Case study
Nasal myiasis in a Spanish intensive care unit
Miasis nasal en una Unidad de Cuidados Intensivos española
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(A) Black arrow: larva found in the sphenoethmoidal recess. (B) Magnified view of the larva.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 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.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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)</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Immediate management was conservative. More than 50 maggots were extracted from the right nasal cavity with an aspiration probe. Afterwards, an initial dose of 6<span class="elsevierStyleHsp" style=""></span>mg oral ivermectin, followed by 12<span class="elsevierStyleHsp" style=""></span>mg every 48<span class="elsevierStyleHsp" style=""></span>h, were administered. The Microbiology Department identified <span class="elsevierStyleItalic">Wohlfahrtia magnifica</span> as the causative fly.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two days later we performed a nasal endoscopy where several biopsies and microbiological samples were taken, with subsequent identification of <span class="elsevierStyleItalic">S. epidermidis</span>, <span class="elsevierStyleItalic">C. krusei</span> and <span class="elsevierStyleItalic">Cutibacterium acnes</span>. 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.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">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.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Human 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). <span class="elsevierStyleItalic">Wohlfahrtia magnifica</span> belongs to the latter family.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">2,3</span></a> There are only two published cases caused by other species of <span class="elsevierStyleItalic">Sarcophaga</span>.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></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 <span class="elsevierStyleItalic">Wholfahrtia magnifica</span> in a human.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The most common predisposing factor for nasal myiasis has been atrophic rhinitis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> However, a recent study postulates diabetes mellitus as the predominant comorbidity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></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"><span class="elsevierStyleSup">8</span></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.</p><p id="par0055" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">9</span></a> In our case, we could clean the nasal cavity completely, being able to remove those larvae found in the sphenoethmoidal recess.</p><p id="par0060" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3</span></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.</p><p id="par0065" class="elsevierStylePara elsevierViewall">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.</p><p id="par0070" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2,7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This 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.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">We received no funding for this work.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no funding, financial relationships, or conflicts of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 5 => array:2 [ "identificador" => "xack651731" "titulo" => "Acknowledgment" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-03" "fechaAceptado" => "2021-09-08" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 571 "Ancho" => 1255 "Tamanyo" => 100165 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Larvae emerging from the patient's right nostril (frontal view). (B) Computed Tomography scan without contrast, coronal plane. Occupation of right ethmoidal cells.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 607 "Ancho" => 1255 "Tamanyo" => 75896 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Endoscopic view of the right nasal cavity. (A) Black arrow: larva found in the sphenoethmoidal recess. (B) Magnified view of the larva.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myiasis and tungiasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.H. 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