pediculosis, the treatment isstraightforward, while the manage-ment of other conditions such aslymphedema can be very challeng-ing. Sensitivity to the patient’s cul-tural background will enhance thepatient-doctor relationship. In anycase, successful management oftropical cutaneous and subcuta-neous disorders is dependent uponaccurate and early diagnosis, whichis itself made easier by heightenedawareness and an understanding ofthe clinical presentation of thesedisorders. �

References1 Edelglass JW, Douglass MC, Stiefler R,

Tessler M. Cutaneous larva migrans in north-ern climates. A souvenir of your dream vaca-tion. J Am Acad Dermatol. 1982 Sep;7(3):353-8.

2 Denning DW, Hope WW. Therapy forfungal diseases: opportunities and priorities.TrendsMicrobiol. 2010May18(5):195–204.

3 Chosidow O. Clinical practices. Scabies.NEngl JMed. 2006Apr 20;354 (16):1718-27.

4 Choulea E, Abeldano A, Pellerano G,

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Figure 16: Mossy lesions on the foot andtoes of lymphedema patient, a resident intheDepartment of Peten inGuatemala.


toddler. The palms and soles arespared. Looking at scrapings fromsome of the lesions under the micro-scope, you identify a mite. Which ofthe following statements about thispatient is NOT correct?

A) Limited, casual contact canspread the infestation.B) The infesting parasite only liveson humans.C) This parasitic infestation can af-fect the palms and soles.D) Permethrin cream should be ap-plied and left on overnight.

6) In the patient described above, theitching is most intense at night. Youwould

A) expect to find only burrowscaused by the mite in addition toexcoriation.B) need a skin biopsy to acquire theparasite.C) explain to the mother that theitching is caused by the laying ofeggs and fecal material in the bur-rows caused by the mite.D) use lindane applied in theevening and left on overnight forthis toddler because of its lowertoxicity.

7) In an Alabama clinic you encountera patient with multiple, painless,raised lesions, some of which have ul-cerated and crusted, adjacent toareas of skin disfigured by scar tissue.The patient has had these progres-sive lesions for years but did not haveaccess to health care, thus no previ-ous treatment has been provided. Heused to work in the jungle harvestingthe gum of the chicle tree. Your pa-tient asks you what this is and whatyou can do about it. You respond:

A) All that will be needed to con-firm the diagnosis will be culturesfor bacteria and fungi.B) A scraping or biopsy lookingfor amastigotes of the sand flymust be performed to confirmthe diagnosis.C) Oral ivermectin must bepromptly prescribed to preventfurther disfigurement.D) All of the patient’s family mem-bers would need treatment andbed linens would have to bewashed.

8) You are treating a 37 year old mi-grant farm worker for draining sinuseson his foot. This all started several yearsago with swelling and slowly pro-gressed to multiple deep nodules andan area of induration. It has not beenparticularly painful, but he became con-cerned when some of the raised areasbroke open and started to drain. Whichof the following statements about thisinfection is MOST accurate?

A) To obtain the diagnosis, youneed only submit material for a fun-gal culture or PAS stain.

1) No matter where you practice, youmay encounter tropical skin disordersbecause

A) Expanding immigrant popula-tions may bring people to yourcommunity from tropical regions.B) Patients may bring such disor-ders home with them from vacationor business travel.C) You may be involved with com-munity outreach or humanitarianmissions.D) All of the above

2) Patients with tropical skin diseasemay come from a cultural backgroundthat differs from yours. Which of thefollowing statements is LEAST correct?

A) A lack of fluency in language canlimit trust between patient andcaregiver and may interfere withcompliance.B) Different religious beliefs, heal-ing practices, herbal remedies, ormaternal traditions followed by thepatient should be discounted be-cause there is no scientific evidenceof their efficacy.C) The podiatrist should show re-spect for the esteem that the pa-tient has for a shaman or medicineman or risk losing the respect of thepatient.D) The patient may be allowed toemploy herbal remedies as long asthey do not directly interfere withyour treatment.

3) Which of the following statementsregarding superficial candidiasis isNOT correct?

A) Oral thrush and diaper rash arecharacteristic manifestations.B) C. albicans is a normal memberof the mucocutaneous flora.C) Candida species are commonlyfound in the nail.D) Yeast is sensitive to commonlyavailable topical antifungals.

4) You are working with an older,obese patient who is a cement workerand who wears rubber boots to workevery day. He complains of nail defor-mities and periungual discoloration.Upon physical examination you alsonotice erosions in the abdominal skinfolds and cheilitis. You suspect thathis dermatologic manifestations arerelated to his employment. Selectfrom the list below, another potentialcontributing factor to the develop-ment of candidiasis:

A) Nutritional deficienciesB) Peripheral vascular diseaseC) Autoimmune disease

5) You are volunteering in a homelessshelter when a mother brings in her 2year old daughter with concernsabout the child’s constant scratching.This has been going on for more thana month. Excoriations cover the armsand legs and much of the torso of the

B) Treatment for bacterially causedinfections of this type must persistfor 10 months.C) Even in non-immunocompro-mised patients, this infection is fre-quently fatal.D) You should attempt to recovergrains discharged from the sinusesto facilitate culture and becausetheir color may give an indicationof the causative organism.

9) After culturing the material obtainedfrom a deep sampling of a nodule inthe patient described above, the lab re-ports the presence of Fusarium oxyspo-rum. Treatment for this infection

A) should include a 10 monthcourse of oral Itraconazole.B) may succeed with dual antibiot-ic therapy including trimethoprimsulfamethoxazole and Rifampin.C) may be augmented by the useof allopurinol.D) must include antimonials to besuccessful.

10) Your daughter is sent home fromelementary school by the school nursebecause she has a communicable dis-ease. You see lots of small white spotsattached to the hair that cannot bebrushed out. You suspect infestationby Pediculus humanus and undertaketreatment which must include all EX-CEPT:

A) Permethrin 1% shampooB) Combing the hair with a finetooth combC) Oral antimonials for resistantcasesD) Laundering all clothing and bedlinen for the entire family

11) PediculosisA) does not cause localized irrita-tion or excoriation from scratch-ing.B) does not occur in neonates.C) typically presents with hun-dreds of lice infesting each patient.D) can be cured with a single doseof oral ivermectin if topical man-agement fails.

12) Which of the following statementsabout Creeping Eruption is MOST cor-rect?

A) It is a highly contagious disease.B) It is the most common tropicallyacquired dermatosis in the world.C) Cutaneous larva migrans occursonly in adults.D) The infestation is transmittedvia a mosquito vector.

13) Causes of lymphedema may in-clude all of the following EXCEPT:

A) A filarial parasiteB) Infestation by ActinomycetesC) ObesityD) Invading dust or mineralparticles

Continuing

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E X A M I N A T I O N

See answer sheet on page 197.


196 PODIATRY MANAGEMENT

14) Your patient from Brazil presents with a multi-yearhistory of severe, unilateral swelling and a bumpy,“mossy” appearance of the skin on the dorsum of hisfoot. He has recently developed cellulitis surroundingsome inflamed nodules. Which of the following state-ments about this patient’s disease is NOT true?

A) Oral antibiotics will resolve both the cellulitis andthe edema.B) The edema could be the result of infestation bythe parasite Wuchereria bancrofti.C) Manual lymph drainage will help to reduce thefluid in the leg.D) The edema of this progressive disease maybe somewhat improved by the use of short stretchbandages.

15) Which of the following statements about MaduraFoot is MOST accurate?

A) Women are more likely than men to acquire thedisease.B) Eumycetoma is caused by microaerophilic bacteria.C) Actinomycetoma presents in only the foot or thehand.D) Two antibiotics administered over five week cyclesare required for actinomycetoma.

16) Your friend recently returned from a vacation to theCaribbean where she spent a lot of time on the beach.She walked every morning along the water with others,some of whom were walking their dogs. She presentswith a stinging rash on the foot that is serpiginous,raised, and erythematous. Your statement to your friendshould be

A) This rash is caused by a parasite that can be treat-ed either with an oral medication or a topical paste.B) This is a fungal infection usually responsive totopical antifungals.C) This rash will not resolve without treatment andwithout sequellae.D) This should be treated promptly to avoid infectingfamily members as well.

17) You performed a needle aspirate of the open, drain-ing lesions on the lower leg of your patient and amastig-otes of the Lutzomyia sand fly were identified. Select thebest course of treatment from the choices below:

A) Intralesional injections of corticosteroidB) Broad spectrum parenteral cephalosporinantibiotics for 6 weeksC) Antimonial sodium stibogluconate orally over 20daysD) Excise the ulcerations and apply a skin graft

18) Which of the following vectors can transmit anorganism leading to lymphedema?

A) sand flyB) hook wormC) mosquitoD) cockroach

19) Which of the following vectors can transmit anorganism leading to Leishmaniasis?


20) Which of the following vectors can transmit anorganism that causes CUTANEOUS LARVA MIGRANS?


E X A M I N A T I O N

(cont’d)

See answer sheet on page 197.

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E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)Continuing

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LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #2/11Tropical Cutaneous andSubcutaneous Disorders

(Page and Jensen)

Documents

Tropical Objectives Cutaneousand Subcutaneous Disorders