Nasal myiasis in a Spanish intensive care unit

Ruiz-García, Carmen; Mateos-Serrano, Blanca; García-Vaz, Claudia; González Menéndez, María

doi:10.1016/j.otoeng.2021.09.003

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(A) Black arrow: larva found in the sphenoethmoidal recess. (B) Magnified view of the larva." ] ] ] "textoCompleto" => "Case reportA 78-year-old patient was admitted to the coronary intensive care unit of a tertiary referral center in Madrid, Spain, with acute pulmonary edema and severe biventricular dysfunction. As medical history, the patient suffered from type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, dyslipidemia and depression.Twenty-four hours after admission the patient presented with ventricular fibrillation and required cardiac resuscitation; two days later a percutaneous coronary intervention (PCI) was performed and triple vessel disease was diagnosed and treated.Three days after the intervention, the Otolaryngology service was consulted because, while taking routine care of the patient, nurses found larvae emerging from his right nostril (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A)<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Immediate management was conservative. More than 50 maggots were extracted from the right nasal cavity with an aspiration probe. Afterwards, an initial dose of 6mg oral ivermectin, followed by 12mg every 48h, were administered. The Microbiology Department identified Wohlfahrtia magnifica as the causative fly.A Computed Tomography scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) was taken the following day, where signs of moderate occupation of right ethmoidal cells and bony remodeling of the sphenoidal sinus were noticed. There were no signs of tissue destruction.Two days later we performed a nasal endoscopy where several biopsies and microbiological samples were taken, with subsequent identification of S. epidermidis, C. krusei and Cutibacterium acnes. The appearance of the mucosa was that of non-specific inflammation, and neither septal perforation nor palatal perforation were observed. Moreover, there was no purulent discharge. Only some larvae were found in the right sphenoethmoidal recess and they could be removed completely (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). After cleaning it up, the nasal cavity was filled with Vaseline and saline rinses were prescribed.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The above treatment was successful, as no more larvae were detected in the days that followed. Unfortunately, our patient was severely ill and deceased nine days after our intervention from cardiac arrest.DiscussionHuman myiasis, which describes the infestation of tissue by fly larvae, is uncommon in Europe. There are several families of dipterous flies; however, human and animal myiasis are caused mostly by three families: Oestridae (botflies), Calliphoridae (screw worms and blowflies) and Sarcophagidae (carrion-feeding flies). Wohlfahrtia magnifica belongs to the latter family.<a class="elsevierStyleCrossRef" href="#bib0050">1</a>Nasal myiasis has seldom been reported, and even less frequently in developed countries. Symptoms include facial pain, epistaxis, purulent discharge, facial edema, fever, headache and shedding of worms while sneezing.<a class="elsevierStyleCrossRefs" href="#bib0055">2,3</a> There are only two published cases caused by other species of Sarcophaga.<a class="elsevierStyleCrossRef" href="#bib0065">4</a> To our knowledge, this is the first case of nasal myiasis identified in peninsular Spain, as well as the first reported case of nasal myiasis caused by Wholfahrtia magnifica in a human.<a class="elsevierStyleCrossRefs" href="#bib0070">5,6</a>The most common predisposing factor for nasal myiasis has been atrophic rhinitis.<a class="elsevierStyleCrossRef" href="#bib0080">7</a> However, a recent study postulates diabetes mellitus as the predominant comorbidity.<a class="elsevierStyleCrossRef" href="#bib0060">3</a> In our case, poorly controlled diabetes mellitus might have contributed to the susceptibility to this infestation, in addition to a suspected lack of personal hygiene. As larvae were fully mature, and this process can take more than a week,<a class="elsevierStyleCrossRef" href="#bib0085">8</a> we could not find out whether the infestation took place before or after admission to the hospital. No other cases in the same intensive care unit were reported previously or afterwards.Conventional management of nasal myiasis includes removal of all the larvae. We believe endoscopy should always be a part of the process, as it permits thorough evaluation of hidden or less accessible areas.<a class="elsevierStyleCrossRef" href="#bib0090">9</a> In our case, we could clean the nasal cavity completely, being able to remove those larvae found in the sphenoethmoidal recess.More recently, evidence regarding the efficacy of oral ivermectin, a drug used to treat infestations caused by nematodes and arthropods, has been published.<a class="elsevierStyleCrossRef" href="#bib0060">3</a> Results show that it is effective in terms of early maggot shedding, objective recovery of the mucosa, decreased morbidity and costs. It can be used via nasogastric tube, being then very useful to treat unconscious patients in intensive care units.Some authors recommend antibiotics as prophylaxis against possible bacterial superinfections accompanying myiasis. However, in cases of early detection of the parasite infestation with no tissue damage, there is no consensus on the need of prophylaxis. Our patient was already receiving antibiotics (linezolid plus metronidazole) for a suspected pulmonary infection. Therefore, contribution of this previous treatment to the final outcome of the infestation is unknown.Occlusive coatings of several substances are used for furuncular myiasis, in order to smother larvae respiratory spiracles, that being our purpose when filling the nasal cavity with Vaseline.<a class="elsevierStyleCrossRef" href="#bib0050">1</a> Other methods like blocking of cavities with adipose tissue or instillation of chloroform and turpentine oil mixture have also been described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0055">2,7</a>ConclusionThis report adds some valuable information related to the management of nasal myiasis in resource-rich settings. Endoscopic assisted extraction, administration of oral ivermectin through nasogastric tube and saline solution irrigations proved to be highly effective in this case.FundingWe received no funding for this work.Conflicts of interestThe authors have no funding, financial relationships, or conflicts of interest to disclose." 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Rajabi Vardanjani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Vet Res Forum" "fecha" => "2014" "volumen" => "5" "paginaInicial" => "329" "paginaFinal" => "332" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25610587" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endoscopy in nasal myiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N.K. Soni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/004947550003000416" "Revista" => array:6 [ "tituloSerie" => "Trop Doct" "fecha" => "2000" "volumen" => "30" "paginaInicial" => "225" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11075658" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack651731" "titulo" => "Acknowledgment" "texto" => "We thank Professor Javier Gavilán, MD, for his writing assistance." 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ISSN: 2173-5735

Acta Otorrinolaringológica Española, the official publication of the Spanish Society of Otolaryngology and Head and Neck Surgery and the Ibero-American Society of Otorhinolaryngology, is the most important journal in Spanish dedicated to Otorhinolaryngology, which reflects the continuous scientific and technical progress of the specialty. It has become an important tool to be kept up to date. The Journal publishes Original Articles (articles on basic research and clinical investigation), reviews, brief communications, case studies and images, which are subjected to a rigorous peer review process.

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Acta Otorrinolaringológica Española has received its first journal Impact Factor (JCR) in 2023. Instructions for authors - Submit an article

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

0.9

Citescore

CiteScore measures average citations received per document published.

Citescore 2023

1.4

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.326

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.54

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Journal Information

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Vol. 73. Issue 6.