IMAJ • VOL 13 • june 2011 Case Communications

Nasal due to ovis Larvae in Israel Kosta Y. Mumcuoglu PhD1 and Ron Eliashar MD2

1Department of Microbiology and Molecular Genetics, Kuvin Center for the Study of Infectious and Tropical Diseases, Institute for Medical Research Israel-Canada, Hebrew University-Hadassah Medical School, and 2Department of Otolaryngology–Head and Neck Surgery, Hadassah University Hospital, Jerusalem, Israel

beyond the first stage. People are affected 2 October 2010, a third, larger, larva was Key words: Oestrus ovis, nasal bot , mainly in areas where sheep and discharged from her nose while sneez- nasopharyngeal myiasis, Israel are raised. From a study conducted in ing, and was brought to our laboratories IMAJ 2011; 13: 379–380 22 townships in the Etnean area in Italy for examination. The larva was black in during which 112 shepherds were inter- color and had shrunk, indicating that it viewed, it was discovered that 80.3% had been dead for some time before it of them, at least once in their lives, had was expelled from the nasal cavity. It was contracted O. ovis myiasis [2]. identified as the third stage of O. ovis. yiasis is the infestation of living Victims usually have the sensation of On examination, including anterior M humans or with the lar- being struck in the eye by an or by rhinoscopy and nasal endoscopy, the vae of dipteran , which at least for a a small foreign object. A few hours later nasal cavity seemed to be normal, with certain period feed on the host’s dead or a painful inflammation develops, causing no discharge or polyps. Mild scarring was living tissues, body substances or ingested an acute catarrhal conjunctivitis. Ocular noticed in the left middle nasal meatus, foods [1]. The larvae of the sheep nasal symptoms, such as foreign body sensa- but the maxillary sinus ostium was patent bot fly, Oestrus ovis L., are well-known tion, irritation, redness and photophobia, and the surrounding mucosa was normal. parasites in the nasal cavities and frontal have been reported. As many as 50 larvae No additional maggots were found. Sinus sinuses, sometimes also in the maxillary have been removed from the conjunctival computed tomography scan showed mild sinuses of domestic sheep, goats and some sac of a single patient, although usually chronic changes in the mucosa, mostly at wild ruminants worldwide, causing the there are considerably less [1]. Larvae are the base of both maxillary sinuses; how- clinical picture known as oestrosis [1]. removed under local anesthesia using ever, the osteo-meatal complex was open The viviparous females swarm around the forceps. on both sides. heads of the animals and deposit the lar- Rarely, the larvae are also deposited vae from a distance of several centimeters into the mouth, nostrils or outer ear into the nostrils, and sometimes also into of humans, where they usually survive Comment the eye orbits, in batches of one to several only a few days without further develop- In Israel, Harvey [2] treated 30 patients dozen. The larvae then migrate into the ment. Nasal symptoms such as sneezing, with conjunctivitis due to O. ovis infes- nasal cavities and the paranasal sinuses nasal discharge and epistaxis have been tation in the Jerusalem area during the where they develop. reported [1]. period 1981–1982. The conjunctivitis In animals, the infestation frequently varied from mild to severe pseudo-orbital induces clinical signs of rhinitis and sinus- cellulites. Features of the conjunctivitis itis that are sometimes severe. Infested Patient Description included pale edema, linear superficial animals excrete a purulent discharge A 33 year old woman living in El’ad, a punctate keratopathy and the presence from the nostrils, shake their heads, grate small city about 25 km east of Tel Aviv in of larvae in the conjunctival sac. Garzozi their teeth, sneeze, have difficulty breath- the middle of a rural area, had suffered for et al. [3] also reported a case of external ing, and rub their noses on the ground years from sinusitis and asthma for which ophthalmomyiasis caused by O. ovis in or against their forelegs. In rare cases, she was treated with antibiotics and pred- the Afula area (in the Lower Galilee). especially in lambs, the larvae reach the nisone. Recently she was not permitted to Infestation of humans with the larvae cranial sinuses and lungs causing death. take part in nature trips and had not left of O. ovis, which remained in the nasopha- Larvae in the 's orbit may cause the country for the last 2 years. On 20 ryngeal cavities until they reached the mild conjunctivitis [1]. May 2010, she observed two small living third larval stage, has been rarely reported O. ovis may attack humans as well, larvae that were expelled from her nose [4]. In Israel, Yeruham and co-workers [5] usually causing ocular myiasis (ophthal- while sneezing. The larvae were sent to reported the case of an 82 year old man momyiasis), but the larvae never develop a neighboring hospital but were lost. On who presented with a white mass that

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appeared in his mouth after sneezing or nasal myiasis, especially if he or she has References coughing. A CT scan of the nasal sinuses visited areas with sheep and hus- 1. Zumpt F. Myiasis in Man and Animals in the Old and eyes was normal and an examination bandry. World. London: Butterworths, 1965: 175-9. by an ear, nose and throat consultant was 2. Harvey JT. Sheep : ophthalmomyiasis externa. Can J Ophthalmol 1986; 21: 92-5. unremarkable. After having produced a Corresponding author: 3. Garzozi H, Lang Y, Barkay S. External ophthal- total of six larvae there were no further Dr. K.Y. Mumcuoglu Dept. of Microbiology and Molecular Genetics, momyiasis caused by Oestrus ovis. IMAJ Isr J episodes. The collected larvae were identi- Kuvin Center for the Study of Infectious and Tropical Med Sci 1989; 25: 162-3. fied as the third larval stage of O. ovis. Diseases, Hebrew University-Hadassah Medical 4. Delhaes L, Bourel B, Pinatel F, et al. Human nasal In conclusion, although occurring very School, P.O. Box 12272, Jerusalem 91120, Israel myiasis due to Oestrus ovis. Parasite 2001; 8: 289-96. (972-2) 675-8093 Phone: 5. Yeruham I, Malnick S, Bass D, Rosen S. An rarely, any patient with nasal complaints Fax: (972-2) 675-7425 apparently pharyngeal myiasis in a patient email: [email protected] and feeling a moving foreign body in the caused by Oestrus ovis (Oestridae: Diptera). Acta nasosinus must be examined to exclude Trop 1997; 68: 361-3.

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B cells promote insulin resistance through modulation of T cells and production of pathogenic IgG antibodies Chronic inflammation characterized by T cell and macrophage immunoglobulin G (IgG) antibodies. Treatment with a B cell- infiltration of visceral adipose tissue (VAT) is a hallmark of depleting CD20 antibody attenuates disease, whereas transfer of obesity-associated insulin resistance and glucose intolerance. IgG from DIO mice rapidly induces insulin resistance and glucose Weiner and colleagues show a fundamental pathogenic role for intolerance. Moreover, insulin resistance in obese humans B cells in the development of these metabolic abnormalities. is associated with a unique profile of IgG autoantibodies. B cells accumulate in VAT in diet-induced obese (DIO) mice, These results establish the importance of B cells and adaptive and DIO mice lacking B cells are protected from disease immunity in insulin resistance and suggest new diagnostic and despite weight gain. B cell effects on glucose metabolism are therapeutic modalities for managing the disease. mechanistically linked to the activation of pro-inflammatory Nature Med 2011; 17: 610 macrophages and T cells and to the production of pathogenic Eitan Israeli

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De novo cardiomyocytes from within the activated adult heart after injury A significant bottleneck in cardiovascular regenerative shown to restore vascular potential to adult epicardium- medicine is the identification of a viable source of stem/ derived progenitor cells with injury. Cumulative evidence progenitor cells that could contribute new muscle after indicates an epicardial origin of the progenitor population, ischemic heart disease and acute myocardial infarction. A and embryonic reprogramming results in the mobilization of therapeutic ideal – relative to cell transplantation – would be this population and concomitant differentiation to give rise to stimulate a resident source, thus avoiding the caveats of to de novo cardiomyocytes. Cell transplantation confirmed limited graft survival, restricted homing to the site of injury a progenitor source, and chromosome painting of labeled and host immune rejection. Smart et al. demonstrate in mice donor cells revealed transdifferentiation to a myocyte fate that the adult heart contains a resident stem or progenitor in the absence of cell fusion. Derived cardiomyocytes are cell population, which has the potential to contribute shown to structurally and functionally integrate with resident bona fide terminally differentiated cardiomyocytes after muscle; as such, stimulation of this adult progenitor pool myocardial infarction. The authors reveal a novel genetic represents a significant step towards resident cell-based label of the activated adult progenitors via re-expression therapy in human ischemic heart disease. of a key embryonic epicardial gene, Wilm’s tumor 1 (Wt1), Nature 2011; doi:10.1038/nature10188 through priming by thymosin β4, a peptide previously Eitan Israeli

“I choose a block of marble and chop off everything I don't need” Auguste Rodin (1840-1917), French sculptor, considered the progenitor of modern sculpture. His most famous works are The Thinker, The Kiss, and The Gates of Hell

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