On the nose

BMJ 2008; 336 doi: (Published 29 May 2008) Cite this as: BMJ 2008;336:1240
  1. Rose McGready, research physician
  1. 1Shoklo Malaria Research Unit, Mae Sot, Thailand
  1. rose{at}

    While on holiday in France from my work in Thailand, I thought I had a left upper molar infection. I wished I’d stocked up on some antibiotics (far too easy to purchase in resource poor settings, where they can least afford problems with drug resistance). The next day I diagnosed left maxillary sinusitis. The following day the supposed sinusitis was now on the left side of my nose as a 1.5 cm, red, slightly raised, circular lesion.

    In Thailand superficial migrating skin lesions are caused by helminths. The commonest is cutaneous larva migrans, where humans are accidental hosts for the cat and dog hookworm. Strongyloides cause larva currens from autoinfection of larvae penetrating the perianal skin. Gnathastomiasis is acquired by eating uncooked foods such as fish, shellfish, frog, or chicken. My lesion was not the classic, erythematous, tunnel-like lesions of cutaneous larva migrans as shown in textbooks. Skin lesions from strongyloides tend to be fleeting and itchy, which mine wasn’t, whereas gnathastomiasis tends to present as migratory skin swellings or subcutaneous lesions.

    I went to the local pharmacy to buy some anthelmintics—albendazole or topical thiabendazole. “C’est impossible”—no easy, over the counter options for wormy things in France. Welcome back to Western medicine. Later that day a courteous and concerned French general practitioner with an enthusiasm for blood tests checked me for eosinophilia, C reactive protein, and, to top it off, Gnathostoma spinigerum antigen.

    I waited a few days for the results of raised eosinophils and slightly raised C reactive protein … and a few months for the antigen result, which was negative. It turned out that the lab in France had sent the sample to Thailand for testing; the result went back to France, by which time I was back in Thailand.

    Meanwhile, I wasn’t allowed anthelmintics in France because I was lactating—whereas our bamboo clinic in Thailand uses mebendazole and albendazole routinely for women in their second and third trimesters and postpartum if they have positive stool results or migrating superficial skin lesions, in line with the WHO Millennium Development Goals.1 So I was unable to access a basic drug in a resource rich country (France) when we dispensed it liberally in our resource poor setting and it was available over the counter in my native Australia.

    Back at the nose, things were getting uncomfortable as the helminth wormed its way to the bridge: there’s not a lot of space for objects under the skin in that area. I turned to our household cure-all, tea tree oil, soaked on to a dressing on my nose while I slept. In the morning there was no sign of further movement, and within 48 hours the lesion was completely gone. After this palaver, I looked up the medicinal properties of the oil (Melaleuca alternifolia): it can be useful for various skin infections,2 but this is the first report I know of treating a superficial helminth infection.


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