Accepted Article
NOT A SIMPLE PLANTAR WART: A CASE OF TUNGIASIS
1
Department of Surgical, Medical, Dental and Morphological Sciences with Interest transplant,
Oncological and Regenerative Medicine; Dermatology Unit; University of Modena and Reggio
Emilia, Modena, Italy.
2
Department of Dermatology, University of Parma, via Gramsci 14, IT-43100 Parma, Italy.
3
Istituto Dermopatico dell'Immacolata, Fondazione Luigi Maria Monti IRCCS, Rome, Italy.
4
Division of Dermatology. UO Multizonale “Santa Chiara” Hospital, Trento. Italy.
Department of Surgical, Medical, Dental and Morphological Sciences with Interest transplant,
Oncological and Regenerative Medicine. Dermatology Unit. University of Modena and Reggio
Emilia, via del Pozzo 71, 41124 Modena. Italy. Phone (+39) 059/4224264, fax (+39) 059/4224271,
E-mail: francescapeccerillo@gmail.com
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jdv.14595
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Acknowledgments: Honorarium, grant, or other form of payment were not given to anyone of the
authors to produce the manuscript. All authors made substantive intellectual contributions to the
Accepted Article
published study and each author listed on the manuscript has seen and approved the submission of the
manuscript.
Sir:
A 62-year-old Caucasian woman complained of a painful nodular lesion on her right heel that
restricted her walking. She had noticed the onset of the itching after approximately 3 weeks of travel
in Brazil. She was initially treated by her general practitioner with topical salicylic acid, suspecting a
plantar wart. After a week of increased itching and unbearable pain, the patient was referred to our
dermatological service. The lesion was roundish and approximately 1 cm in diameter, hard in
consistency (Fig. 1). After gentle curettage, dermoscopy was performed. We noticed a white halo of
hyperkeratosis with an incomplete, dark brownish ring, blue-black blotches, and a central orifice
surrounded by white ovoid structures (Fig. 2). After a few insightful questions, she was diagnosed
with tungiasis. We curetted out the eggs and fecal material and further performed spray cryotherapy,
instructing her to apply a topical antibiotic ointment for 2 weeks; this resulted in her full recovery.
Tungiasis is a cutaneous parasitosis which is caused by a flea, Tunga penetrans. This infection is
widely distributed among mammals, affecting humans and small animals. It is endemic to South and
Central America, sub-Saharan Africa, and rarely, European countries1-2. The infestation cycle of the
flea lasts nearly 1 month. The female penetrates the skin of mammalian hosts and causes a
hypertrophic, rounded lesion with a central black dot. This represents the abdominal and genital
opening where the flea produces and expels its eggs3. In order to avoid severe complications such as
digit deformation, chronic lymphedema, tetanus, and sometimes sepsis, early diagnosis is decisive.
This holds especially in endemic areas where severe infestation often occurs4. Diagnosis in these areas
is usually straightforward; nevertheless, it can be tricky in nontropical areas, due to a low index of
“Zebra retreat” refers to the hesitation with which one considers a rare diagnosis (zebra) even though
it may be the most likely diagnosis. Gentle curettage followed by dermoscopy has the potential to
overcome this flaw in the reasoning process, avoiding missing a rare diagnosis.
References
1. Sachse MM, Guldbakke KK, Kachemoune A. Tunga penetrans: a stowaway from around the
2. Palicelli A, Boldorini R, Campisi P, et al. Tungiasis in Italy: an imported case of Tunga penetrans
and review of the literature. Pathol Res Pract. 2016; 212: 475–483.
3. Maco V, Maco VP, Tantalean ME, Gotuzzo E. Histopathological features of tungiasis in Peru. Am
4. Mazingo HD, Behamana E, Zinga M, Heukelbach J. Tungiasis infestation in Tanzania. J Infect Dev
5. O’Brien BM. A practical approach to common skin problems in returning travelers. Travel Med
Figure legends: