Myiasis: Destructive Disease and Effective Therapy Joshua Miedema Biology 1A Laboratory Judy Ikawa Wakabayashi

Myiasis, the infestation of obligate parasite larvae in vertebrates, is a major concern in the dermatological realm of medicine. It has been found to be the fourth most common travelassociated skin disease and can be contracted in tropical climates around the world (Robbins and Kachemoune, 2009). Relatively simple to treat, it is more of a nuisance than anything else, however, given the right circumstances it can be life threatening. In contrast, certain species of maggots can be used in maggot therapy to debride wounds containing necrotic tissue and consume bacteria, preventing opportunistic infections. Myiasis is caused by the eggs of a parasitic fly, such as the human botfly, entering an open wound, or hatching on the skin (Patel and Sethi, 2009). The larvae hatch and burrow into the flesh and feed on the host tissue. In the case of a cutaneous infestation, the larvae actually break the skin in order to reach the underlying flesh. When this occurs, boil will erupt at the site, accompanied by severe irritation, edema, and a small amount of excrement from the larvae. The boils also have a small opening at the top which is maintained by the larvae in order to obtain oxygen. The boils or open wound that the larvae inhabit is also susceptible to secondary infection from opportunistic bacteria. After a period of 1-3 months, the larvae reach full size and drop to the ground and pupate (Norlund, 2009). After reaching maturity, the newly hatched flies repeat the cycle. Myiasis most commonly occurs in the skin, however, other sites are susceptible to myiasitic infection, such as the ear, nasal passages, intestine, and genitalia. Infections of the head, buttocks, and scalp are typical (Norlund, 2009). Aural infection is the most dangerous in particular because if the larvae burrow far enough, they will eventually reach the brain (Hatten, et. all, 2010). Human myiasis is predominantly caused by several species of blow flies and flesh flies including D. hominis, C. anthropophaga, cuterebra spp., and Wolfhartia vigil and opaca, and of this, infestation by D. hominis is the most common (Patel and Sethi, 2009). Myiasis occurs most often in tropical climates, such as South America or Africa, and it is not unusual for travelers to return from a trip to such areas and have contracted myiasis

unknowingly. In Paris, a study yielded results that 25 of 269 travelers had contracted myiasis on their trip, and 20 of these had gone to Saharan Africa, and 5 to South America (Norlund, 2009). It can be obtained from multiple sources including mosquitos, where the fly will attach its eggs to a mosquito with a quick-drying glue. When the mosquito feeds on a human or another organism, the eggs respond to body heat and hatch onto the skin (Robbins and Kachemoune, 2009). Infestations are also obtained from sitting in dirt where eggs have been laid, or in wearing soiled clothing on which a fly has laid eggs. The eggs are laid in the shade as direct sunlight or heat will kill them. In addition, ironing clothing will destroy the eggs (Norlund, 2009). However, this is rarely done, as most homes in countries such as Africa do not have electricity. Thus ironing must be done with hot charcoal, make it very difficult. Articles of clothing such as diapers are usually contaminated with eggs. Symptoms of myiasis include pruritis, excretion of pus from the lesion, stabbing or stinging pain, and somatic sensations of movement due to the larvae. Accompanying these symptoms is the appearance of a raised papule with a central cavity, usually 1-3 cm in diameter. Inside this cavity, small black spiracles of the larvae can be seen excreting a black liquid containing faeces (Robbins and Kachemoune, 2009). Around the papule or papules, the skin is inflamed from the presence of the foreign larvae. Myiasis is often confused with other skin diseases such as pyoderma, bacterial infections that result in abscesses, and various infestations of parasitic worms such as nematodes (Norlund, 2009). This is due to the similarity in appearance of the burrowed larvae to any other disease that causes abscesses. At this point, the infestation is usually treated with antibiotics, but larvae will show no response to such treatment. In order to avoid incorrect diagnoses, a check of the patient's travel history and an ultrasound of the infected area can provide confirmation of a myiasitic infestation (Norlund, 2009). Treatment is fairly simple in most cases. Unless the larvae have progressed beyond the outer layer of flesh, stopping the flow of oxygen to the parasite will cause it to emerge from its burrow, at which point it can be removed easily with forceps (Patel and Sethi, 2009). This can be accomplished with numerous techniques such as the application of Vaseline or a similar barrier to seal the pore through which the larvae obtain oxygen. Home remedies such as gum, wax, and glue will suffice, as well as similar procedures to removing a tick by use of a wet

cloth being held over the site of infestation. However, some species of myiasitic larvae are not as easily removed because they burrow deeper into the flesh (Hatten, et. all, 2010). In such cases, a small incision or removal with a needle may be necessary to excise the larvae. In addition to the aforementioned treatments, dermatologists utilize a number of solutions that are toxic to the larvae. These include lindane solutions, benzyl benzoate, and permethrin, all of which are topical insecticides applied to the site which will target and kill the parasites (Norlund, 2009). In the United States, doctors utilize a pair of oral medications, Albendazole and Ivermectin, both of which are non-toxic to humans and are processed by the liver. Albendazole is a glucose blocker that prevents the worm from absorbing glucose, as well as inhibit the production of microtubules in the worm's cells, cause them to lyse, killing the worm. Ivermectin, in contrast, works through the human secretion of sebum through the skin, bringing it in contact with the parasite. The chemical causes paralysis in the worm, eventually killing it. Ivermectin usually will kill the larvae a 48 hour period, leaving no trace of infestation (Costa, et. all, 2005). Albendazole alone has been shown to have a 97% cure rate, and Ivermectin is also a common follow up treatment after occlusion or surgical removal (Norlund, 2009). In modern medicine, myiasis is utilized in a procedure known commonly as maggot therapy. Since the 1930's maggots have been used in wounds to clear away necrotic tissue from large wounds that could not heal on their own. The maggots also reduce risk of bacterial infection by ingesting bacteria and infectious microbes within the wound. However, these two functions do not alone comprise a maggots entire potential in healing a wound. Maggots secrete compounds that are beneficial to the genesis of new endothelial cells by stimulating angiogenesis in otherwise non-responsive injuries (Bexfield, et. all, 2009). Finally, waste that maggots excrete consists of ammonia and allatonin, both of which promote cell proliferation and contribute to wound healing (Bexfield, et. all, 2009) Maggot therapy is applied by containing the larvae to the wound with a woven synthetic net, which confines the larvae to the wound while allowing them to seek out and consume necrotic tissue (Francesca, 2010). This manner of application is normally used on smaller or more shallow wounds. On larger or deeper wounds, maggots are applied directly to the wound but contained with netting formed into a boot or tube. Maggots are left in place for up

to three days, and biofoam dressing is changed every five days. However, some wounds may be completely cleaned with only one application of maggots. Maggot therapy has a number of benefits in contrast to normal debridement of a nonhealing wound. First among them is cost. According to one nurse who has worked with maggot therapy since 2007, hydrogel debridement (the other form of non-surgical debridement) can cost nearly twenty times that of maggot therapy (Francesca, 2010). In addition, maggot therapy achieves debridement much faster than other forms. In a clinical setting, maggot therapy took as little as 5 days to completely rid the wound of necrotic tissue, while the alternative took an average of 89 days to clear away the dead tissue (Francesca, 2010). Despite all these benefits, the one thing that prevents wide use of maggot therapy is its unconventional status. Patient and care-giver squeamishness toward the use of maggots is not unfounded, as maggots are usually associated with rotting flesh and dead animals, as well as the unpleasant nature of uncontrolled myiasitic infestations, however, if this attitude can be breached, maggot therapy may see a much wider use. To summarize, myiasis all comes down to location. When it is unregulated and ends up in an undesirable area, it can yield very unpleasant results. However, through careful control and restriction, myiasis is a useful tool that can help people suffering from non-healing or chronic wounds to recover quickly, saving money, time, and resources. Even myiasis has seen limited use in recent years, its benefits will likely bring it back to the level of use it once had for centuries.

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