Abstract

Myiasis disease was defined by Zumpt as a parasitic invasion of the tissues of humans by diptereous larvae. Myiasis agents, affect mainly the uncovered areas of the body. In addition to their medical importance as mechanical vectors of parasitic disease agents’ dipteran true flies can make myiasis in hospital environment called nosocomial myiasis which is rarely reported. In this paper we report the first case of anal nosocomial myiasis in a Tunisian patient caused by Musca domestica.

Keywords: Nosocomial; Myiasis; Musca domestica; Tunisia.

Citation: Bousbia C, Mtibaa L, Rebai A, Baccouchi N, Boughariou S, et al. A case report of nosocomial myiasis caused by Musca domestica and literature review. Open J Clin Med Images. 2022; 2(1): 1047.

Introduction

Myiasis disease was defined by Zumpt as a parasitic invasion of the tissues of humans by diptereous larvae [1]. It is distributed throughout the world, particularly in tropical and subtropical regions [2]. Due to her geographic conditions, which provide suitable conditions for the presence of various myiasis agents, Tunisia is not except from this kind of infestation. It most commonly found in elder, debilitated, immunocompromised individuals, low socioeconomic status or others who are not able to ensure basic hygiene. Based on the involved tissues or cavitites of body organs, myiasis may be categorized clinically as: cutaneous myiasis, myiasis of external orifice and myiasis of internal organ [3]. Myiasis agents, affect mainly the uncovered areas of the body which are easy accessible to egg-laying and development of the larvae that explain the fact that cutaneous myiasis, is the most commonly reported entity among all. In addition to their medical importance as mechanical vectors of parasitic disease agents’ dipteran true flies can make myiasis in hospital environment called nosocomial myiasis which is rarely reported [4-6]. In this paper we report the first case of anal nosocomial myiasis in a Tunisian patient caused by Musca domestica.

Case Report

A 31-year-old male patient, without pathological history, was victim of a traffic accident (collision between 2 cars), on 02/11/2021. There was no death on the spot. The patient was referred to the nearest emergency room with on admission examination: Glasgow score 4/15, pupils in tight miosis, Polypnea at 22 cycles per minute, SpO₂ 88% in air ambient, bilateral snoring rales and tachycardia. The patient was intubated. He underwent a body-scan that showed a meningeal hemorrhage and fractures in the cervical vertebrae C5/C6. The patient was kept in the emergency room for 36 hours before his admission to the Intensive Care Unit of the Military Hospital of Tunis (Day 0). On the second day, the evolution was marked by a fever (39.8°C) and, a biological inflammatory syndrome with hyperleukocytosis (16200 cells/mm3) and high level of C-reactive protein (360 mg/l) and procalcitonin (34 μg/l). He was put on Augmentin® for suspected aspiration lung disease. An infectious investigation was requested including a microbiological examination of Cerebrospinal fluid, urine, protected tracheal sample and blood culture. On day 3 due to the persistence of septic shock, the patient was put on Tazocillin, Vancomycin. At the same day and after the patient’s care (shower, diaper change, etc.), the nurse reported the presence of a multitude of small, sticky white worms in the patient’s intimate areas, which were collected and sent to the laboratory of parasitology for identification. The intimate areas were shaved with classic toilet and antiseptic desinfection. The evolution was marked by a devastating worsening of the patient’s condition and death on Day 4 due to septic shock and multiple visceral failures.

Figure 1: Musca domestica larval stage L3.

Figure 2: Tapered anterior end of the larva containing one pair of hooks (red arrow).

Laboratory diagnosis
Based on Zumpt criteria, the larval specimens were identified Musca domestica larval stage L3. They are creamy-white cylindrical larvae measuring 8 mm (Figure 1). The anterior end of the larva was tapered and contained one pair of hooks (Figure 2). The posterior end was broad and flatened with respiratory spiracles which have three sinuous slits surrounded by a heavily sclerotized ring with a conspicuous perforated button (Figure 3).

Figure 3: The posterior end of the larva showing: Pair of brown ‘D’ shaped respiratory spiracles, a chitinised ring (red arrow) and 3 sinuous ‘m’ shaped stigmatic slits on each spiracle (yellow arrows).

Table 1: Overview of cases of human myiasis due to Musca domestica.

Table 2: Overview of cases of nosocomial myiasis.

Discussion

Musca domestica commonly known house fly, lives close to humans and contaminate the food, and breed in garbage and animal faeces [7]. We present here the first evidence of this species in Tunisa. Cases of myiasis caused by the house fly are rarely reported in the literature. It is a cosmopolitan pest of both farm and home, where can curry serious diseases. The virulence of this insect is related to the annoyance and the indirect damage caused by the transmission of pathogens such as bacteria, virus, fungi, protozoa, and nematodes. There are two ways of infestation of maggots into humans. The most frequent one is the direct inoculation of eggs on living tissues or on the mucous membranes of natural body orifices [8]. The second way is by ingestion of contaminated food, which is described in patients with poor food hygiene.

In table 1, we summarized the recent case reports of human myiasis due to Musca domestia and their epidemiological characteristics. The majority of patients had predisposing factors mainly poor hygiene (71.4%). The patients lived in the Asian continent in 87% of cases. The average age of the patients is 17.3 years with 57% females. Oral cavity is the most affected anatomic site in 3 cases (43%).

Lifecycle of these flies takes around 7 to 10 days from the egg stage to larval, pupa and adult fly. However, under suboptimal conditions, the lifecycle may require up to 2 months. Female fly can lay up to 500 eggs in several batches. The maggot emerges from the egg in warm weather within 8 to 20 hours. The larva goes through 3 instars and become a full- grown maggot. Maggots feed on the decomposing tissue that is why, an intermediate host is always required. Pupae, which have a different shape from the larva, complete their development in 2 to 6 days at 32°C to 37°C [9].

We confirmed the nosocomial infection in our patient based on two arguments. First, larvae of M.domestica, which were at the third instar transition, were noted, five days after hospitalization: 36 H at the emergency room + 72 H at the intensive care Unit. The second argument is based on the fact that the margin anal was cleaned at time of admission and larvae were found long after 72 hours of admission to the intensive care unit of the Military hospital of Tunis.

As long as the fly larvae are free living and only circumstantially adapt themselves to parasitic dependence to a host, it is referred as facultative. The larvae of Musca domestica are among the main agents of facultative myiasis, in addition to other species such as Calliphora. SpPhaenicia.sp, Lucilia. Sp. Nosocomial myiasisis a facultative and accidental infestation.Despite it is caused by facultative agents, it can be fatal and life treating [10]. This kind of infestation, mainly affects patients with predisposing factors such as mental retardation, hemiplegia and patients in comatose state as our case. Nosocomial myiasis is also rarely reported even in endemic areas [11,12].

A review of the literature (table 2) from 2012 through 2021 disclosed 13 cases of nosocomial myiasis. Based on the clinical/anatomical features, the majority of cases (84%) were nasal (46%) and oral (38%) myiasis. The patients’ age ranged from 5 months to 91 years old. The majority of the myiasis cases were due toLucilia sericata (60%). More than 38% of all cases are reported from Iran. Analysis of the documented cases based on gender showed 60% were male and 40% were female.

The traditional treatment consists in the mechanical removal of the larvae because standard guidelines for treating oral myiasis do not exist. The use of ivermectine, a semisynthetic macrolide antibiotic, allows having favorable results. Topical antibiotics can be used as coadjuvants in treatment [33]. The fatal evolution in our case is not linked to the parasitic attack but rather to a multiorgan failure.

Control offlies is an important step to prevent infestation. Collective prevention is based on setting up a fly-management program to fight against adult flies. Personal prevention could be done by the use of mosquito nets, to prevent maggots from reaching the human body and residual wall sprays, which can be applied where flies congregate.

Conclusion

Known as a mechanical transmitter of organisms pathogenic, Musca domestica is also a myiasis-producer. This is the first report of nosocomial myiasis in Tunisia probably due to a lack of expertise in identifying fly larvae.

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