Severe Tungiasis in Underprivileged Communities: Case Series from Brazil

Hermann Feldmeier, Margit Eisele, Rômulo César Sabóia-Moura, Jôrg Heukelbach


Emerging Infectious Diseases. 2003;9(8) 

In This Article

Materials and Methods

Study Area

The favela Morro de Sandras is on the outskirts of Fortaleza, the capital of Ceará State, northeast Brazil, and is similar to other economically depressed areas there. During the high transmission season (July-December), approximately one third of the population is affected by tungiasis.[24] Other ectoparasitic diseases such as head lice, scabies, and cutaneous larva migrans are also very common in the study area.[25] This area is built on a dune close to the beach and has a total population of 1,500 persons. Sixty percent of the population has a monthly family income of less than two minimum wages (1 minimum wage = US$80.00). Adult illiteracy is 30%, unemployment rates are high, and crime is common. Ninety-seven percent of the households have electricity, and about 60% have access to running water.[26] Many houses are made with improvised construction material and do not have concrete floors. Waste and sewage disposal are insufficient, and hygienic conditions are precarious. Most streets are not paved. Innumerable stray dogs and cats roam the area, in addition to dogs and cats kept as pets. Rodents are numerous; Rattus rattus can be seen during the day feeding on organic waste disposed of in backyards or outside family compounds. The prevalence of tungiasis ranges from 5% to 35% according to the season (J. Heukelbach, unpub. data).

Study Population

The study was performed at the PHCC that serves the population of the favela. During a 6-week period, 86 persons with tungiasis were identified among patients who visited the center for medical reasons unrelated to the ectoparasitosis. Severe tungiasis was arbitrarily defined as the presence of >50 lesions. Sixteen of the 86 patients fulfilled this criterion and are described in this case series. They ranged in age from 2 to 50 years of age.

Clinical Examination

As tungiasis may occur at any topographic site,[9] the whole body surface of the patient was examined for the presence of vital, egg-producing, involuting, or dead fleas. Lesions were classified according to the Fortaleza Classification, a recently elaborated staging system.[7] The following findings were considered diagnostic for tungiasis: flea in statu penetrandi, stage I, a dark and itching spot in the epidermis with a diameter of 1-2 mm with or without local pain; stage II (early lesion), lesions with as a white halo with a diameter of 3-10 mm with a central black dot; stage III (mature flea), a brownish-black circular crust with or without necrosis of the surrounding epidermis; stage IV (dead parasite), circular residue punched out in the keratin layer of the sole of the foot or irregular thickening of the nail rim; and stage V, lesions altered through manipulation by the patient (such as partially or totally removed fleas, which leaves a characteristic crater-like sore in the skin) and suppurative lesions, mainly caused by using nonsterile perforating instruments such as needles and thorns.

During the examination, location and number of lesions were noted, and the following signs and symptoms were observed: erythema, edema, tenderness, itching, pain, shining skin, desquamation, hyperkeratosis, fissures, pustules, suppuration, ulcers, deformation of the toes (defined as deviation of the normal axis of the toe caused by intense swelling), deformation of nails, loss of nails, and difficulty in walking or gripping.

Clinical pathologic findings were classified as follows: acute inflammation or painful lesion surrounded by erythema, edema, and tenderness; chronic inflammation, edema, tenderness, shining skin with or without desquamation, or deformation of digits; superinfection, presence of pustules, suppuration, or ulcers; and physical disability, difficulty in walking, or gripping (if lesions were located on the hands), based on patients' statements that pain restricted their movements. Lesions tended to occur in clusters, which were arbitrarily defined as a group of five or more lesions that occurred in close proximity (e.g., on the periungual region of the toe, the heel, or the fingertip).

Statistical Analysis

Statistical analysis was performed by using the StatView software package version 1.5 (SAS, Cary, NC). The Wilcoxon signed rank test, the Spearman rank correlation coefficient test, and the Fisher exact test were applied when appropriate.

Ethical Considerations

The study was approved by the Ethical Committee of the Federal University of Ceará State, Fortaleza, Brazil. Before the study, meetings with community health workers, community leaders, and staff members of the PHCC were held in which the objectives of the study were explained. Informed written consent was obtained from each patient after the objectives of the study were explained. In the case of a minor, the caregivers were asked for their consent. After the examination, all patients were treated topically with thiabendazole 5% and, in the case of superinfection, with neomycin ointment. All patients received a pair of tennis shoes and were encouraged not to walk barefoot.


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