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An Exotic Abscess Within the United Kingdom from the Gambia: a Case Report Estelle Hong How, Darren Yap and Nik Mbakada*

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An Exotic Abscess Within the United Kingdom from the Gambia: a Case Report Estelle Hong How, Darren Yap and Nik Mbakada* How et al. Journal of Medical Case Reports (2017) 11:310 DOI 10.1186/s13256-017-1472-3 CASE REPORT Open Access An exotic abscess within the United Kingdom from The Gambia: a case report Estelle Hong How, Darren Yap and Nik Mbakada* Abstract Background: Furuncular myiasis is a parasitic infection of a live mammal by fly larvae commonly seen in Africa. However, with an increase in international tourism, there is a significant rise in exotic infection in non-endemic areas which can pose a diagnostic challenge to doctors and potentially lead to delay in treatment. From the current literature, only 12 cases were reported in the UK. Case presentation: We report an unusual case of multiple abscesses in a 32-year-old white British woman presenting to our Emergency department in the UK after returning from a holiday in The Gambia, West Africa. She did not complain of systemic symptoms and was otherwise fit and healthy with no significant past medical history. During examination, two maggots were expressed from the abscesses by applying lateral pressure to each lesion. The larvae were found to be Cordylobia anthropophaga. She was discharged with antibiotics to prevent secondary infection with no further follow-up. Conclusion: With globalization, the need for increasing awareness of tropical diseases has become important to win the battle against future epidemics. Keywords: Tumbu fly, Gambia, Furuncular myiasis, Cordylobia anthropophaga Background ledge, only 12 cases of furuncular myiasis by the tumbu Furuncular myiasis is a parasitic infestation of the body fly have been reported in the UK and we present the of a live mammal by fly larvae of dipterous insects that 13th case of this unfamiliar condition [4–7] (Table 1). feed on their host’s tissue to grow and mature. This con- dition is only prevalent in tropical countries where these Case presentation flies are common; these flies normally do not thrive in A 32-year-old white woman presented to her general the United Kingdom (UK) [1, 2]. However, with practitioner (GP) with a 1-week history of two thigh globalization and the prodigious advancement in trans- lumps and another on her left flank. She first noticed portation, there is an increase in the number of reported these lumps a week after returning from her holiday in cases of furuncular myiasis in the UK [1, 3]. This exotic The Gambia. She was otherwise well with no significant infestation can in fact pose a significant diagnostic chal- past medical history. Her GP had treated her as having lenge for clinicians. In this era, where exotic infections multiple skin abscesses and started her on a course of anti- could potentially lead to catastrophic life-threatening ep- biotic therapy (amoxicillin). Two days later, she expressed idemics, it is important to take a good travel history. It two live maggots from the thigh abscesses which prompted is extremely important to have an awareness of disease hertovisitourEmergencydepartment(ED). prevalence in the areas of travel and the ability to access On initial examination she was systemically well and up-to-date information [1, 2]. To the best of our know- apyrexial. Two abscesses, each measuring approximately 2 × 2 cm were noted on her right thigh and one on her left flank. The lesions had a punctum surrounded by a ring of erythema with no obvious discharge as shown in * Correspondence: [email protected] Fig. 1. There was no evidence of tracking cellulitis or Department of Emergency medicine, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire BB2 3HH, UK © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. How et al. Journal of Medical Case Reports (2017) 11:310 Page 2 of 5 Table 1 Reported cases of furuncular myiasis within the current literature Characteristics of furuncular myiasis in returning travelers in the United Kingdom Article Study year Number Country Gender Age Number of lesions Number of Location of Symptoms of cases of origin (years) extracted maggots lesions McGarry et al.[4] 1994–2000 6 The Gambia * * * * * * 2 Nigeria * * * * * * 1 Equatorial *** * * * Guinea Lee and Robinson [5] 2006 1 Angola Male white 39 1 + (unreported 1 Face, thigh, Pain, swelling, number of lesions) buttocks erythema James and Stevenson [6] 1992 1 Nairobi Male 26 12 12 Mid-scapular Pain, itch region Whitehorn et al.[7] 2009 1 (via household Uganda Male 40 1 1 Right forearm Itch, swelling, contact) erythema *unreported UK United Kingdom lymphadenopathy. A live maggot approximately 6 mm Discussion long was expressed when pressure was applied to her What is furuncular myiasis? flank lesion as shown in Fig. 2. Cases of myiasis affecting humans have been described She was discharged home on a course of flucloxacillin in the literature as far back as 1840 [8]. Myiasis is (1 g, four times a day for 7 days) and a follow-up ap- derived from the ancient Greek word for fly: “Myia.” pointment was arranged. We contacted The Liverpool Furuncular myiasis is a cutaneous parasitic infection School of Tropical Medicine for advice and the African caused by a particular species of Diptera flies called tumbu fly was suggested to be the culprit. No formal en- Cordylobia anthropophaga, also known as the African tomology examination was carried out and microbiology tumbu fly, giving rise to “boil” (furuncular)-like le- culture samples yielded no growth after 48 hours. The sions [9, 10]. Liverpool School of Tropical Medicine recommended covering the lesions with Vaseline (petroleum jelly) and occlusive dressing to suffocate any further larvae and re- placing flucloxacillin with co-amoxiclav. Our patient was seen 2 days later and the diagnosis was explained. The wounds were healing remarkably and she was discharged with an antibiotic course of co-amoxiclav (500/125 mg tablet, three times a day for 7 days) with no further follow-up required. Fig. 1 A 2 cm in diameter abscess on the right thigh with a central punctum surrounded by an erythematous ring Fig. 2 A live maggot expressed from left flank region How et al. Journal of Medical Case Reports (2017) 11:310 Page 3 of 5 Epidemiology During this time, the papule has developed into an It is a common condition in the equatorial regions of inflamed tender and edematous abscess-like furuncle Africa. It infests mainly animals such as dogs and wild approximately 2 cm in diameter surrounded by an ery- rats which constitute an important reservoir of the infec- thematous ring. An ulcer or central punctum is formed tion to humans. In this part of the world, the disease at the top of the lesion whereby the posterior end of the spreads widely due to animal migration and rainy sea- larvae allows respiration. Sometimes, the spiracle of the sons [1, 2, 10, 11]. Myiasis in tropical Africa is predom- larvae or a rhythmical movement can be seen through inantly caused by tumbu fly larvae [10, 12]. In Africa, this central depression. On some occasions, the white there is a higher incidence in children compared to body of the larvae can also be seen projecting from the adults due to the fact that children have thinner skin lesion [1, 2, 13–16]. The larvae normally exit the host which is more easily penetrated by the larvae [1, 2]. In a through the breathing pore after approximately 8 to 15 7-year study conducted by experts at The Liverpool days to become hard pupae that become adult flies in a School of Tropical Medicine and Hygiene from 1994 to period of 3 to 4 weeks [2, 5, 10, 14]. 2000, in order to determine the epidemiology of ecto- parasitic diseases in returning travelers, where 73 speci- Clinical presentation mens were studied; 18 cases (67%) of myiasis were more In humans, the most common sites affected are the common in returning travelers in comparison to 6 cases neck, back, and trunk. Other common sites of infection are (33%) infected within the UK [4]. Furuncular myiasis lar- the scrotum in men and breast in women [1, 10, 13, 17]. val infestation by tumbu fly (n = 9, 50%) in travelers To the best of our knowledge, less than ten larvae are returning was the predominant cause of myiasis. The usually extracted in an infected patient. However, up to 64 commonest countries visited by those infected were The maggots were retrieved from a white soldier based in West Gambia (n = 6), Nigeria (n = 2), and Equatorial Guinea Africa and 94 from a child in Ghana [14, 18]. (n = 1). It was concluded by the authors that exotic in- The symptoms, which usually develop within 2 days of fection especially myiasis, predominated in returning infestation, can vary from being asymptomatic to very travelers from Africa and Latin America [4]. severe [15]. The lesions are usually tender and pruritic but ultimately benign. In general, patients do not have sys- temic symptoms such as fever or malaise [5, 13, 15–17]. A The life cycle of the tumbu fly few cases were reported where patients had fever [10, 19, Thetumbufly(Cordylobia anthropophaga), a large brown 20, 21]. This was the case when there were multiple infes- yellowish fly, is endemic in the subtropics of Africa.
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