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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 145-148

Furuncular myiasis in two Nigerian siblings – Case report and review of the literature


1 Department of Paediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission04-Mar-2018
Date of Decision18-Oct-2018
Date of Acceptance16-Nov-2018
Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Halima Kabir
Department of Paediatrics, Bayero University/Aminu Kano Teaching Hospital, P.M.B. 3011, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_12_18

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  Abstract 


Myiasis is an infestation of the body of a mammal by fly larva that grows inside and feeds on the tissue of the host. It is endemic to sub-Saharan Africa, southeast Mexico, South America, and Central America. It can occur in any age group and has no sex predilection. It is mostly seen among the rural population with many cases unreported and undiagnosed. We report two otherwise healthy Nigerian siblings with furuncular myiasis, who were initially diagnosed with furunculosis and received antibiotics from various hospitals without improvement. The larvae were removed with forceps after application of petroleum jelly and had full healing of all lesions on follow-up. Furuncular myiasis should be considered a differential diagnosis of furunculosis that is not responding to antibiotics, especially in travellers to endemic areas.

Keywords: Children, furuncular, myiasis, Nigeria


How to cite this article:
Kabir H, Abdallah RJ, Lawal NO, Farouk ZL. Furuncular myiasis in two Nigerian siblings – Case report and review of the literature. Niger J Basic Clin Sci 2019;16:145-8

How to cite this URL:
Kabir H, Abdallah RJ, Lawal NO, Farouk ZL. Furuncular myiasis in two Nigerian siblings – Case report and review of the literature. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Dec 9];16:145-8. Available from: http://www.njbcs.net/text.asp?2019/16/2/145/270996




  Introduction Top


Myiasis occurs when fly larva grows and feeds in the body of a mammal.[1],[2] The word “Myiasis” was first coined by Reverend Frederick William Hope in 1840.[1] Myiasis can be classified based on the area affected as intestinal, cutaneous, wound, and cavitatory or based on the ecological living which includes obligate, facultative, and accidental larvae.[1],[2] The cutaneous form is commoner and can be caused by bloodsuckers (Congo floor maggot – Auchmeromyia luteola), subcutaneous (tumbu fly – Cordylobia anthropophaga; human botfly – Dermatobia hominis), and by dermal myiasis (Gastrophilus, Hypoderma, Gnathosthoma).[2] The C. anthropophaga is commoner in sub-Saharan Africa and southern Spain and commonly caused by tumbu fly, putzi fly, or ver de Cayor fly.[1],[2] Risk factors for myiasis include poor personal and environmental hygiene, extremes of age, low socioeconomic status, immunosuppression, neglected children, malnutrition, diabetes mellitus, and chronic skin diseases.[1],[2],[3],[4],[5],[6],[7] It rarely occurs on intact skin but usually invades open wounds and lesions. It is commoner in children and in the rainy season.[1],[2],[3],[4],[5]

Tumbu fly is a large yellow fly. The female lays about 100–300 eggs in the soil contaminated with animal feces, urine, on damp clothing or bed linens that have been hung to dry outside.[1],[2],[8] The eggs hatch in about 1–3 days and crawl over the soil. Sometimes, the eggs can remain for 15 days until a suitable host is available. Once the larvae come in contact with a host, they penetrate the skin and lie in the subcutaneous tissue. Furuncular myiasis first appears as a red papule at the penetration site, then becomes an erythematous furuncle-like nodule which enlarges with intermittent and slight itching.[1],[8] Subsequently, pain develops with increasing frequency and intensity. The furuncle aperture opens and the respiratory sinuses, and occasionally, the posterior end of the larva may be seen. The larvae are usually cream in color. Typical lesion is that of a papule or nodule with a central punctum with serosanguinous exudates.[1],[4],[5],[6],[7],[8] This punctum permits blood and waste products of the larva to drain. Clinical variants described include pustular, erosive, ecchymotic, bullous, vesicular, and ulcerative lesions.[1],[2],[8] The larva then pupate between 8 and 12 days and fall to the ground hatching as adults within 10–20 days.[1] There have been reports of human myiasis from different parts of Nigeria.[3],[4],[5],[6],[7] We report this case because furuncular myiasis rarely occurs in intact skin and can be confused with furunculosis to the unsuspecting clinician.

Case 1

A 4-year-old boy presented to the emergency pediatric unit with 10 days history of multiple body swellings on the axillae, upper limbs, and trunk. The swellings were initially like rashes and then became boil-like and progressively increased in size with associated body itching, insomnia, painful sensation, and feeling of abnormal movement underneath the skin, no associated fever, vomiting, or preceding history of trauma, and no history of recent travel. He lives with both parents and elder sibling in Abuja metropolis. They live in a modern duplex house and do not keep animals in the home. The parents and other members of the family except a 9-year-old sibling have no similar complaints. The children's laundry is done at home, spread to dry on flower beds and lawn grass in the family courtyard, and no ironing is done due to erratic electricity. In contrast, the parent's laundry is done at a laundromat. Both parents have tertiary education and the father is a businessman and a traditional leader. They had sought care from various hospitals where he had oral antibiotics (ampiclox, erythromycin, cefixime), vitamin C, paracetamol, and chlopheniramine with no significant improvement as swellings persisted and continued to enlarge.

On examination, he was in painful distress, afebrile, and had normal vital signs with multiple erythematous nodules on the axillae, upper limbs, and trunk. No regional lymphadenopathy was found. His anthropometry was normal (weight – 22 kg, Mid upper arm circumference ( MUAC) – 15 cm, height – 113 cm). Careful inspection of one of the nodules revealed a central pore with a white structure protruding from it [Figure 1]. Attempts to extract the structure revealed a live larva with serous exudates [Figure 2]. A diagnosis of furuncular myiasis was made. Petroleum jelly was applied on the remaining nodules following which the larvae were manually extracted with forceps. A total of 12 larvae [Figure 3] were manually extracted from the remaining nodules. Other systemic examinations were unremarkable and human immunodeficiency virus (HIV) screening was negative.
Figure 1: White structure (arrow) protruding from one of the nodules

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Figure 2: Extraction of the white structure revealed a live larva (arrow)

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Figure 3: Larvae on white background extracted from both siblings, and total of 20 extracted from both siblings

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Case 2

A 9-year-old boy, a sibling of the first patient reported above, presented to the emergency pediatric unit at the same time with a 10-day history of multiple swellings on the chin, upper limbs, and trunk. Swellings started initially as small rashes, then became boil-like that progressively increased in size and number. Swellings were itchy, with painful sensation and feeling of abnormal movement underneath the skin. The symptoms were severe to prevent patient from sleeping. However, no associated constitutional symptoms or preceding history of trauma or recent travel. He lives with his younger sibling and parents in Abuja metropolis in a duplex surrounded by flower beds and carpet grass. Family socioeconomic background and environmental history is as documented above. He also had the same medications as his younger sibling over the 10 days with no significant improvement as the swellings continued to enlarge in size and in number.

On examination, he was afebrile and had normal vital signs with multiple erythematous nodules on the chin and trunk. Had normal anthropometry, BMI 21.8 (weight 32 kg, height 121 cm). Systemic examinations were unremarkable. HIV screening was negative. Examination of the nodules on the trunk revealed a central punctum with serous exudates and a white structure noticed to be protruding from one of them. A live larva was extracted from this nodule. Petroleum jelly was applied on the remaining nodules, following which eight larvae were extracted manually using forceps from all the remaining. The larval specimens were sent to the Microbiology Department of AKTH. It was identified as the larva of tumbu fly.

They were both treated with oral flucloxacillin 25 mg/kg/day 6 hourly for 10 days, tablets ivermectin 0.2 mg/kg stat dose, tetanus toxoid 0.5 ml stat, paracetamol, and chlorpheniramine. Both boys were observed after the procedure and discharged after 6 h. Parents were counseled on use of insect repellents, use of window screens around the house, also against spreading washed clothes on the grass, and the importance of ironing them to kill the eggs of the tumbu fly. They were seen a week later for follow-up and most of the lesions had healed completely.


  Discussion Top


The two brothers in this report presented at 4 and 9 years of age. Preponderance of myiasis in children has been commonly observed.[4],[5],[6],[7],[9] They presented during the rainy season, a time the tumbu fly approaches human settlements searching for food and where to lay its eggs.[1],[2],[4] It is less common in dryer conditions of north central Nigeria in comparison to the more humid southern parts of Nigeria.[4],[7] Their damp clothes that were dried on the flower beds and grass probably served as the source of infestation as the female fly tends to deposit its eggs on contaminated soil or damp clothes. Our patients' clothes were not ironed which would have killed the eggs. This is most likely the route of infestation in these cases. Lack of regular electricity was cited by the parents as the reason for not ironing the clothes. This highlights the impact of poor infrastructure on health in general and hygienic practices. However, the parents were probably not infested despite living in the same house because their clothes were washed and dried outside the house and were ironed.

The distribution of the lesions on the trunk, upper limbs, and axillae is consistent with covered areas of the body, and hence, eggs deposited on their damp clothes were able to penetrate the skin. This was similar to reports from Ibadan[7] and Gambia[6] The lesions can be furuncular, nodular, pustular, vesicular, or ulcerative.[1],[2] In these cases, we report nodular lesions. There was delay in the correct diagnosis in these two boys despite consultations at several hospitals. This is the classical presentation of furuncular myiasis where one needs a high index of suspicion to arrive at the correct diagnosis.[1],[5],[6],[7],[9],[10],[11] This is due to similarity of the lesion with other cutaneous conditions such as insect bites, cellulitis, and nodular furunculosis of bacterial etiology.[1],[4],[7],[9] This will explain the initial treatment in these two boys with antibiotics at the peripheral clinics before coming to our hospital. This might have also contributed to the delay in the diagnosis. Our patients had skin lesions that did not heal despite use of numerous antibiotics. They classically complained about feeling of movement under the skin with associated itching causing insomnia. In addition, the attending physician identified a white structure protruding from the center of the lesion. This aided the correct diagnosis, as reportedly clues suggesting myiasis include the presence of nonhealing skin lesions, pruritus, pain, feeling of movement under the skin, and small white structure protruding from the skin.[1],[2],[4],[5],[6][7],[9],[10] Others are recent travel to an endemic area, which was not obtained in these boys.

We extracted 12 larvae from case 1 and 8 larvae fromcase 2; this is similar to a report by Oluwatosin et al.,[7] where about 14 larvae were extracted from one of their patients. This however contrasts with findings by Onyeama et al.,[6] where 47 larvae were extracted from a 6-week-old infant.

The cases in this report are from high socioeconomic background, urban dwellers, and adequately nourished with an urban clean environment. Unlike the usual presentation of myiasis that is reportedly commoner among low socioeconomic status, malnourished or immunosuppressed individual, and poor environmental hygiene.[1],[4],[5],[7] This highlights the importance of thorough physical examination, and a high index of suspicion when dealing with cutaneous lesions, especially if they are not responding to treatment.

We report prompt extraction of these larvae and adequate treatment with antibiotics, antiparasitic medication, tetanus prophylaxis as well as appropriate health education. This is the recommended management of myiasis.[1],[2],[3],[4],[5],[6],[7],[9],[10],[11]

Prevention of myiasis is by eradicating adult flies using good sanitation, exterminating flies using insecticides, washing clothes thoroughly, drying away from flies, and ironing. Health education is important. The parents were counseled on use of window screens, mosquito nets, and use of insect repellents. They were also counseled on improved personal and environmental hygiene, to wash the children's clothes with hot water and to dry away from the flower beds and iron thoroughly to kill eggs.


  Conclusion Top


These cases highlight lack of awareness of furuncular myiasis by health-care providers, leading to delay in the diagnosis and management of these children. We recommend public health education on myiasis and the need for environmental hygiene.

Acknowledgments

The authors acknowledge the department of Microbiology of Aminu Kano Teaching Hospital for identification of the larval specimen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fabio F, Omar L. Myiasis, Clin Microbiol Rev 2012;25:79-105.  Back to cited text no. 1
    
2.
Robbins KK. Cutaneous Myiasis, a review of the common types of Myiasis. Int J Dermatol 2010; 49:1092-8.  Back to cited text no. 2
    
3.
Adisa CA, Charles A, Augustus M. Furuncular Myiasis of the breast caused by the larvae of the Tumbu fly (Cordylobia anthropophaga). BMC Surg 2004;4:5.  Back to cited text no. 3
    
4.
Ogugua KO, Ted GA, Eme EO, Dorcas SB, Chika HA, Lekia K, et al. Human Myiasis in neonates and children of the Niger Delta wetlands and South-East Nigeria. JCDSA 2011;1:171-6.  Back to cited text no. 4
    
5.
Edungbola LD. Cutaneous Myiasis due to Tumbu fly, Cordylobia anthropophaga in Ilorin, Kwara state, Nigeria. Acta Trop 1982;39:355-62.  Back to cited text no. 5
    
6.
Onyeama CO, Njai PC. Cutaneous Myiasis (Tumbu fly larvae): A case report. Niger J Paediatr 2005;32:26-7.  Back to cited text no. 6
    
7.
Oluwatosin MA, Fadahunsi IF. Cutaneous and intestinal Myiasis in Lagelu L.G.A of Oyo state, Afr J Clin Exp. Microbiol 2003;4:44.  Back to cited text no. 7
    
8.
Geary MJ, Hudson BJ, Russel RC, Hardy A. Exotic myiasis with Lund's fly (Cordylobia rodhaini). Med J Aust 1999;171:654-5.  Back to cited text no. 8
    
9.
Al Junaid A, Al Zahrani W. Furuncular Myiasis in a child: A case report and literature review. Saudi J Med Med Sci 2017;5:77-9.  Back to cited text no. 9
    
10.
Akhter J, Quadri SM, Imam AM. Cutaneous Myiasis due to Dermatobia hominis in Saudis. Saudi Med J 2000;21:689-91.  Back to cited text no. 10
    
11.
Omar MS, Abdalla RE. Cutaneous Myiasis caused by Tumbu fly larvae, Cordylobia anthropophaga in Southwestern Saudi Arabia. Trop Med Parasitol 1992;43:128-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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