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


The demographic characteristics of the patients in the study and the number of lesions present are shown in Table 1 . Patients had at least 52 lesions with a maximum of 145 and a median of 88 lesions. Of the 1,474 lesions, 1,092 (76%) occurred in clusters. A significant correlation existed between the number of lesions per patient and the number of lesions occurring in clusters (rho=0.94; p=0.003; Figure 1). No significant relationship existed between the number of lesions and age (rho=0.44, p>0.05). However, manipulated lesions were more frequent in patients >15 years of age (38% vs. 13%; p<0.05). No difference existed in the median number of lesions between female and male patients.

Figure 1.

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

The topographic distribution of lesions is summarized in Table 2 . All patients had lesions on the toes and soles of the feet. The periungual region of the toe was clearly a predilection site. Other regions of the toes, such as the tip, the plantar, or the dorsal site were also frequently affected. Fifteen patients (88%) had lesions on their heels, and two patients (13%) had lesions on the dorsum pedis. Lesions on the hands were found in six patients (38%); one person had a lesion in the gluteal area, and another patient had a lesion on the chest.

Clinical findings are shown in Table 3 . In all patients, signs of acute as well as chronic inflammation were present. Acute and chronic inflammation occurred simultaneously in different topographic sites or in lesions at different stages of development. In three patients, the entire foot and lower leg were inflamed. Deformation or nail loss was common (69%). All patients had difficulty walking, and half of the patients with lesions at the fingers had difficulty gripping. Intense itching, a common symptom, prevented patients from sleeping soundly. The number of lesions was particularly high in patients with signs of generalized inflammation, when fissures were present or when superinfection had occurred ( Table 4 ). We describe four cases that are typical examples of severe tungiasis.

Case 1

A 2-year-old girl had 90 lesions; 49 of these lesions were located on the toes, 33 on the soles of the feet, and 3 on the heels. Five lesions were at ectopic sites (four of them on the fingertips and one in the gluteal region). One sand flea was trying to penetrate the skin of the chest. Many lesions were superinfected as indicated by pustules or suppuration, and the nails of six toes were deformed or had already fallen off. The lesions on the fingertips were particularly painful and caused difficulty gripping. The child also had pediculosis and was underweight. The family (three children and the parents) lived in a small hut with a sandy floor. The mother was 18 years of age; both parents were illiterate.

Case 2

A 6-year-old girl had 96 lesions. Of the 96, a total of 30 were located on the toes; all toes but one were infested with sand fleas; one sand flea was trying to penetrate the skin of on the second toe of the left foot (Figure 2). Forty-eight lesions occurred on the soles of the feet, and eight were located on the heels. Ten lesions were found on the hands and impeded the girl from gripping (Figure 3). Most lesions were surrounded by severe erythema and edema. Pustules and suppurations were frequent. Sleep was reported to be severely disturbed, and the child woke up in the night and cried. The family lived in a hut with sandy soil. The mother devoted most of her attention to two younger siblings. The mother was unmarried and illiterate.

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.

Case 3

A 50-year-old man had 123 lesions. Thirty-six lesions were located on the toes, 33 on the soles, and 54 on the heels. Nine nails were lost (Figure 4). Bacterial superinfection with pustules or suppuration was present on both feet. Nineteen ulcers were also found. Severe desquamation and hyperkeratosis occurred alternately. The patient had persistent pain and could walk only with considerable difficulty. He had manipulated many lesions with a nonsterile needle or a thorn and had also treated his feet with candle wax diluted in used motor oil to get rid of the sand fleas. Presumably, the self-treatment added to the aspect of general inflammation of both feet. The patient was unemployed and lingered around in the favela all day. He had no shoes and only wore slippers.

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.

Case 4

A 55-year-old woman had 76 lesions. Forty-eight lesions were located at periungual sites, and 17 in other regions of the toes. Eleven lesions were on the soles of the feet. Both feet were edematous; the edema extended over the entire lower legs. Several toes were deformed and all nails were damaged (Figure 5). Pustules and suppuration occurred in all toes. The patient was unable to walk and had to remain in her hammock. The patient was farsighted and did not have appropriate glasses. She lived alone in a small hut. The sandy compound was littered with waste and organic material.

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.


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