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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 58  |  Issue : 4  |  Page : 391-393

Extensive myiasis of the leg in a patient with filarial lymphedema: implications for morbidity care in filariasis elimination program


1 ICMR-Vector Control Research Centre, Indira Nagar, Puducherry, India
2 Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, Ansari Nagar, New Delhi, India

Date of Submission26-Jun-2020
Date of Acceptance29-Jan-2021
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr Vijesh S Kuttiatt
ICMR-Vector Control Research Centre, Indira Nagar, Puducherry-605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9062.318314

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  Abstract 

Myiasis, infestation of the human body by larva of flies is an under-recognized and ignored medical condition. Not only is this condition unsightly and extremely distressing to the patient, but it also generates a ghastly feeling in care givers and health care workers as well. The authors report extensive myiasis of the leg in a patient with filarial lymphedema from southern India, which is rarely illustrated in published literature. Treatment of myiasis is described in brief. There is a need for strengthening morbidity management in filariasis elimination program.

Keywords: Myiasis; Filarial lymphedema; Morbidity management; Filariasis elimination program; Ivermectin


How to cite this article:
Kuttiatt VS, Venkatesan S, Srinivasan V, De Britto L, Rahi M, Kumar A. Extensive myiasis of the leg in a patient with filarial lymphedema: implications for morbidity care in filariasis elimination program. J Vector Borne Dis 2021;58:391-3

How to cite this URL:
Kuttiatt VS, Venkatesan S, Srinivasan V, De Britto L, Rahi M, Kumar A. Extensive myiasis of the leg in a patient with filarial lymphedema: implications for morbidity care in filariasis elimination program. J Vector Borne Dis [serial online] 2021 [cited 2022 May 21];58:391-3. Available from: https://www.jvbd.org/text.asp?2021/58/4/391/318314




  Introduction Top


Myiasis is a condition where the live vertebrate body is infested by the larva of flies[1]. This is an under-recognised and neglected medical condition, often seen in elderly, chronically ill bedridden individuals, patients with advanced malignancies, mentally ill and homeless[2]. Patients with advanced filarial lymphedema have hyper-keratotic fungating growths and skin folds in their legs. They develop frequent skin infections and ulcers with foul smelling discharge making them prone to myiasis. However, there is only limited published literature on myiasis and its treatment in the context of filarial lymphedema[3]

Although, lymphatic filariasis was targeted for elimination by 2020 employing mass drug administration (MDA), most endemic countries including India (which contributes 40% of the global infection burden), are unlikely to achieve this target[4]. Global Program for Elimination of LF (GPELF) has devised the morbidity management and disability prevention (MMDP) for those with lymphedema which focus on home-based self-care - limb hygiene (daily washing with soap and water), limb elevation, manual massage and exercises[5]. However, this component often does not get enough consideration at the implementation level and some endemic countries are yet to initiate this in their national program[4]. The authors report extensive myiasis of the leg in an elderly patient with filarial lymphoedema, review the treatment options and stress the need for strgethening the MMDP program.

Case history

A 70-yr-old man, a known case of filarial lymphedema in the right lower limb of 30 years duration was brought to our clinic in last week of December 2019, with complaints of pain and maggots coming out of a large ulcer in his right leg. He belonged to Cuddalore district, Tamil Nadu which was previously endemic for bancroftian filariasis. He reported no fever or any other symptoms; and was not suffering from diabetes or other chronic illnesses. He was conscious and oriented; vital signs were normal. His personal hygiene was however poor. Grade IV lymphedema with fungating growths and multiple ulcers with foul smelling discharge, were noted in the right leg; the other limb was unaffected. A huge ulcer measuring 15 cm length × 5 cm breadth with necrotic tissue on the posterior aspect of the right lower leg extending on to the foot was noted with large numbers of wiggling maggots [Figure 1].
Figure 1: Maggots wiggling in the ulcer on the right lower leg with lymphedema

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Patients and his relatives were reassured and analgesics were administered to the patient. Turpentine oil was applied on the leg and numerous maggots were removed manually without rupturing. Leg was cleaned by flushing with normal saline; betadine and hydrogen peroxide solution were also applied. Oral amoxicillin, ofloxacin and metronidazole was prescribed for broad antibacterial coverage. Additionally, 1% metronidazole cream was given for topical application. He was asked to report daily for further removal of maggots and to consider ivermectin, if required[3]. Arrangement has been made for larva harvesting and identification during his visit next day. However, the patient did not turn up for follow-up.


  Discussion Top


Chrysomya bezziana, Cochliomyia hominivorax and Wohlfahrtia magnifica are the most common flies, worldwide, that cause obligatory human wound myiasis[1],[2]. Chrysomyia bezziana, The Old World screwworm fly (OWSF) is common in the Eastern Hemisphere whereas infestation by Cochliomyia hominivorax, the New World screwworm fly (NWSF) is reported from Western Hemisphere. Recently, OWSF has been expanding into geographical regions out of its typical range through livestock commerce and possibly due to climate change; a modelling study predicts its potential spread to countries with a large live stock production[6].

The first case of Chrysomyia rufifacies infestation in the lymphoedematous leg of a filariasis patient was reported from Puducherry, India in 1992[7]. Later, three more cases of Chrysomyia bezziana were published; one from Puducherry and two from Chertalai, Kerala[8]. There is one report of oral myiasis by C. bezziana in a woman suffering from filarial lymphedema and leprosy from Puducherry[9]. Cochliomyia hominivorax infestation had been reported in 21 patients with swollen limbs in a filariasis endemic area Recife, Brazil[3]. Apart from eating the necrotic issue, fly larvae can damage healthy tissues and increase the risk of secondary infection which may worsen lymphatic dysfunction[3]

Standard management of cutaneous myiasis is the local treatment of the affected area with hypoxia inducing agents like turpentine oil, ether, lidocaine or other chemicals that make the larva out of the tissue or skin followed by manual picking of the maggots. Care should be taken, not to rupture the larva to avoid invoking allergic reactions and to prevent secondary bacterial infections. Surgical debridement may be necessary sometimes. Recently, ivermectin or albendazole alone or in combination with clindamycin has been found to be effective for treating myiasis[3],[10],[11],[12]. Ivermectin kills the larvae and is reported to relieve the pain within hours of use and the dead larva can be removed manually, even by the patient[3]. The psychosocial effect of myiasis in patients and caregivers is often overlooked; proper counselling is important. Myiasis is often ignored by the health workers and, the patients often restrict to self medications due to social stigma. When medical care is sought, clinicians often do not attempt to identify the species involved. Therefore, the epidemiological data related to myiasis is scant. It was planned to collect the larva for identification in our patient during his next visit, but he did not turn up.

Home based self-care alone may not be sufficient to address the health needs of LF patients. A local health centre based approach to supplement self care need to be considered. Integrating filariasis morbidity management with the diabetic foot care in the noncommunicable diseases clinic in health centres may be feasible. As India is planning for accelerated LF elimination with IDA (Ivermectin, Diethylcarbamazine, Albendazole) based MDA, this is the right time to strengthen the MMDP component as well.

Conflict of interest: None

Ethical statement

Written consent was obtained from the relative (son) for clinical photograph and publication.



 
  References Top

1.
Francesconi F, Lupi O. Myiasis. Clin Microbiol Rev 2012; 25(1): 79-105.  Back to cited text no. 1
    
2.
Singh A, Singh Z. Incidence of myiasis among humans-a review. Parasitol Res 2015; 114(9): 3183-99.  Back to cited text no. 2
    
3.
Dreyer G, Mattos D, Lins R, Fraiha H. Myiasis in a bancroftian filariasis endemic area. J Lymphoedema 2008; 5(1): 10-18.  Back to cited text no. 3
    
4.
WHO. Global programme to eliminate lymphatic filariasis: progress report, 2018. Wkly Epidemiol Record 2019; 94(41): 457-72.  Back to cited text no. 4
    
5.
Addiss, DG, Brady MA. Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis: a review of the scientific literature. Filaria J 2007; 6: 2  Back to cited text no. 5
    
6.
Hosni EM, Nasser MG, Al-Ashaal SA, Rady MH, Kenawy MA. Modeling current and future global distribution of Chrysomya bezziana under changing climate. Sci Rep 2020; 10: 4947.  Back to cited text no. 6
    
7.
Srinivasan R, Pani SP. Myiasis in human filarial lymphedema. Southeast Asian J Trop Med Public Health 1992; 23(4): 807-8.  Back to cited text no. 7
    
8.
Radhakrishnan R, Srinivasan R, Krishnamoorthy K, Sabesan S, Pani SP. Myiasis in filarial lymphoedema due to Chrysomyia bezziana. Natl Med J India 1994; 7(3): 117-8.  Back to cited text no. 8
    
9.
Candamourty R, Venkatachalam S, Yuvaraj V, Sujee C. Oral myiasis in an adult associated with filariasis and Hansen’s disease. J Nat Sc Biol Med 2013; 4: 259-62.  Back to cited text no. 9
    
10.
Patel BC, Ostwal S, Sanghavi PR, Joshi G, Singh R. Management of malignant wound myiasis with ivermectin, albendazole, and clindamycin (triple therapy) in advanced head-and- neck cancer patients: a prospective observational study. Ind J Palliat Care 2018; 24: 459-64.  Back to cited text no. 10
    
11.
Singh S, Athar M, Chaudhary A, Vyas A, Tiwari S, Singh S. Effect of ivermectin on wound myiasis- a hospital based study. Ann Clin Lab Res 2017; 5(4): 200.  Back to cited text no. 11
    
12.
Sivekar S, Senthil K, Srinivasan R, Sureshbabu L, Chand P, Shanmugam J, et al. Intestinal myiasis caused by Muscina stabulans. Indian J Med Microbiol 2008; 26: 83-5  Back to cited text no. 12
    


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