Myiasis in Children : Fly Larval Infestation

Myiasis is a parasi c infesta on caused by the larvae of several species. Risk factors for human myiasis are poor hygiene, low educa on level and immunocompromised individuals1. Human myiasis can be classifi ed based on clinical condi on causing cutaneous myiasis, ocular myiasis, urogenital myiasis and intes nal myiasis2. We present here two case of fl y larval infesta on including one scalp myiasis in six year old male street child and other vulvar myiasis in 18 year old unmarried girl suff ering from insulindependent diabetes mellitus and psychiatric illness.


Introduction
M yiasis is a parasi c infesta on caused by the larvae of several species.Risk factors for human myiasis are poor hygiene, low educa on level and immunocompromised individuals 1 .Human myiasis can be classifi ed based on clinical condi on causing cutaneous myiasis, ocular myiasis, urogenital myiasis and intes nal myiasis 2 .We present here two case of fl y larval infesta on including one scalp myiasis in six year old male street child and other vulvar myiasis in 18 year old unmarried girl suff ering from insulin-dependent diabetes mellitus and psychiatric illness.

Case 1
A six year street brought by a social worker to the paediatric emergency for scalp wound and complained about the presence of blood stained pus discharge.He was found with numerous live, larval forms in scalp wound.The symptoms were present for more than four weeks.He had loss of appe te, showed signs of fa gue and there were signifi cant reduc on in weight over one month.Ini ally about 10 maggots were removed using the non-toothed forceps, and the wound was cleaned with betadine.He was then treated with chloroform and turpen ne oil in the ra o 1:4 which was followed by manual removal of the maggots (n=20) and was made maggot-free in 2-3 days.He was put on cefuroxime empirically from the 1st day.He was also given a tetanus toxoid injec on on admission.No complica ons were seen and was advised to take necessary precau ons and prevent possible re-exposure along with prescrip on for nutri onal and vitamin supplements.

Case 2
An 18-year old unmarried girl was admi ed to department of Obstetrics and Gynaecology with a history of vaginal discharge and vulval irrita on for two week.She had also noted some worms around the vulva.Her hygiene was poor and as wearing dirty clothes.The pa ent was a known case of insulin dependent diabetes mellitus (IDDM) but under improper medica on.She was also on an depressant drugs.She was living with her rela ves because her mother had died when she was a small child.There was a history of normal regular maggots.No maggots were found in the vagina or rectum.Ini ally about 31 magots were removed with help of non-toothed forceps and clean the wound with betadine.An bio cs (Ce riaxone, metronidalzole and doxycylcline) were started empirically.She was also received tetanus toxoid injec on on admission.By the second day, turpen ne oil was applied on the ulcer.By the 4th day, with 3 days of treatment with turpen ne oil, the maggots had completely disappeared and the ulcer was healing.Pa ent was followed up for four weeks and was found to be completely cured.She was given advice on personnel hygiene to avoid reinfesta on.
In both cases larvae were preserved in laboratory for development of adult fl y.A er development in to adult fl y it was confi rmed as belonging to the house fl y.

Discussion
Myiasis is defi ned as a disease caused by the infi ltra on of body ssues by larvae of several fl y species of veterinary and medical interest.It occurs predominantly in rural areas and is associated with poor hygiene and low educa onal level 1,2 .It is also common in children 1 .Human myiasis can be classifi ed based on clinical condi on it causes like cutaneous myiasis, ocular myiasis, urogenital myiasis and intes nal myiasis 2 .Maggots can enter through intact skin or through a wound.Very few cases have been retrieved from literature on the occurrence of scalp and vulvar myiasis in children throughout the world.Probably due to under repor ng many clinicians and pediatricians s ll have inadequate knowledge about clinical implica ons of human myiasis.Vulvar myiasis cons tutes only 0.7% of human infesta on 4 .We consider our both pa ents as a case of myiasis as the maggots have invaded the scalp and vulvar ssue.The most common species that infest wounds in USA is found to be Phaenicia sericata 4 .The fl y species that infest healthy ssue are called Biontophages and responsible for the cutaneous forms of this condi on (furunculoid myiasis) 1 .Complica ons include secondary infec ons and tetanus.Treatment is removal of larvae and thorough cleaning of the aff ected area.Applying turpen ne oil makes the respira on impossible for the larvae and is one modality of treatment 1 .A small surgical procedure may be required to remove larvae and a er removal the area should be cleaned and covered with an an bio c ointment 4 .Treatment of secondary infec on and administering tetanus toxoid is mandatory.
As poor hygiene is known to be associated with vulvar myiasis 5 washing and keeping the genital area On examina on, there was oedema and infl amma on of the labia minora.Few maggots were found on the perineum.An examina on under local anaesthesia revealed an ulcer on the inner surface of the le labium minora involving the hymen ring as well.The ulcer was infested by a large number of clean may prevent to a great extent the occurrence of this condi on.It is important to exclude sexually transmi ed diseases as a high propor on of cases had sexually transmi ed diseases including HIV 1,2 .Sherman recommends maggots to be submi ed for species iden fi ca on 4 .Species iden fi ca on is important for determining pathogenesis, its poten al invasiveness, in determining the exact ming and circumstances of infesta on.
Turpen ne oil has been advocated in many cases of cutaneous myiasis worldwide 6 but none have men oned its use in vulvar myiasis.In both cases, the use of turpen ne oil produced excellent results.

Conclusion
We re-emphasize the role of human myiasis and the associated morbidity it can cause, as evidenced by increasing reports worldwide.Children are predisposed more to infesta on with fl y larvae due to their playing habits and lack of knowledge of hygiene, especially in rural areas.Paediatricians should be aware of myiasis causing larvae and advise from the microbiologists for laboratory iden fi ca on and also ini ate appropriate suppor ve treatment wherever necessary to minimize the morbidity.