In November, 2009, a 38-year-old man presented with an itchy serpiginous eruption on the plantar aspect of his right foot that had developed after a trip to Mexico (figure A). He reported walking barefoot in the sand where cats and cat faeces were present. Physical examination showed an erythematous serpiginous eruption on the sole of his right foot. A clinical diagnosis of cutaneous larva migrans was made. Cutaneous larva migrans is most often caused by the larvae of the animal hookworm Ancydostoma braziliense, which is able to penetrate and migrate through the epidermis of a host by releasing degradative enzymes. Usually, a clinical diagnosis is made, on the basis of typical clinical features, and empirical treatment with topical (thiobendazole) or oral (thiobenzadole, albendazole, ivermectin) anthelmin-tics are intitated. Histopathological confirmation and removal of the larvae are not usually attempted because the migrating larvae are difficult to locate. We used a high-resolution bedside instrument, a reflectance confocal microscope (Viva Scope 1500, Lucid, Henrietta, NY, USA) currently employed in experimental and clinical dermatology, to effectively locate the larvae. Imaging showed a dark disruption in the normal honeycomb pattern of the epidermis corresponding to the larval burrow, and a highly refractile oval larva (figure B). We identified the larvae and did a 4 mm punch biopsy extraction. The intact hookworm larva was successfully revealed within the epidermis and was richly eosinophilic on routine histology (figure C). Our patient's symptoms resolved after removal of the larvae; however, he also requested treatment with thiobendazole.
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