Wiadomoci Parazytologiczne 2011, 57(1), 2730

Copyright 2011 Polish Parasitological Society

The human aural myiasis caused by Lucilia sericata1

Dariusz Kaczmarczyk1, Jerzy Kopczyski2, Joanna Kwiecie2, Marek Michalski3, Piotr Kurnatowski4
1 Department of Head and Neck Neoplasms Surgery, Medical University, 4 Paderewskiego Street, 93-509 Lodz, Poland 2 ENT Department, Provincial Specialistic Hospital, Zgierz, Poland 3 Natural History Museum, University of Lodz, Lodz, Poland 4 Chair of Biology and Medical Parasitology, Medical University, Lodz, Poland

Corresponding author: Dariusz Kaczmarczyk; E-mail: [email protected] ABSTRACT. Myiasis is a rare, worldwide, human disease with seasonal variation, caused by developing larvae of a variety of fly species. It can be dangerous when infestations penetrate into the brain. In the available literature, we have found only a few papers concerning ear myiasis caused by Lucilia sericata. Here, we report 2 cases of aural myiasis. Early intervention (surgical removal, occlusion) in these cases should prevent complications. Larvae, for further examination, should be killed by immersion in very hot water, then preserved in an ethanol. Key words: aural myiasis, Lucilia sericata

Introduction
Myiasis is a rare, worldwide, human disease with seasonal variation, caused by developing larvae of a variety of fly species; the most commonly reported include infections by Dermatobia hominis and Cordylobia anthropophaga [1]. Prevalence of myiasis is highest in the tropical and subtropical zones; in the United States and in Europe, the cases reported are mainly found in travelers returning from these destinations [1]. In moderate climates larvae of cosmopolitan dipteran flies are accidental parasites, i.e., human skin (Hypoderma bovis and Gasterophilus intestinalis), nose, paranasal sinuses, pharynx, and ears (Calliphora sp., Lucilia sericata and Musca domestica), alimentary tract and urogenital system (Fannia canicularis), and eyes, orbits, and periorbital tissue (Calliphora vicina, H. bovis). Blowflies (Calliphoridae) are found worldwide. They can cause myiasis of relatively short duration, by both obligatory and/or facultative parasites, which mature within 47 days, usually in the hosts

body orifices and in wounds. They must feed on host tissues, body fluids or ingested by people food for a certain period of time. While in flight, the fly may even drop its eggs in flight on the skin, wounds, or natural openings of an immobile person. The larvae pass through 3 stages before wandering from the lesion and dropping to the ground where they pupariate. The time required to complete the life cycle from egg to adult takes usually about 46 weeks. Myiasis can be classified as accidental (larvae ingested along with food may produce internal infection), semi-specific (larvae are laid on necrotic tissue associated with wounds), and obligatory (larvae affect undamaged skin) [2]. The symptoms and signs depend on affected organs. Patients mainly complain of boil-like, painful, pruritic and tender lesions, with the sense of something moving; sometimes, they induce fever, swollen glands, and headache. Based the literature, the average age of hosts is approximately 60 years, with a male:female ratio of 5.5:1; homelessness, alcoholism, psychiatric diseases, mental disturbances and peripheral

1 This study was supported by Medical University in Lodz, projects no. 503/7-061-04/503-01 and 503/1-013-01/503-01

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vascular disease are frequent cofactors [3,4]. However, cases of neonatal myiasis have also been reported [5]. In the available literature from 1960, we found only a few papers dealing with ear myiasis caused by Lucilia sericata [2,3,69], i.e., 4 in the United States [10] and one in Poland [11]. It should be emphasized that infestation of the ears can be dangerous, because of the possibility of larval penetration into the brain, which occurs in about 8% of such cases. Here, we report 2 cases of ear myiasis, caused by Lucilia sericata larvae.

D. Kaczmarczyk et al.
his own accord and became homeless; sleeping in the forest. At admission to the hospital the patient was dirty and untidy. He complained of otalgia, fetid otorrhea, itching, and bleeding. His left auricle was deformed, with perforation and ulceration of the congested skin; the upper part of the auricle cartilage was lost, and uncovered; the entire auricle and external auditory meatus were filled with fly larvae (Figs. 13). All larvae were carefully removed and placed into 3% formalin for further examination. Because of the lack of part of auricular cartilage, skin of auriculae was removed; healing of the wound followed without complications. The patient received a prophylactic antibiotic therapy to prevent secondary infections. After 6 weeks, a follow up examination revealed no larvae (Fig.4).

Cases report
Case No. 1. A 57-yr-old man was admitted to ENT Department of Provincial Specialistic Hospital in Zgierz, Poland. He was a resident of the convalescence home of MONAR (Polish Organization Counteracting Addiction). However, 4 weeks before admission to the hospital he had left of

Fig.3. removed larva

Patient No. 1: Fig.1. auricula and external auditory meatus filled with fly larvae

Fig.4. follow up (6 weeks)

Fig.2. after surgical removal of larvae

Case No. 2. A 44-yr-old woman was admitted to the Department of Head and Neck Neoplasms Surgery, Medical University of Lodz, Poland with carcinoma of the middle ear, which was treated by radio- and chemotherapy; during a follow up visit otorrhea was found, and the patient complained of aural fullness, otalgia, and the sensation of a foreign

Human aural myiasis

body inside. During an examination, a number of larvae filling the destroyed pyramid of the temporal bone were detected. All larvae were carefully removed manually and surgical debridement of devitalized tissue was performed. After the removal, antiseptic dressing was applied. Larvae were placed into 3% formalin for further examination. The patient did not receive any local or systemic treatment. After 3 months, a follow up examination revealed no new larvae. The maggots collected in both cases were indentified using a key and description given in a monograph of Polish Calliphoridae [12], prepared for forensic entomology applications [13]. Due to fixation in 3% formalin, their external diagnostic features were difficult to examine, as their cuticles were swollen and detached from the body. Because of deformation of papillae surrounding spiracular field and the field itself, it was impossible to measure the papillae and spiracular distance factor. For this reason, several specimens were prepared for microscopic examination after dissolving in 10% KOH. The specimens revealed a cephaloskeleton, anterior and posterior spiracles, and spines of thoracic segments. In all cases, the oral sclerite was not sclerotized and there were no clerotized area below the posterior tip of ventral cornua was not observed. The anterior spiracles were divided into 710 lobes. The slits of posterior spiracles were linear, surrounded by a thin, but complete, peritrema. The shape of spines of thoracic segment II was consistent with the description and illustrations given in keys. On the basis of features observed, all maggots were identified as 3rd stage larvae of Lucilia sericata Meigen (Diptera: Calliphoridae), the most common species causing otomyiases in central Europe.

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induce otalgia, fetid otorrhea, aural fullness, perforation of the tympanic membrane, bleeding, itching, a roaring sound, tinnitus, vertigo, and furuncle of external auditory canal. Damage to the auditory meatus can lead to deafness and meningitis [2,14,16]. Maggots are able separate necrotic tissue from the living tissue and for this reason, they are sometimes employed in biosurgery. This procedure involves continuous flushing or irrigation of the wound with copious exudates formed by the host in response to maggots, which kill, ingest and digest bacteria. Maggots also cause granulation of host tissue due to continuous larval movement in the wound, which results in liquefaction of necrotic tissue as well as increasing the presence of total human fibroblasts. In the case of aural myiasis, early intervention will avoid complications. Surgical removal of larvae with local anesthesia (lidocaine) is the most important procedure that should be undertaken. Intervention should be undertaken to avoid lacerating the larvae since retained larval parts may lead to foreign body reaction. After the removal, antiseptic dressings are advised; antibiotics should be administered only if secondary infection is noted. If such procedure is insufficient, occlusion using petroleum jelly, liquid paraffin, beeswax, hair gel or heavy oil should be employed; lard or bacon strips placed over the central punctum have been used to coax the larva to emerge spontaneously head-first over the course of several hours. Occlusion may occasionally result in asphxiation of the larvae without inducing them to exit and the dead larvae may elicit an inflammatory response with the formation of foreign body granuloma and calcification. Treatment may also include oral administration of ivermectin (200 g/kg/24h per os) or topical use (1% solution) [1]. After removal, larvae should be killed by immersion for 30 seconds in very hot (>80 C ), but not boiling water, which prevents decay and maintains the natural color; then they should be preserved in 70% to 95% ethanol. Formalin should not be used as fixative, since it causes excessive hardening of the larval tissues, making the larvae difficult to identify.

Discussion
Myiasis usually occurs in neglected chronic lesions, especially among patients with poor hygiene, as in case No.1. Case No. 2 is unique because it occurred in a patient with no hygienic or socioeconomic risk factors conducive to egg deposit or larval growth [1]. Myiasis in humans may be either asymptomatic, or severe and life threatening since larval infestations of the eye, nose, and ears may penetrate into the brain [15]. Aural myiasis may present a number of different signs and symptoms, i.e., larvae in the ear can variously

Conclusions
1. Larvae of cosmopolitan flies can induce

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human parasitosis. 2. Clinicians must have a clinical suspicion of aural myiasis not only to patients traveling to warm, humid climates or living in poor hygienic conditions, but also in a moderate climate with no hygienic or socioeconomic risk factors. 3. Treatment should include manual removal of larvae, as well as local and systemic drugs. 4. For the exact identification, larvae should be killed by immersion in very hot water and fixed in 70% to 95% ethanol.

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(Insecta: Diptera). Fauna Poloniae 23. Warszawa. [13] Szpila K. 2010. Key for the Identification of Third Instars of European Blowflies (Diptera: Calliphoridae) of Forenscic Importance. In: Curent Concepts in Forensic Entomology (Eds. J. Amendt, M. Lee Goff, C.P. Campobasco, M. Grassberger): 43- 56. [14] Sood V.P., Kakar P.K., Wattal B.L. 1976. Myiasis in otorhinolaryngology with entomological aspects. Journal of Laryngology and Otology 90: 393-399. [15] Caa I., Satar A., Unl K., Sakalar Y.B., Ari S. 2006. External ophthalmomyiasis infestation. Japanese Journal of Ophthalmology 50: 176-177. [16] Hatten K., Gulleth Y., Meyer T., Eisenman D.J. 2010. Myiasis of the external and middle ear. Annals of Otology, Rhinology and Laryngology 119: 436-439.

References
[1] Grammatikopoulou E., Wilson B.B. 2009. Myiasis: treatment and medication. E-medicine. [2] Yuca K., Caksen H., Sakin Y.F., Yuca S.A., Kiris M., Yilmaz H., Cankaya H. 2005. Aural myiasis in children and literature review. Tohoku Journal of Experimental Medicine 206: 125-130. [3] Chigusa Y., Shinonaga S., Matsumoto J., Kirinoki M., Otake H. 1999. Aural myiasis due to Lucilia sericata (Diptera: Calliphoridae) in a patient suffering from diabetes, hypochondriasis and depression. Medical Entomology and Zoology 50: 295-297. [4] Maturo S., Michaelson P.G., Horlbeck D., Brennan J. 2007. Auricular myiasis. Otolaryngology Head and Neck Surgery 138: 668-669. [5] Jain S., Audhya A., Nagpure P.S. 2008. Aural myiasis in a 1 day old neonate. Indian Journal of Medical Sciences 62: 164-165. [6] Yaghoobi R., Tirgari S., Sina N. 2005. Human auricular myiasis caused by Lucilia sericata: clinical and parasitological considerations. Acta Medica Iranica 43: 155-157. [7] Demirci M., Oguz H., Arslan N., Safak M.A. 2006. Aural myiasis. Journal of Otolaryngology 35: 192193. [8] Yuca K., Yuca S.A. 2003. Aural live foreign bodies in children. Joyrnal of Emergency Medicine 25: 102104. [9] Cho J.H., Kim H.B., Cho C.S., Huh S., Ree H.I. 1999. An aural myiasis case in a 54 year-old male farmer in Korea. Korean Journal of Parasitology 37: 51-53. [10] Sherman R.A. 2000. Wound myiasis in urban and suburban United States. Archives Internal Medicine 160: 2004-2014. [11] Sokoowski Z., Woniak S. 1969. A case of infestation of a postoperative cavity within the ear by larvae of the fly. Wiadomoci Lekarskie 22: 281-283. [12] Draber-Moko A. 2004. Calliphoridae, Plujki

Muszyca u ludzi wywoana przez Lucilia sericata

D. Kaczmarczyk, J. Kopczyski, J. Kwiecie, M. Michalski, P. Kurnatowski
Muszyca jest chorob pasoytnicz zwierzt, niekiedy take czowieka, wywoan obecnoci i wdrwk larw much, gwnie Dermatobia hominis i Cordylobia anthropophaga. W dostpnym pimiennictwie udao si znale tylko 8 prac dotyczcych muszycy ucha. Celem pracy jest przedstawienie 2 przypadkw muszycy ucha zewntrznego wywoanych przez larwy Lucilia sericata. Przypadek 1. dotyczy 57-letniego pacjenta, podopiecznego Orodka MONAR w Sokolnikach (woj. dzkie), przyjtego na Oddzia Otolaryngologii Wojewdzkiego Specjalistycznego Szpitala w Zgierzu; ok. 4 tygodnie wczeniej samowolnie opuci Orodek i bdc bezdomnym, nocowa w lesie. Przy przyjciu stwierdzono liczne, ywe larwy w obrbie rozlegych zmian maowiny usznej, obejmujcych jej skr i chrzstk. Przypadek 2. dotyczy 44-letniej pacjentki leczonej w Klinicznym Oddziale Chirurgii Nowotworw Gowy i Szyi Katedry Chirurgii Gowy i Szyi Uniwersytetu Medycznego w odzi z powodu raka ucha rodkowego. Po radio- i chemioterapii wystpio ropienie, a w czasie wizyty kontrolnej stwierdzono liczne, ywe larwy w obrbie zniszczonej piramidy koci skroniowej. U obydwu chorych zastosowano bardzo dokadne oczyszczenie zmienionych miejsc i usunicie wszystkich larw. Usunite larwy zostay zidentyfikowane jako larwy Lucilia sericata. Received 13 January 2011 Accepted 10 February 2011