Clinical and epidemiological survey of tungiasis in Madagascar.

BACKGROUND: Tungiasis is a dermal parasitic infection, classified as a neglected tropical disease. Madagascar is one of endemic countries which have been committed for decades to control the tungiasis as a public health issue. Despite this medical importance, little is known about the prevalence and epidemiology of the disease in this country. METHODS: A descriptive cross-sectional survey was performed in two endemic foci of Antananarivo and Toamasina. RESULTS: In total, 2971 suspected individuals were surveyed. Of them, 643 individuals were excluded due to absence or refusing clinical examinations. Therefore, 2328 individuals with aforementioned criteria were clinically examined, 320 cases (13.7%) were found infected by Tunga penetrans. Of these 320 infected cases, 241 individuals came from rural regions against 79 from urban areas. The sex ratio of infected cases was 1.15 with an age average of 34.7 years old. Most of them were illiterate (185/320, 57.8%) with no habit of feet washing (210/320, 65.6%). The majority (198/320, 61.9%) inhabited in the houses constructed by falafa providing a suitable breeding location for Tunga ectoparasites. Based on clinical examination, most of the patients (298/320, 93.1%) had the lesions on their toes followed by those possessed the lesions on the plantar (140/320, 43.7%). The lesion stages of IV and V were observed in 49.1% (157/320) of visited patients which were more common in rural regions (86%) than in urban areas (14%). For treatment, removing the fleas using needle (122/320, 38.1%), followed by the application of petroleum (100/320, 31.2%) were among the most traditional remedies used by our patients. CONCLUSION: This investigation highlights a high burden of tungiasis in studied endemic foci in particular in rural regions. These results can be helpful in control management strategies against this parasitosis in Madagascar.

Case Report: Evidence of Tungiasis in the Amazon Rain Forest of Ecuador.

Tungiasis occurs in tropical and subtropical areas in Central and South America and sub-Saharan Africa and is a Neglected Tropical Disease. We diagnosed three cases of tungiasis in a Dutch family visiting indigenous communities in the Amazon basin of Ecuador. Eight days after returning, they presented papular, pruritic, and painful lesions on the feet, with a whitish halo and a blackish central point with abundant whitish eggs upon extraction. For the first time, we demonstrate that Tunga spp. transmission is present in remote indigenous communities in the Amazon rainforest of Ecuador. It will be important to investigate the occurrence of tungiasis and associated morbidity among local inhabitants and consider prevention measures among locals and travelers to these areas.

Clinical and macroscopic morphological features of canine tungiasis.

Tungiasis is a public health problem in endemic resource-poor communities, where dogs are important reservoirs of Tunga spp., contributing significantly to the process of transmission of this zoonosis. In order to optimize the diagnosis of canine tungiasis, macroscopic morphological characteristics and clinical signs of the lesions were investigated, based on the inspection of 40 dogs infested by T. penetrans from an endemic rural community in northeastern Brazil. Of the 1546 lesions found in these dogs, including all stages of development of the parasite, 89.1% (1378) were located on the paw pads. Dogs aged up to 5 years had the greatest number of lesions. Dark pigmentation and hyperkeratosis of the paw pads made it difficult to identify the lesions. Among all the clinical signs observed were hyperemia (38; 95%), pain (32; 80%), fissure (11; 27.5%), onychogryphosis (29; 72.5%), cluster of lesions (26; 65%), hyperkeratosis (25; 62.5%), lameness (15; 37.5%), and fissure (11; 27.5%). Ectopic lesions were found especially in the nipples (64; 4.1%) and abdomen (51; 3.3%). The maximum diameter of the stage III neosomes was 6 mm. Dogs with a higher number of lesions had a higher degree of hyperkeratosis. Age over 1 year was associated with a higher rate of dispersion of the parasite in the environment (p = 0.04). The identification of the initial stages of tungiasis can guarantee a more effective control of the disease in dogs, which will mainly depend on the treatment of adult animals and the application of continuous preventive actions based on One Health in these communities.

Clinical and pathological aspects of first report of Tunga penetrans infestation on southern brown howler monkey (Alouatta guariba clamitans) in Rio Grande do Sul, Brazil.

BACKGROUND: Tungiasis is a neglected neotropical disease caused by penetration of Tunga spp. into the skin of the host. METHODS: Two primates were rescued from nearby different indigenous villages, and the clinical, pathological, and parasitological features of tungiasis were described. Flea identification occurred through their morphometry and was confirmed with the use of a dichotomous key. RESULTS: Monkey 1 was parasitized by 23 sand fleas and, after treatment, was assigned to the animal rehabilitation center. Monkey 2 was in poor body condition and died shortly after clinical examination. At necropsy, this primate was parasitized by 26 specimens of sand fleas. CONCLUSIONS: Both animals altered their tree behavior by staying on the ground for long periods. This parasitic relationship implies the possibility of enlargement of the sand flea dispersion. Thus, this is the first record of Tunga penetrans occurrence in wild Alouatta guariba clamitans.

Efficacy of a mixture of neem seed oil (Azadirachta indica) and coconut oil (Cocos nucifera) for topical treatment of tungiasis. A randomized controlled, proof-of-principle study.

BACKGROUND: Tungiasis is a neglected tropical skin disease caused by the female sand flea (Tunga penetrans), which burrows into the skin causing intense pain, itching and debilitation. People in endemic countries do not have access to an effective and safe home treatment. The aim of this study was to determine the efficacy of a traditionally used and readily available mixture of neem and coconut oil for treatment of tungiasis in coastal Kenya. METHODOLOGY: Ninety-six children aged 6-14 years with at least one embedded viable flea were randomized to be treated with either a mixture of 20% neem (Azadirachta indica) seed oil in coconut oil (NC), or with a 0.05% potassium permanganate (KMnO4) foot bath. Up to two viable fleas were selected for each participant and monitored for 6 days after first treatment using a digital microscope for signs of viability and abnormal development. Acute pathology was assessed on all areas of the feet using a previously established score. Children reported pain levels and itching on a visual scale. RESULTS: The NC was not more effective in killing embedded sand fleas within 7 days than the current standard with KMnO4, killing on average 40% of the embedded sand fleas six days after the initial treatment. However, the NC was superior with respect to the secondary outcomes of abnormal development and reduced pathology. There was a higher odds that fleas rapidly aged in response to NC compared to KMnO4 (OR 3.4, 95% CI: 1.22-9.49, p = 0.019). NC also reduced acute pathology (p<0.005), and there was a higher odds of children being pain free (OR 3.5, p = 0.001) when treated with NC. CONCLUSIONS: Whilst NC did not kill more fleas than KMnO4 within 7 days, secondary outcomes were better and suggest that a higher impact might have been observed at a longer observation period. Further trials are warranted to assess optimal mixtures and dosages. TRIAL REGISTRATION: The study was approved by the Kenya Medical Research Institute (KEMRI) Scientific and Ethical Review Unit (SERU), Nairobi (Non-SSC Protocol No. 514, 1st April 2016) and approved by and registered with the Pharmacy and Poisons Board's Expert Committee on Clinical Trials PPB/ECCT/16/05/03/2016(94), the authority mandated, by Cap 244 Laws of Kenya, to regulate clinical trials in the country. The trial was also registered with the Pan African Clinical Trial Registry (PACTR201901905832601).

Very severe tungiasis in Amerindians in the Amazon lowland of Colombia: A case series.

BACKGROUND: Tungiasis is a parasitic skin disease caused by penetrating female sand fleas. By nature, tungiasis is a self-limiting infection. However, in endemic settings re-infection is the rule and parasite load gradually accumulates over time. Intensity of infection and degree of morbidity are closely related. METHODOLOGY/PRINCIPAL FINDINGS: This case series describes the medical history, the clinical pathology, the socio-economic and the environmental characteristics of very severe tungiasis in five patients living in traditional Amerindian communities in the Amazon lowland of Colombia. Patients had between 400 and 1,300 penetrated sand fleas. The feet were predominantly affected, but clusters of embedded sand fleas also occurred at the ankles, the knees, the elbows, the hands, the fingers and around the anus. The patients were partially or totally immobile. Patients 1 and 3 were cachectic, patient 2 presented severe malnutrition. Patient 3 needed a blood transfusion due to severe anemia. All patients showed a characteristic pattern of pre-existing medical conditions and culture-dependent behavior facilitating continuous re-infection. In all cases intradomiciliary transmission was very likely. CONCLUSION/SIGNIFICANCE: Although completely ignored in the literature, very severe tungiasis occurs in settings where patients do not have access to health care and are stricken in a web of pre-existing illness, poverty and neglect. If not treated, very severe tungiasis may end in a fatal disease course.

Clinical and histopathologic study of 39 patients with imported tungiasis.

BACKGROUND: Tungiasis is an infestation caused by the penetration into the skin of the flea Tunga penetrans. Histopathologic studies on imported tungiasis are rare and based on a limited number of cases. METHODS: We carried out a review of 39 biopsy specimens collected from 39 patients with imported tungiasis. In all patients, ethnicity, gender, age, location, and clinical features of the lesions, Fortaleza classification and countries of infestation were recorded. RESULTS: Histopathologic study revealed hyper- parakeratosis and acanthosis. Fragments of the flea were located in the epidermis and upper dermis and were circumscribed by a pseudo-cystic cavity. Inside this cavity, we observed: the exoskeleton, made up of a thickened and eosinophilic cuticle; the striated muscle; the tracheal rings and the digestive organs (observed only in some specimens); the ovaries, very rich in eggs, and an inflammatory infiltrate, made up of lymphocytes and neutrophils, with numerous eosinophils. The hypodermic layer was never observed. CONCLUSION: Histopathologic examination is helpful for the correct diagnosis of tungiasis in travelers returning from tropical and subtropical countries in which the infestation may be characterized by an atypical clinical presentation.

Prevalence and risk factors of tungiasis among children of Wensho district, southern Ethiopia.

BACKGROUND: Tungiasis is an ectoparasitic infestation, which still has public health importance in deprived populations of developing countries. Data on the prevalence and risk factors of tungiasis is rare in Ethiopia. Hence, this study was designed to determine the prevalence and risk factors of tungiasis among children in Wensho district, southern Ethiopia. METHODS: From February to May 2016, we conducted a community-based cross-sectional study on 366 children 5-14 years old. Data about the presence and severity of tungiasis were obtained through inspection and data on risk factors were collected through interviews of parents/guardians of the children using structured questionnaire and through observation of the housing environment using structured checklist. RESULTS: Two hundred fifteen (58.7%, 95% confidence interval [CI]: 53.7%, 63.8%) of the 366 children were infested with Tunga penetrans. Most lesions were localized in the feet and the distribution of the disease by sex was similar (57.4% among males and 60.3% among females). Children of illiterate mothers (adjusted odds ratio [AOR]: 3.62, 95% CI: 1.35, 9.73) and children whose mothers have attended only primary education (AOR: 2.72, 95% CI: 1.06, 6.97), children from cat owning households (AOR: 4.95, 95% CI: 1.19, 20.60) and children who occasionally use footwear (AOR: 7.42, 95% CI: 4.29, 12.83) and those who never use footwear (AOR: 12.55, 95% CI: 3.38, 46.58) had a significantly higher odds of tungiasis infestation. CONCLUSION: Tungiasis is an important public health problem with considerable morbidity among children in Wensho. Hence, implementation of tungiasis prevention strategies such as promoting shoes wearing, provision of health education, fumigating the residential houses and applying insecticides on pets are recommended.

Tungiasis-related life quality impairment in children living in rural Kenya.

BACKGROUND: Tungiasis (sand flea disease) is a neglected tropical skin disease caused by female sand fleas (Tunga spp.) embedded in the skin of the host. The disease is common in sub-Saharan Africa and predominantly affects children living in impoverished rural communities. In these settings tungiasis is associated with important morbidity. Whether tungiasis impairs life quality has never been studied. METHODS: The study was performed in 50 children with tungiasis, living in resource-poor communities in coastal Kenya. Based on the Dermatology Life Quality Index (DLQI) a tool was developed to determine life quality impairment associated with tungiasis in children, the tungiasis-related Dermatology of Life Quality Index (tungiasis-related-DLQI). Pain and itching were assessed using visual scales ranging from 0-3 points. The intensity of infection and the acute and chronic severity of tungiasis were determined using standard methods. RESULTS: Seventy eight percent of the patients reported a moderate to very large effect of tungiasis on life quality at the time of the diagnosis. The degree of impairment correlated with the number of viable sand fleas present in the skin (rho = 0.64, p < 0.001), the severity score of acute clinical pathology (rho = 0.74, p < 0.001), and the intensity of pain (rho = 0.82, p < 0.001). Disturbance of sleep and concentration difficulties were the most frequent restriction categories (86% and 84%, respectively). Four weeks after curative treatment, life quality had improved significantly. On the individual level the amelioration of life quality correlated closely with the regression of clinical pathology (rho = 0.61, p < 0.001). CONCLUSION: The parasitic skin disease tungiasis considerably impairs life quality in children in rural Kenya. After effective treatment, life quality improves rapidly.

Prevalence, intensity and risk factors of tungiasis in Kilifi County, Kenya: I. Results from a community-based study.

BACKGROUND: Tungiasis is a neglected tropical disease caused by female sand fleas (Tunga penetrans) embedded in the skin. The disease is associated with important morbidity. Tungiasis is endemic along the Coast of Kenya with a prevalence ranging from 11% to 50% in school-age children. Hitherto, studies on epidemiological characteristics of tungiasis in Africa are scanty. METHODS: In a cross-sectional study 1,086 individuals from 233 households in eight villages located in Kakuyuni and Malanga Sub-locations, Kilifi County, on the Kenyan Coast, were investigated. Study participants were examined systematically and the presence and severity of tungiasis were determined using standard methods. Demographic, socio-economic, environmental and behavioral risk factors of tungiasis were assessed using a structured questionnaire. Data were analyzed using bivariate and multivariate regression analysis. RESULTS: The overall prevalence of tungiasis was 25.0% (95% CI 22.4-27.5%). Age-specific prevalence followed an S-shaped curve, peaking in the under-15 year old group. In 42.5% of the households at least one individual had tungiasis. 15.1% of patients were severely infected (≥ 30 lesions). In the bivariate analysis no specific animal species was identified as a risk factor for tungiasis. Multivariate analysis showed that the occurrence of tungiasis was related to living in a house with poor construction characteristics, such as mud walls (OR 3.35; 95% CI 1.71-6.58), sleeping directly on the floor (OR 1.68; 95% CI 1.03-2.74), the number of people per sleeping room (OR = 1.77; 95% CI 1.07-2.93) and washing the body without soap (OR = 7.36; 95% CI 3.08-17.62). The odds of having severe tungiasis were high in males (OR 2.29; 95% CI 1.18-44.6) and were very high when only mud puddles were available as a water source and lack of water permitted washing only once a day (OR 25.48 (95% CI 3.50-185.67) and OR 2.23 (95% CI 1.11-4.51), respectively). CONCLUSIONS: The results of this study show that in rural Kenya characteristics of poverty determine the occurrence and the severity of tungiasis. Intra-domiciliary transmission seems to occur regularly.

Serie parasitosis en dermatología: tungiasis / Dermatology iconography: tungiasis

La tungiasis es una ectoparasitosis causada por la penetración en la piel de la pulga hembra Tunga penetrans. Esta enfermedad no es específica del hombre y se distribuye en regiones cálidas y secas alrededor del mundo. Se adquiere por contacto directo con el suelo en donde habitan los parásitos adultos. En zonas endémicas, su alta prevalencia se asocia a pobreza y falta de acceso al sistema de salud. Además es frecuente entre viajeros que visitan regiones endémicas y que regresan a sus lugares de origen. Presentamos un caso típico de tungiasis en un paciente 39 años que había realizado un viaje reciente a zona endémica. (AU)

Tungiasis is an ectoparasitosis caused by penetration into the skin of the female flea Tunga penetrans. This disease is not human-specific and is distributed worldwide in warm, dry regions. It is acquired by direct contact with the soil where the adult parasites live. In endemic areas, its high prevalence is associated with poverty and lack of access to the health system. It is also frequent among travelers visiting endemic regions and returning to their places of origin. We present a typical case of tungiasis in a 39 year old patient who had made a recent trip to an endemic area. (AU)

High intensity of Tunga penetrans infection causing severe disease among pigs in Busoga, South Eastern Uganda.

BACKGROUND: Towards the improvement of stakeholders' awareness of animal tungiasis, we report 10 unusual severe clinical cases of pig tungiasis which were associated with very high infection intensities of T. penetrans in an endemic area. RESULTS: Morbidity of ten pigs with high sand flea intensities detected during high transmission seasons in an endemic area in Busoga sub region, Uganda is described in detail. The cases of pigs presented with a very high number of embedded sand fleas (median = 276, range = 141-838). Acute manifestations due to severe tungiasis included ulcerations (n = 10), abscess formation (n = 6) and lameness (n = 9). Chronic morphopathological presentations were overgrowth of claws (n = 5), lateral deviation of dew claws (n = 6), detachment (n = 5) or loss of dew claws (n = 1). Treatment of severe cases with a topical insecticidal aerosol containing chlorfenvinphos, dichlorvos and gentian violet resolved acute morbidity and facilitated healing by re-epithelialisation. CONCLUSIONS: The presentations of tungiasis highlighted in this report show that high intensities of embedded T. penetrans can cause a severe clinical disease in pigs. Effective tungiasis preventive measures and early diagnosis for treatment could be crucial to minimize its effects on animal health.

Disseminated tungiasis in a 78-year-old woman from Tanzania: a case report.

BACKGROUND: Tungiasis is one of the neglected tropical diseases; it affects up to 40% of individuals living in societies with poor housing and sanitation standards. In endemic areas, Tunga infestation, which predominantly affects the periungual areas of the lower limbs in humans, is associated with considerable morbidity and poor quality of life. CASE PRESENTATION: A 78-year-old woman of African descent presented with pain, inflammation, suppuration, ulceration, and deformation of digits of all four limbs. She had a total of 1146 embedded sand fleas: 812 in lower limbs and 334 in her hands. She was febrile; her full blood count revealed pancytopenia and blood cultures were positive for Staphylococcus aureus and Streptococcus pyogenes isolates. Furthermore, she had severe hyponatremia. We applied 20% salicylated petroleum jelly followed by the manual removal of embedded sand fleas with a sterile needle. Intravenously administered piperacillin-tazobactam, topical ivermectin, ferrous sulfate, folic acid, tolvaptan, albendazole, multivitamins, and tetanus prophylaxis were instituted. She was discharged home after 16 days of hospitalization. CONCLUSIONS: Tungiasis is a neglected disease of concern in underprivileged societies that is preventable and curable. Early recognition and prompt treatment is crucial to prevent complications in this disease which may potentially mimic other conditions resulting in erroneous management.

Tungiasis-associated morbidity in pigs and dogs in endemic villages of Uganda.

BACKGROUND: Tunga penetrans (Insecta, Siphonaptera, Tungidae) causes severe morbidity among heavily infected humans and animals in Latin America and sub-Saharan Africa. The clinical pathology of tungiasis in animals has never been studied systematically. METHODS: This was a cross-sectional study conducted between January to March 2015, aimed at describing tungiasis-associated clinical pathology in 121 and 20 T. penetrans-infected pigs and dogs, living in nine and five endemic rural villages respectively located in Bugiri District, Busoga, Uganda. RESULTS: The parasite load of infected animals ranged from one to 246 (median 8) and one to eight (median 2) in pigs and dogs, respectively. In pigs 99.3% and in dogs 100% of the lesions were located on feet. In pigs, hind legs were significantly more affected than front legs (90.9% vs. 57.9%; p = 0.002) and also had more lesions than the front legs (median 5 vs. 1; p = 0.0001). However, in dogs localization of lesions between front and hind legs never differed significantly (front, 50% vs. hind, 65%; p = 0.51) and so were the number of lesions (median front = 0.5 vs. median hind = 2; p = 0.7). Acute and chronic clinical pathology coexisted. The most common disease manifestations in pigs were hoof wall erosions (68.6%), tissue necrosis of hoof wall and skin (66.1), pain at infection sites (47.9%), hoof deformity (45.5%), fissures (44.6%) and edema (44.6%). In dogs, tungiasis mainly presented with pain at attachment site (80%), ulcers (55%), necrosis (30%) as well as hyperemia and edema (both 15%). One pig had lost dew claws while two had loose detaching claws. Despite a lower number of sand fleas, a higher proportion of infected dogs (20%) than pigs (5.8%) exhibited functional limb use difficulties (p = 0.05). CONCLUSIONS: The pattern of clinical manifestations in pigs and dogs were very similar to those reported from affected humans and rats. The important morbidity associated with animal tungiasis makes the disease a serious veterinary health problem in sub-Saharan Africa warranting treatment and control for optimal animal production.