Management of Tungiasis with Dehydration and Malnutrition
This patient requires immediate aggressive oral rehydration with ORS at 50-100 mL/kg over 3-4 hours (approximately 1100-2200 mL for a 22-year-old male), surgical extraction of embedded sand fleas, and nutritional rehabilitation. 1
Immediate Priorities: Address Life-Threatening Dehydration
The constellation of lethargy, fatigue, joint pain, and minimal water intake over 6 days indicates significant volume depletion. These symptoms—lethargy, fatigue, muscle/joint discomfort—are classic manifestations of dehydration-associated electrolyte disorders. 2
Rehydration Protocol
- Initiate oral rehydration solution immediately with low-osmolarity ORS containing 75-90 mEq/L sodium for initial rehydration 1, 3
- Target volume: 50-100 mL/kg over 3-4 hours, totaling approximately 1000-2000 mL for this patient 1
- Ongoing replacement: Provide 120-240 mL ORS for each episode of continued fluid loss 1
- Monitor response: Reassess hydration status after 3-4 hours by evaluating mental status, mucous membranes, skin turgor, and urine output 1
Critical pitfall: Do not use coconut water, sports drinks, or other inappropriate fluids despite their availability on the island—these have inappropriate osmolality and electrolyte content that can worsen the clinical picture. 1, 3
Signs Requiring IV Therapy Escalation
If the patient shows signs of severe dehydration (altered mental status, poor perfusion, inability to tolerate oral intake), transition to intravenous isotonic crystalloid boluses of 20 mL/kg until vital signs normalize, then resume oral rehydration. 1
Tungiasis Management
Diagnosis and Clinical Features
The diagnosis is clinical based on the history of barefoot exposure to sand in Panama and characteristic lesions on feet and hands. 4, 5 Tungiasis presents with intense local inflammation, and the clinical manifestations depend on the disease stage. 4, 6
Definitive Treatment
- Surgical extraction remains the treatment of choice for all embedded sand fleas using sterile technique 7, 6
- Complete removal is essential—incomplete extraction leads to persistent inflammation and secondary bacterial infection 7
- Apply topical antibiotics after extraction to prevent superinfection, which is common in tungiasis 7, 6
Important caveat: No effective drug treatment exists for tungiasis. Oral ivermectin or albendazole (effective for cutaneous larva migrans) do not treat tungiasis. 4, 7 Clinical trials of pharmacologic agents have shown disappointing results, making surgical extraction the only proven effective therapy. 7
Managing Inflammation and Superinfection
The mild swelling and joint pain likely reflect the intense inflammatory response to embedded parasites, which increase their volume by a factor of 2,000 within 2 weeks of penetration. 8 Bacterial superinfection is frequent and may be contributing to systemic symptoms. 4, 6
Nutritional Rehabilitation
After 6 days of exclusively coconuts and minimal fish, this patient has significant caloric and protein deficiency contributing to his lethargy and fatigue.
Feeding Strategy
- Resume normal feeding immediately—do not delay nutritional rehabilitation 2
- Provide energy-rich, easily digestible foods as soon as appetite returns 2
- Increase fluid intake with ORS and plain water; avoid alcohol and excessive caffeine 2
- No justification for "bowel rest" or fasting—this worsens nutritional status 2
Monitoring and Follow-Up
- Weight monitoring: Track body weight to assess adequacy of rehydration 2
- Urine output: Normal urine volume indicates successful rehydration 2
- Wound surveillance: Examine extraction sites daily for signs of bacterial superinfection (purulence, expanding erythema, systemic fever) 7
- Complete parasite removal: Ensure all embedded fleas are identified and extracted, as patients often harbor multiple parasites 8, 7
Common pitfall: Do not rely solely on resolution of lethargy to assess hydration—use objective markers including urine output, mucous membrane moisture, and vital signs. 1