Severe tungiasis in underprivileged communities: case series from Brazil

Abstract

Tungiasis is caused by infestation with the sand flea (Tunga penetrans). This ectoparasitosis is endemic in economically depressed communities in South American and African countries. Tungiasis is usually considered an entomologic nuisance and does not receive much attention from healthcare professionals. During a study on tungiasis-related disease in an economically depressed area in Fortaleza, northeast Brazil, we identified 16 persons infested with an extremely high number of parasites. These patients had >50 lesions each and showed signs of intense acute and chronic inflammation. Superinfection of the lesions had led to pustule formation, suppuration, and ulceration. Debilitating sequelae, such as loss of nails and difficulty in walking, were constant. In economically depressed urban neighborhoods characterized by a high transmission potential, poor housing conditions, social neglect, and inadequate healthcare behavior, tungiasis may develop into severe disease.

Figure 1

Correlation between total number of lesions and number of lesions occurring in clusters (rho=0.94; p=0.0003).

Figure 2

Left foot of a 6-year-old girl. The first, second, third, and fifth toe are infected with Tunga penetrans. These toes are inflamed, and the second and the third toe are distorted by severe edema. The first toe shows hyperkeratosis. The nails of the first, second, and fifth toe are deformed, and the nail of the third toe is falling off. A flea is trying to penetrate the skin at the edge of the pustule on the medial side of the second toe (11 clockwise). An ulcer has formed above the proximal phalangeal joint of the third toe.

Figure 3

Second finger of the right hand of the same patient. Acute inflammation with intense erythema and a slight edema is shown. Two stage III lesions are located at the lateral side of the finger and another lesion is lifting up the nail.

Figure 4

Right foot of a 50-year-old man. All nails have been lost. Embedded fleas have been manipulated by the patient, leaving innumerable sores. Desquamation and ulceration are merged. The skin tends to bleed where the stratum corneum is eroded.

Figure 5

Fourth toe of a 50-year-old women. The nail is lifted up by a lesion. An abcess has formed near the nail wall, and the toe is distorted because of intense edema.