AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Tungiasis is an infestation with the human flea, Tunga penetrans. The condition is rarely diagnosed in North America, but it should no longer be obscure to physicians because of increasing international travel to tropical destinations.

Tungiasis is spread by the parasitic flea known in various locations as chigger flea, sand flea, chigoe, jigger, nigua, pigue, and le bicho de pe. Tungiasis is common in Central America, South America, India, and tropical Africa.

Tungiasis may have been the first exotic infection experienced by European explorers to the West Indies in the late 15th century. Sailors traveling with Columbus in 1492 suffered chigoe flea infestation while in Haiti and probably were the first to introduce it to Europe. The flea was introduced to Africa in the 1600s and again around 1873. High rates of morbidity from T penetrans were noted among soldiers in the East African campaign of World War I and in Ethiopia during World War II.

Pathophysiology

Although both male and female fleas intermittently seek blood meals, only the female flea can produce the typical skin lesion of tungiasis (Fein, 2001). The pregnant flea burrows into the skin of the host near the plantar surfaces of the foot, in the webbing between the toes, and around the periungual region. Inflammation is marked by painful swelling that occurs at the site of infestation, leading to the development of a fibrous cyst at the site. Very heavy infestation may cause ulceration and fibrosis that may cause secondary infections such as bacteremias, tetanus, or gas gangrene.

Frequency

United States

The incidence of tungiasis is unknown because it is not a reportable disease. A review article from 1989 cited 14 cases (Sanusi et al, 1989).

International

Approximately 42% of Nigerian school children are infected. The average incidence in Trinidad is 21%. In a traditional fishing village in northeastern Brazil, the overall prevalence was 51% (Muehlen, 2003).

Mortality/Morbidity

Uncomplicated infestation results in pain, swelling, tenderness, and some limitation in mobility. Ultimately, the risk of severe morbidity or mortality from tungiasis is dependent upon the occurrence of secondary infections, which may follow attempts to extract the flea. Bacteremia, tetanus, or gas gangrene complications carry extraordinarily high mortality rates.

Race

No racial predisposition is apparent. Infection rates among native inhabitants of developing countries, however, are much higher than among visitors.

Sex

In endemic regions such as Trinidad, males were consistently more likely than females to have an infestation and had higher chigoe flea burdens, with about twice the number of fleas detected per subject (Chadee, 1998).

Age

In Trinidad, tungiasis reaches a peak infestation rate of 54% among males aged 25-35 years. Among females, the peak occurs in those aged 55 years and older (Chadee, 1998). In a village in northeastern Brazil, bimodal prevalence peaks were noted in children aged 5-9 years and in adults older than 60 years (Muehlen, 2003).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Travel to areas with T penetrans, including Central America, South America, India, and tropical Africa
• Walking along beach areas with bare feet or in sandals
• Pain or itching and papular or nodular eruptions, usually on the feet (can occur on any area of the body to which the flea has access)

Physical

• Typical areas of involvement include the plantar surface of the foot, the intertriginous regions of the toes, and the periungual regions. However, other ectopic sites of infection have also been reported, including the hands, elbows, thighs, and gluteal region (Heukelbach, 2002).
• Infestation in its simplest form is manifested by the appearance of a white patch with a black dot. More advanced infestation manifests as crusted erythematous papules, painful pruritic nodules, crateriform lesions, and secondary infections, including lymphangitis and septicemia. More recently, a case presenting with a large bullous lesion has been described (Veraldi, 2005).

Causes

• The major risk factor for exposure to T penetrans is failure to wear shoes when walking in sand in an area with active infestation. Wearing shoes and not sitting or lying in the sand are the most important steps to reduce infection risk.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Tick bite
Myiasis
Cercarial dermatitis
Ingrown toenail
Fire ant sting
Creeping eruption due to Ancylostoma species
Dracunculiasis
Scabies

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• In general, no laboratory studies are indicated other than a histologic examination of excised tissue to confirm the presence of the flea.

Imaging Studies

• No imaging studies are indicated unless there is a secondary infection with a complication such as gas gangrene.

Other Tests

• Dermoscopy (direct skin microscopy) may be helpful in identifying typical features, including an irregular central brown discoloration with a plugged opening in the middle or a gray-blue discoloration (Di Stefani, 2005).

Procedures

• Extraction of the gravid flea using a sterile needle is both diagnostic and therapeutic.

Histologic Findings

Microscopically, the flea has a thick cuticle and a band of striated muscle stretching from the head to the abdominal orifice. Also visible are hollow, ring-shaped elements from the flea's tracheal and digestive system and numerous round or oval eggs. A report from a small series of skin biopsies indicated that the exoskeleton, hypodermal layer, trachea, digestive tract, and developing eggs were present in all specimens; striated muscle and the hindquarters were present in about half; the head was found in none of the biopsy samples (Smith, 2002). Detailed histopathological findings from 86 cases, including scanning electron microscopy images, elucidated the stages of infestation (Eisele, 2003).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Following extraction of the flea, thoroughly cleanse and cover the remaining crater with a topical antibiotic cream.
• A course of oral antibiotics may be instituted if secondary infection is suspected. Ensure that tetanus prophylaxis is up to date.

Surgical Care

Enucleation of the lesion using a sterile needle or curette cures the infestation.

Consultations

Consultations are only rarely indicated and are generally for complications of a secondary infection.

Activity

No restriction of activity is indicated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

A randomized, controlled clinical trial of topical therapies for tungiasis among a native population in northeastern Brazil indicated that both thiabendazole and ivermectin lotions applied on 2 consecutive days appear to be effective in speeding eradication of the infestation (Heukelbach, 2003). Neither topical preparation is currently available in the United States.

Use of systemic therapy for primary treatment has not been advocated for US travelers, particularly if infestation involves only a small number of lesions.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Follow-up care confirms a complete resolution of all pain and physical findings.

Deterrence/Prevention

• The most effective preventive measure is to wear shoes (not sandals) when walking along sandy areas in affected regions and to refrain from sitting or lying in the sand.

Complications

• Secondary infections, including bacteremia or septicemia, lymphangitis, tetanus, and gas gangrene. Among a native population in Brazil, the most common causes of bacterial superinfection included Staphylococcus aureus and various enterobacteriaceae; anaerobic streptococci and Clostridium species were also found (Feldmeier, 2002).
• Autoamputation of digits or other extensive soft tissue debridement

Prognosis

• Prognosis is excellent if proper sterile methods are followed for extraction of fleas.

Patient Education

• Travelers to affected countries must be counseled to wear shoes (not sandals) when walking along sandy areas in affected regions and to refrain from sitting or lying in the sand.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Special Concerns

• None except as noted under secondary infections

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Basler EA, Stephens JH, Tschen JA. Tunga penetrans. Cutis. Jul 1988;42(1):47-8. [Medline].
• Brothers WS, Heckmann RA. Tungiasis in North America. Cutis. Jun 1980;25(6):636-8. [Medline].
• Chadee DD. Tungiasis among five communities in south-western Trinidad, West Indies. Ann Trop Med Parasitol. Jan 1998;92(1):107-13. [Medline].
• Di Stefani A, Rudolph CM, Hofmann-Wellenhof R. An additional dermoscopic feature of tungiasis. Arch Dermatol. Aug 2005;141(8):1045-6. [Medline].
• Douglas-Jones AG, Llewelyn MB, Mills CM. Cutaneous infection with Tunga penetrans. Br J Dermatol. Jul 1995;133(1):125-7. [Medline].
• Eisele M, Heukelbach J, Van Marck E. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man. Parasitol Res. Jun 2003;90(2):87-99. [Medline].
• Fein H, Naseem S, Witte DP. Tungiasis in North America: a report of 2 cases in internationally adopted children. J Pediatr. Nov 2001;139(5):744-6. [Medline].
• Feldmeier H, Heukelbach J, Eisele M. Bacterial superinfection in human tungiasis. Trop Med Int Health. Jul 2002;7(7):559-64. [Medline].
• Goldman L. Tungiasis in travelers from tropical Africa. JAMA. Sep 20 1976;236(12):1386. [Medline].
• Heukelbach J, Wilcke T, Eisele M. Ectopic localization of tungiasis. Am J Trop Med Hyg. Aug 2002;67(2):214-6. [Medline].
• Heukelbach J, Eisele M, Jackson A. Topical treatment of tungiasis: a randomized, controlled trial. Ann Trop Med Parasitol. Oct 2003;97(7):743-9. [Medline].
• Lowry MA, Ownbey JL, McEvoy PL. A case of tungiasis. Mil Med. Feb 1996;161(2):128-9. [Medline].
• Mashek H, Licznerski B, Pincus S. Tungiasis in New York. Int J Dermatol. Apr 1997;36(4):276-8. [Medline].
• Muehlen M, Heukelbach J, Wilcke T. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil. II. Prevalence, parasite load and topographic distribution of lesions in the population of a traditional fishing village. Parasitol Res. Aug 2003;90(6):449-55. [Medline].
• Poppiti R Jr, Kambour M, Robinson MJ, Rywlin AM. Tunga penetrans in south Florida. South Med J. Dec 1983;76(12):1558-60. [Medline].
• Sanusi ID, Brown EB, Shepard TG, Grafton WD. Tungiasis: report of one case and review of the 14 reported cases in the United States. J Am Acad Dermatol. May 1989;20(5 Pt 2):941-4. [Medline].
• Smith MD, Procop GW. Typical histologic features of Tunga penetrans in skin biopsies. Arch Pathol Lab Med. Jun 2002;126(6):714-6. [Medline].
• Veraldi S, Schianchi R, Cremonesi R. Bullous tungiasis. Int J Dermatol. Dec 2005;44(12):1067-9. [Medline].
• Zalar GL, Walther RR. Infestation by Tunga penetrans. Arch Dermatol. Jan 1980;116(1):80-1. [Medline].

Article Last Updated: Apr 28, 2006