Jebmh.com Case Report Facial Myiasis- Challenge of a Despairing Case Inderjit Kaur1, Mandeep Kaur2, Jagdeepak Singh3, Anureet Gill4, Oshin Thomas5 1 Professor, Department of Ophthalmology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab. Assistant Professor, Department of Ophthalmology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab. 3Professor, Department of ENT, Government Medical College, Amritsar, Punjab. 4Junior Resident, Department of Ophthalmology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab. 5Junior Resident, Department of ENT, Government Medical College, Amritsar, Punjab 2 PRESENTATION OF CASE A 61-year-old homeless man was brought to Ophthalmology OPD, sadly after having been refused admission at various healthcare facilities due to gravity of his diseased condition. Upon arrival, his face was completely disfigured, and he complained of itching, crawling sensation on the face and foul-smelling discharge since 4 weeks. His other major concern was bilateral diminution of vision (LE > RE) since 3 weeks back. That was gradual in onset and progressive in nature. Patient himself was not in a condition to communicate much due to marked involvement of face. People who brought him to the hospital mentioned that he was picked from roadside, after being spotted in very unhygienic surroundings, adjoining a garbage dumping ground. Past medical and surgical history was insignificant and moreover limited. Examination revealed enormous facial swelling and defacement. Particularly left side of the face showed nodules, ulcers, necrotic tissue, extensive swelling, blood stained discharge and was teeming with maggots. No detail of left eye could be appreciated, just maggots and necrotic tissue was seen. Left orbital region seemed to be composed of a mass of flesh with many white larvae in it. Right eye, though less severely affected, still revealed presence of maggots, lid oedema and hazy cornea. Visual acuity was difficult to ascertain in such condition (Figure 1). Corresponding Author: Dr. Mandeep Kaur, Department of Ophthalmology, Sri Guru Ram Das University of Health Sciences, Amritsar, Punjab. E-mail: sidhumandeep_73@hotmail.com DOI: 10.18410/jebmh/2019/589 Financial or Other Competing Interests: None. How to Cite This Article: Kaur I, Kaur M, Singh J, et al. Facial myiasis- challenge of a despairing case. J. Evid. Based Med. Healthc. 2019; 6(43), 2836-2838. DOI: 10.18410/jebmh/2019/589 Submission 03-10-2019, Peer Review 05-10-2019, Acceptance 17-10-2019, Published 28-10-2019. Figure 1. At the Time of Presentation (14th September 2018) D I F F E RE N T I A L D I A G N O S I S Cutaneous Larva Migrans, Insect Bite Reaction, Cutaneous Leishmaniasis, Fungal Infection, Cellulitis, Elephantiasis, Lymphadenopathy, Furunculosis. J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 43/Oct. 28, 2019 Page 2836 Jebmh.com Case Report CLINICAL DIAGNOSIS DISCUSSION OF MANAGEMENT Facial Myiasis (Encompassing Ophthalmomyiasis, Nasal Myiasis and Oral Myiasis). Given the serious condition of the patient, treatment was commenced immediately and intensively. Aim was to relieve the patient of symptoms as well as to remove all maggots as far as possible to avoid complications caused by their spread, like intracranial extension, which can prove fatal. Injection tetanus toxoid was administered, along with tablet Ivermectin 10 mg stat. Maggots were immobilized with turpentine oil before mechanically debriding the wounds. Maggots were removed under local anaesthesia, from ocular, nasal, maxillary sinus and oral cavity over the next 8 days. During this period patient was on oral antibiotics, analgesics and antihistaminics. Particular attention was paid to meticulous dressing of involved regions twice daily, after debridement and local application of antibiotic ointment, that led to granulation tissue formation and gradual healing. A month later facial anatomy could be better appreciated, but eyelids were still oedematous and eyelashes were absent in left eye. Left eye conjunctiva was congested, and cornea was hazy in both eyes. Visual acuity could now be checked that revealed presence of perception to light. Oral and local treatment was continued as before. Keeping the most common predisposing factor in mind, special care was taken post-treatment to maintain adequate sanitation. Ophthalmomyiasis is an uncommon ocular disease (5-14% of human myiasis cases)9,10 and meticulous manual removal of larvae is the cornerstone of therapy to prevent tissue damage and eyeball destruction.11 This case was definitely challenging to deal with, given the wide extent of involvement of orbit, nose and mouth, due to which the patient was refused admission by other hospitals, but was admitted and treated in collaboration with (Government Medical College, Amritsar), along with full assistance from All India Charitable Society (Pingalwara, Amritsar). Final outcome was quite gratifying as patient recovered to a degree that was unexpected given the extent of involvement, hence emphasizing the importance of combating the disease full throttle no matter how far it has progressed (Figure 4). PATHOLOGICAL DISCUSSION Affliction of ocular structures with larvae of dipterous flies is ophthalmomyiasis.1 Ocular myiasis maybe in the form of ophthalmomyiasis externa, ophthalmomyiasis interna or orbital myiasis, depending upon the structures involved.2 Our patient had ophthalmomyiasis externa and interna, with involvement of eyelids, conjunctiva, cornea and anterior segment in which fly larva were seen. (Figure 2) 52 larvae were removed in total during the course of hospital stay, out of which few were sent for microbiological examination that revealed the typical structure of mouth hooks and cuticular spines around the body of larvae. Figure 2. After 1 Month (10th October 2018) Our patient’s disease course was complicated by nasal and aural myiasis as well. Extensive infestation of nose and oral cavity had led to difficulty in breathing and decreased oral intake (Figure 3). It is well known in literature that oral myiasis is associated with poor oral hygiene,3,4 senility,5 severe halitosis6 and mental debility.7 Poor hygiene, being the most important risk factor, is common to almost all cases.8 Our patient had all these risk factors that predisposed him to the infestation. Mouth examination revealed swollen lips, decaying teeth and highly edematous gingiva. He had blood-stained nasal discharge with foul smell emitting from nose, and worms were clearly seen inside the nasal cavity. Laboratory work-up revealed Total Leucocyte Count of 13,200 and eosinophilia. Hb of 8.4 was attributed to his malnourished state. CT scan of face revealed round hypolucent images in left maxillary sinus implying invasion by the larvae, causing sinusitis. Mucosal oedema and ulcers were found on rhinoscopic examination. Figure 4. After 8 Months (Approx.) (24th May 2019) FINAL DIAGNOSIS Figure 3. After 2 Months (Approx.) (5th November 2018) Ocular, Nasal and Aural Myiasis J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 43/Oct. 28, 2019 Page 2837 Jebmh.com Case Report RE F E R E N C E S [1] Nene AS, Mishra A, Dhand P. Ocular myiasis caused by chrysomya bezziana - a case report. Clin Ophthalmol 2015;9:423-427. [2] Francesconi F, Lupi O. Myiasis. Clinical Microbiology Reviews 2012;25(1):79-105. [3] Bozzo L, Lima IA, de Almeida OP, et al. Oral myiasis caused by sarcophagidae in an extraction wound. Oral Surg Oral Med Oral Pathol 1992;74(6):733-735. [4] Lata J, Kapila BK, Aggarwal P. Oral myiasis. A case report. Int J Oral Maxillofac Surg 1996;25(6):455-456. [5] Gealh WC, Ferreira GM, Farah GJ, et al. Treatment of oral myiasis caused by Cochliomyia hominivorax: two cases treated with ivermectin. Br J Oral Maxillofac Surg 2009;47(1):23-26. [6] de Souza Barbosa T, Salvitti Sá Rocha RA, Guirado CG, et al. Oral infection by Diptera larvae in children: a case report. Int J Dermatol 2008;47(7):696-699. [7] Rossi-Schneider T, Cherubini K, Yurgel LS, et al. Oral myiasis: a case report. J Oral Sci 2007;49(1):85-88. [8] Droma EB, Wilamowski A, Schnur H, et al. Oral myiasis: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(1):92-96. [9] Baliga MJ, Davis P, Rai P, et al. Orbital myiasis: a case report. Int J Oral Maxillofac Surg 2001;30(1):83-84. [10] Jain A, Desai RU, Ehrlich J. Fulminant orbital myiasis in the developed world. Br J Ophthalmol 2007;91(11):1565-1566. [11] Santosh KY, Surakasha S, Ajit KS. Extensive myiasis infestation over a malignant lesion in maxillofacial region. Int J pharmaceutical and biological archives. 2012;3(3):530-533. J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 43/Oct. 28, 2019 Page 2838