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BMJ Case Reports 2018; doi:10.1136/bcr-2017-223535
  • Images in…

Larval infestation of chronic ischaemic leg ulcer

  1. Ahmed Subahi
  1. Internal Medicine, Wayne State University, Detroit, Michigan, USA
  1. Correspondence to Dr Walid Ibrahim, wibrahim{at}med.wayne.edu
  • Accepted 18 December 2017
  • Published 9 January 2018

Description

Several cases of obligatory wound myiasis have been reported in the medical literature.1–3 For a long time, such infestation was perceived as a complication of poor quality wound care in patients with chronic ulcers. There are only three cases of wound myiasis reported in the literature. Demirel et al reported on a 68-year-old male patient with larvae infestations of diabetic wound that were discovered during surgical debridement.3 Another two cases of traumatic larval infestation associated with Bowen carcinoma and with chronic leg ulcer were reported.3 Up to date, there is no report of chronic ulcer with massive larvae infestation as in this patient.

Figure 1 with video capture (video 1) demonstrates a massive larvae infestation of severe chronic ischaemic ulcer in a 60-year-old homeless male patient with HIV, who presented with unilateral leg pain without systemic or local signs of infection. The local examination of the ulcer site demonstrates a significant diamond-shaped ulcer 4.7 inch × 2.3 inches exposing the Achilles tendon and the surrounding granulation tissue with no evidence of local signs of infections.

Figure 1

Myiasis infestation of chronic ulcer.

Video 1

Myiasis infestation of chronic ulcer.

Management of chronic wound ulcer is usually prolonged and challenging. Therefore, different approaches have been implemented in wound management, including what is called maggot debridement therapy (MDT). MDT can improve debridement, disinfection, bacterial biofilm eradication, and ultimately wound healing.4 Consequently, therapeutic maggot debridement has been approved as a novel modality of ulcer treatment.5 Our patient’s circumstances of poor hygiene, homeless situation and severe peripheral vascular disease drastically increased his risk of repeated wound infection. However, the presence of the associated larvae infestation appears to help natural wound debridement and prevent bacterial infection.

Learning points

  • Management of chronic ulcer is challenging; multidisciplinary approaches seem to be effective in treating and preventing chronic ulcer of all types.

  • Biotherapy of ulcer with maggots is a reintroduced modality in treatment, which has been approved by the Food and Drug Administration in 2004 for that purpose.

  • Coinfection with maggots my play a significant counteractor role in preventing superadded bacterial infection.

Footnotes

  • Contributors WI: provided the discussion and the idea. LO: provided the learning points: AS: conducted the literature review, provided the pictures and prepared the video.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

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