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Furuncular Myiasis in 2 American Travelers Returning from Senegal Furuncular Myiasis in 2 American Travelers Returning From Senegal Lauren Rimoin, MD; Julie Jackson, MD; Aparche Yang, MD; Carolyn Goh, MD; Teresa Soriano, MD Practice Points Cutaneous myiasis is caused by an infestation of fly larvae and can present as furuncles (furuncular myiasis), migratory inflammatory linear plaques (migratory myiasis), and worsening tissue destruction in existing wounds (wound myiasis). Furuncular myiasis should be included in the differential diagnosis in patients with furuncular skin lesions who have recently traveled to Central America, South America, or sub-Saharan Africa. Furuncular myiasis may be treated by both occlusive and extraction techniques. copy Furuncular myiasis caused by Cordylobia care physician and a local dermatologist, the patient anthropophaga larvae is commonly seen in Africa began taking oral cephalexin for suspected bacterial but rarely is diagnosed in travelers returning furunculosisnot with no considerable improvement. from the sub-Saharan region. We report 2 cases Over the course of 1 week, the lesions became of furuncular myiasis due to Cordylobia spe- increasingly painful and pruritic, prompting a visit to cies in adolescent American travelers returningDo the emergency department. Prior to his arrival, the from Senegal. patient reported squeezing a live worm from one of Cutis. 2014;94:281-284. the lesions on the right ankle. On presentation, the patient was afebrile Case Reports (temperature, 36.7°C) and his vital signs revealed Patient 1—A 16-year-old adolescent boy presented no abnormalities. Physical examination revealed to the emergency department with painful, pru- tender erythematous nodules on the bilateral heels, ritic, erythematous nodules on the bilateral legs of ankles, and shins with pinpoint puncta noted at the 1 week’s duration. The lesionsCUTIS had developed 1 week center of many of the lesions (Figure 1). The nodules after returning from a monthlong trip to Senegal were warm and indurated and no pulsatile move- with a volunteer youth group. He did not recall ment was appreciated. The legs appeared to be well sustaining any painful insect bites or illnesses while perfused with intact sensation and motor function. traveling in Africa and only noticed the erythema- The patient brought in the live mobile larva that he tous papules on the legs when he returned home to extruded from the lesion on the right ankle. Both the the United States. After consulting with his primary departments of infectious diseases and dermatology were consulted and a preliminary diagnosis of furun- cular myiasis was made. The lesions were occluded with petroleum jelly and the patient was instructed to follow-up with the dermatology department later that same day. Dr. Rimoin is from the Department of Dermatology, Emory University, On follow-up in the dermatology clinic, the tips Atlanta, Georgia. Drs. Jackson, Yang, Goh, and Soriano are from of intact larvae were appreciated at the central the Division of Dermatology, David Geffen School of Medicine, puncta of some of the lesions (Figure 2). Lidocaine University of California, Los Angeles. The authors report no conflict of interest. adrenaline tetracaine gel was applied to lesions on Correspondence: Lauren Rimoin, MD, 1525 Clifton Rd, Atlanta, the legs for 40 minutes, then lidocaine gel 1% was GA 30329 ([email protected]). injected into each lesion. On injection, immobile WWW.CUTIS.COM VOLUME 94, DECEMBER 2014 281 Copyright Cutis 2014. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Furuncular Myiasis Figure 1. Tender erythematous nodules on the bilateral Figure 3. Dead larva extracted by lidocaine injection heels, ankles, and shins. and punch biopsy. copy not Figure 2. The tips of intact larvae were appreciated Do at the central puncta of some of the lesions following occlusion with petroleum jelly. Figure 4. Deep dermal cavity containing larval frag- ments encased by a thick chitinous cuticle with spines surrounded by mixed dermal inflammation (H&E, origi- nal magnification 40). larvae were ejected from the central puncta of most of the lesions; the CUTISremaining lesions were treated via 3-mm punch biopsy as a means of extrac- tion. Each nodule contained only a single larva, all of which were dead at the time of removal (Figure 3). The wounds were left open and the patient was instructed to continue treatment with cephalexin with leg elevation and rest. Pathologic examination of deep dermal skin sections revealed larval fragments encased by a thick chitinous cuticle with spines that were consistent with furun- cular myiasis (Figures 4 and 5). Given the patient’s recent history of travel to Africa along with the morphology of the extracted specimens, the larvae were identified as Cordylobia anthropophaga, a com- mon cause of furuncular myiasis in that region. Patient 2—The next week, a 17-year-old adoles- cent girl who had been on the same trip to Senegal Figure 5. Larval intestinal components were visualized as as patient 1 presented with 2 similar erythematous well as striated muscle (H&E, original magnification 200). 282 CUTIS® WWW.CUTIS.COM Copyright Cutis 2014. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Furuncular Myiasis nodules with central crusts on the left inner thigh more often than adults because they have thinner and buttock. On noticing the lesions approximately skin and less immunity to the larvae.2 3 days prior to presentation, the patient applied There are 2 mechanisms by which infestation of topical antibiotic ointment to each nodule, which human hosts by C anthropophaga can occur. Most incited the evacuation of white tube-shaped struc- commonly, female flies lay eggs in shady areas in soil tures that were presented for examination. On pre- that is contaminated by feces or urine. The hatched sentation, the nodules were healing well. Given larvae can survive in the ground for up to 2 weeks the patient’s travel history and physical examination, and later attach to a host when prompted by heat a presumptive diagnosis of furuncular myiasis from or movement.3 Therefore, clothing set out to dry C anthropophaga also was made. may be contaminated by this soil. Alternatively, female flies can lay eggs directly onto clothing that Comment is contaminated by feces or urine and the larvae The term myiasis stems from the Greek term for subsequently hatch outside the soil with easy access fly and is used to describe the infestation of fly to human skin once the clothing is worn.2 larvae in living vertebrates.1 Myiasis has many Common penetration sites are the head, neck, classifications, the 3 most common being furuncu- and back, as well as areas covered by contaminated lar, migratory, and wound myiasis, which are differ- or infested clothing.2,3 Penetration of the human skin entiated by the different fly species found in distinct occurs instantly and is a painless process that is rarely regions of the world. Furuncular myiasis is the noticed by the human host.3 The larvae burrow into most benign form, usually affecting only a localized the skin for 8 to 12 days, resulting in a furuncle that region of the skin; migratory myiasis is characterized occasionally secretes a serous fluid.2 Within the by larvae traveling substantial distances from one first 2 days of infestation, the host may experience anatomic site to another within the lower layers of symptoms rangingcopy from local pruritus to severe pain. the epidermis; and wound myiasis involves rapid Six days following initial onset, an intense inflam- reproduction of larvae in necrotic tissue with subse- matory response may result in local lymphadenopa- quent tissue destruction.2 thy along with fever and fatigue.2 The larvae use The clinical presentation of the lesions noted theirnot posterior spiracles to create openings in the in our patients suggested a diagnosis of furuncular skin to create air holes that allow them to breathe.3 myiasis, which commonly is caused by Dermatobia On physical examination, the spiracles generally hominis, C anthropophaga, Cuterebra species, appear as 1- to 3-mm dark linear streaks within Wohlfahrtia vigil, and Wohlfahrtia opaca larvae.Do3 furuncles, which is important in the diagnosis of Dermatobia hominis is the most common cause of C anthropophaga furuncular myiasis.1,3 If spiracles are furuncular myiasis and usually is found in Central not appreciated on initial examination, diagnosis and South America. Our patients likely developed can be made by submerging the affected areas in an infestation of C anthropophaga (also known as the water or saliva to look for air bubbles arising from the tumbu fly), a yellow-brown, 7- to 12-mm blow- central puncta of the lesions.1 fly commonly found throughout tropical Africa.3 All causes of furuncular myiasis are characterized Although C anthropophaga CUTISis historically limited to by a ratio of 1 larva to 1 furuncle.16 Although most sub-Saharan Africa, there has been a report of a case of these types of larvae that can cause furuncular acquired in Portugal.4 myiasis result in single lesions, C anthropophaga In a review of the literature, C anthropophaga infestation often produces several furuncles that myiasis was documented in Italian travelers return- may coalesce into plaques.1,2 The differential diag- ing from Senegal5-7; our cases are unique because nosis for C anthropophaga furuncular myiasis includes they represent North American travelers
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