Asian Journal of Research in Dermatological Science 3(1): 25-29, 2020; Article no.AJRDES.57549 A Case of Cutaneous Myiasis Due to Cordylobia anthropophaga in Infant in Makkah, Saudi Arabia Amal M. Almatary1,2 and Raafat A. Hassanein3,4* 1Parasitology Unit, Maternity and Children Hospital, Makkah, Saudi Arabia. 2Department of Parasitology, Faculty of Medicine, Assiut University, Assiut, Egypt. 3Department of Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University, Saudi Arabia. 4Department of Zoonoses, Faculty of Veterinary Medicine, Assiut University, Assiut, Egypt. Authors’ contributions This work was carried out in collaboration between both authors. Author AMA designed the study, wrote the protocol and wrote the first draft of the manuscript. Author RAH managed the analyses of the study and managed the literature searches. Both authors read and approved the final manuscript. Article Information Editor(s): (1) Dr. Peela Jagannadha Rao, Quest International University Perak, Malaysia. Reviewers: (1) Sujith M, Kerala University of Health Sciences, India. (2) C. Soundararajan, Tamil Nadu Veterinary Animal Sciences University, Madras Veterinary College, India. Complete Peer review History: http://www.sdiarticle4.com/review-history/57549 Received 26 March 2020 Case Report Accepted 04 June 2020 Published 17 June 2020 ABSTRACT Myiasis caused by Cordylobia anthropophaga is rare in the Saudi Arabia, however, scarce morphological information exists regarding this dipteran. A female Saudi infant, one-month-old with tender erythematous nodules with small central ulceration in the arm and abdominal wall. During investigation, 2 larvae came out from the lesion. Cordylobia anthropophaga was identified by paired spade-like mouth hooks and 2 posterior spiracles, which lack a distinct chitinous rim. Skin lesions were markedly improved and the patient is fully recovered after the remove of larvae and 2- week antibiotic treatment. Although rarely described in Saudi Arabia until now, cutaneous myiasis should be expected in people living in poor hygienic conditions. Keywords: Cutaneous myiasis; Cordylobia anthropophaga; infant; Makkah; Saudia Arabia. _____________________________________________________________________________________________________ *Corresponding author: E-mail: [email protected]; Almatary and Hassanein; AJRDES, 3(1): 25-29, 2020; Article no.AJRDES.57549 1. INTRODUCTION larva visualized inside the swelling with white and bloody discharge (Fig. 1). Myiasis is the invasion of tissues and organs both in humans and animals by dipterous larvae. The case subjected to thorough clinical Those larvae feed on the host tissues, body examination of suspected lesions to record site fluids, or ingested food as parasites in the skin, and shape of the lesions. In addition, the case subcutaneous tissues, mouth, stomach, eyes, was subjected to complete history taking that nose, ears, intestines, urinogenital system, and included medical history, past lesions or trauma other soft tissues of humans and warm-blooded as well as travel history. Blood samples were vertebrate animals [1]. Relevant cases were collected from suspected cases for complete mainly reported in Europe, Asia and Africa at blood count. present. The cutaneous myiasis is the most frequent and impressive form, and it can be divided into 3 types by clinical features and type of larvae: furuncular, creeping (migratory), and wound (traumatic) myiasis [2]. Furuncular myiasis is defined as the penetration of the larvae inside the healthy skin and Fig. 1. Larva (maggot) of C. anthropophaga development of a boil-like nodule. It is more extracted from the infant arm common in tropical countries and can be caused by Dermatobia hominis, C. anthropophaga, A third instar larva 6×4 mm in sizewas removed Cuterebra sp., and Wohlfahrtia vigil [3,4,5,6,7,8]. from two of the lesions and identified in the parasitology unit, Maternity and Children Hospital In the Saudi Arabia, myiasis is caused by (Fig.2). The larvae were first washed in distilled different genera of dipterans, such as Cordylobia, water and then cleared in 10% sodium hydroxide Wohlfahrtia, Sarcophaga, Chrysomya, Cuterebra (NAOH) solution for 1 h. The larvae were washed and Oestrus. Larvae of these dipterans can again in distilled water, transferred to 10% acetic cause a broad range of symptoms depending on acid for 30 min and washed again in distilled the infestation site and the relationship between water. The specimens were then dehydrated in the larvae and the host [9,10,11,12,13,14]. ascending series of ethanol (30%, 50%, 70% and In humans, myiasis is seen more frequently in 90%) for 30 min each. The larvae were then rural regions where people are in close contact soaked in absolute alcohol for at least 1 h and with pets. Infestation with fly larvae may occur then transferred into Xylene for one hour. At this stage, all the internal organs of the maggot were when flies deposit eggs or first stage larvae on the human body or body apertures. The portion removed and the posterior spiracles were cut of the body affected varies with the habits and transversely, also the anterior end cut preferences of the fly species and may also transversely and the medium portion depend on other factors [10]. longitudinally, then specimens were mounted onto a glass slide using DPX and left to dry to the In the current study, we present the case of next day. The slides were examined under a light cutaneous myiasis in an infant inMakkah, KSA. microscope for taxonomy studies and The larva was removed from a boil-like lesion of identification [15]. infant arm and abdominal wall, identified as Cordylobia anthropophaga. 2. CASE REPORT A one-month-old Saudi female infant presented to the emergency department in Maternity and children hospital, Makkah, Saudi Arabia. She came with her mother to seek medical advice for red swelling in the right upper arm and right flank Fig. 2. Barrel-shaped larvae of C. in the abdominal wall with mild fever for 5 days. anthropophagawas6 mm in length, and 4 mm The swelling diameter is approximately 1 cm. in width 26 Almatary and Hassanein; AJRDES, 3(1): 25-29, 2020; Article no.AJRDES.57549 The larvae body was almost completely covered 3. DISCUSSION by conic small black, scattered spines with a brown apex, pointing towards the posterior end The definitive study on the Tumbu fly (C. (Fig. 3.). Two copper-colored posterior spiracles, anthropophaga) was carried out in Sierra Leone each bearing 3 sinuous spiracular slits which lack in 1923 [3]. C. anthropophaga, is an agent of a distinct chitinous rim (Fig. 4.). In the anterior obligatory cutaneous (furuncular) myiasis, widely end of larva, the mouth with a pair of spade-like distributed in the sub-Saharan region [1], In stout hooks with curved and sharp tips without Africa, furuncular myiasis is caused by 3 species cluster of conic denticles and anterior spiracles of the genus Cordylobia: C. anthropophaga were characteristically observed (Fig. 5). These (endemic throughout Africa), C. rodhaini (parts of morphological characteristics were consistent Africa with rainforests), and C. ruandae (Zaire withthose described for C. anthropophaga [16]. border and Rwanda), whereas rare cases has been reported in Asia, Saudi Arabia [11,14,17. 18] while D. hominis is common in Central and South America [19]. Among Cordylobiaspp., C. anthropophaga is the dominant causative agent compared with the other species [20]. The larvae can penetrate the unbroken skin of the host, who is usually lying on the ground or by the contaminated clothes. Interestingly, the host usually feels no symptoms at the time of skin penetration by larvae. Therefore, most patients do not think maggots as a cause of their skin Fig. 3. Conic spines on the body of C. problems. Within 1 to 2 weeks, the larvae anthropophaga with a brown apex, pointing develop into the second and third instars, and towards the posterior end (magnification 10X) mature larvae can emerge from the central pore of the skin lesions [21]. Early lesions may resemble other reactions due to insect bite, but furuncular lesions with an intense inflammatory reaction in the surrounding tissue rapidly develop [21,22]. Identification of the species of maggots prior to treatment is important since not all types of myiasis are benign [10]. In the current report, morphological characteristics of larvae of C. Fig. 4. Two copper-colored posterior anthropophaga (ex, a pair of spade-like hooks, spiraclesofC. anthropophaga, each carrying 3 anterior spiracles, and posterior spiracles) are sinuous spiracular slits which lack a distinct well observed in Figs. 3,4 and 5. These chitinous rim(magnification 10X) morphological characteristics were consistent Skin lesions were markedly improved after the withthose described for C. anthropophaga [7,8, remove of larvae and 2-week antibiotic 11,14,16,17,18,23]. In the posterior spiracles, the treatment, and there was no recurrence. 3 spiracular openings are slightly sinuous slits in C. anthropophaga, whereas tortuously sinuous in C. rodhaini. C. anthropophaga has mouthhooks with curved and sharp tips, but there is neither cluster of conic denticles nor oral grooves. On the other hand, C. rodhaini has mouth-hooks with broad and rounded tips and cluster of conic denticles as typical feature. Therefore, sufficient knowledge and experience . for diagnosis is needed to avoid misdiagnosis, such as pyoderma, impetigo, staphylococcal Fig. 5. Anterior end of C. anthropophaga furunculosis and cutaneous leishmaniasis [4]. showing paired spade-like mouth hooks protruded ventrally from anterior 2 black The infestation for our case may be occurs mouth-hooks (magnification 10X) through a fly itself where the infant family lived in 27 Almatary and Hassanein; AJRDES, 3(1): 25-29, 2020; Article no.AJRDES.57549 poor hygienic conditions. This case report again world. Annu Rev Entomol. 2016;61:159– highlights this disease should be expected in 176. people living in poor hygienic conditions. These 2. Robbins K, Khachemoune A. Cutaneous people should be taught hygienic practices and myiasis: A review of the common types of methods to control fly population.