The patient, a 24-year-old white man, presented with a pruritic rash on his right buttock (left) after being exposed to soil at a Georgia farm. Over several weeks, the rash spread to his back and abdomen despite treatment with hydroxyzine, diphenhydramine, permethrin cream, and cephalexin. Subsequent evaluation by a dermatologist led to a diagnosis of cutaneous larva migrans, based on visualization of worm movement on skin examination, peripheral eosinophila (21%), and biopsy specimens showing numerous eosinophils. The patient simultaneously experienced worsening of back pain and new right hip pain. Magnetic resonance imaging demonstrated unilateral right sacroiliitis and small erosions consistent with reactive arthritis, as shown in the coronal T1-weighted fat-suppressed (middle) and inversion recovery (right) images of the right sacroiliac joint. The rash and esosinophila were successfully treated with ivermectin. The back pain did not respond to sacroiliac corticosteroid injection or high-dose indomethacin and is currently being treated with adalimumab. The literature contains reports of reactive arthritis secondary to infection with parasites such as Schistosoma species, Strongyloides stercoralis (pinworm), and Giardia lamblia, but this is the first description of reactive arthritis secondary to New World hookworm (Necator Americanus) infection.
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