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Myasis in uterine prolapse, successful treatment

2011; Elsevier BV; Volume: 205; Issue: 3 Linguagem: Inglês

10.1016/j.ajog.2011.03.019

1097-6868

Wilmar Saldarriaga, Enrique Herrera, D. A. M. Castro,

Female Genital Mutilation/Cutting Issues

We describe the case of an elderly female with total genital prolapse and superinfected uterine myasis. The successful treatment included mechanical extraction of the larvae, antibiotics, and ivermectin (this last one reported for the first time); along with the surgical correction of the prolapse. We describe the case of an elderly female with total genital prolapse and superinfected uterine myasis. The successful treatment included mechanical extraction of the larvae, antibiotics, and ivermectin (this last one reported for the first time); along with the surgical correction of the prolapse. Myasis is a parasitic infestation of humans or other vertebrates by fly larvae. Affecting skin and exposed necrotic tissue, colonization has also been described in natural cavities, especially ears, nostrils, gastrointestinal, and genitourinary tracts; and less frequently, involving the uterus.1Ting P.T. Barankin B. Cutaneous myiasis from Panama, South America: case report and review.J Cutan Med Surg. 2008; 12: 133-138PubMed Google Scholar Usually, it is present in individuals from rural areas with deficient hygienic habits, psychiatric problems, and limited access to the health care system.2Chan J.C. Lee J.S. Dai D.L. Woo J. Unusual cases of human myiasis due to Old World screwworm fly acquired indoors in Hong Kong.Trans R Soc Trop Med Hyg. 2005; 99: 914-918Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar The basis of the treatment lies on the mechanical removal of the larvae; recently, the use of ivermectin has been suggested. This last is an 80:20 avermectin B1a to B1b mixture, which are macrocyclic lactones produced by actinobacteria Streptomyces avermitilis, with broad antiparasitic properties, microfilaricide.3Dourmishev A.L. Dourmishev L.A. Schwartz R.A. Ivermectin: pharmacology and application in dermatology.Int J Dermatol. 2005; 44: 981-988Crossref PubMed Scopus (154) Google Scholar An 82-year-old illiterate female attending gynecologic service at Valle University Hospital, Cali, Colombia, with total genital prolapse noted for the last 5 years. Four ulcers were observed in the prolapsed uterus, the biggest one with a diameter of 6 × 3 cm, with necrotic edges. These were cavitated and infested by live larvae, Sarcophagidae (fleshflies) vs Calliphoridae (blowflies) families; with fetid discharge and inflammation of adjacent tissue (FIGURE 1, FIGURE 2). The patient had a body mass index (BMI) of 31, personal neglect, poor hygiene, without signs of senile dementia. Antecedents of one vaginal delivery without complications. No chronic pathology. She is originally from a rural area, but has been living in an urban area for the last 5 years, in an industrial zone far from animal breeding or sanitary landfills. She was hospitalized for 7 days, received intravenous ceftriaxone-metronidazole; oral ivermectin (drops at 0.6%, 1 drop per kilogram of body weight) and topical ivermectin. Additional treatment included mechanical extraction of larvae with forceps and daily washing of lesions until obtaining granulation tissue (Figure 3). Posthospitalization, topical estrogen was applied on the genital prolapse for 1 month. Surgical correction of the genital prolapse was performed via vaginal hysterectomy with anterior and posterior colporrhaphy; a procedure without complications.FIGURE 2SuperinfectionShow full captionSaldarriaga. Case of a woman with total genital prolapse and uterine myasis. Am J Obstet Gynecol 2011.View Large Image Figure ViewerDownload Hi-res image Download (PPT)FIGURE 3Uterine myasis after initial treatmentShow full captionSaldarriaga. Case of a woman with total genital prolapse and uterine myasis. Am J Obstet Gynecol 2011.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Saldarriaga. Case of a woman with total genital prolapse and uterine myasis. Am J Obstet Gynecol 2011. Saldarriaga. Case of a woman with total genital prolapse and uterine myasis. Am J Obstet Gynecol 2011. The patient and a responsible family member accepted and signed a written informed consent for the medical procedures and for publication of this report. Myasis is the parasitic infestation of humans or other vertebrates by fly larvae. The flies are insects belonging to the Diptera order, nearly 16 families, of which 5 bear medical importance: Muscidae, Sarcophagidae (fleshflies), Calliphoridae (blowflies), Oestridae (botflies), and Cuterebridae. This occurs directly when the flies deposit their eggs on affected parts of the body and indirectly when consuming contaminated water or food, or via the phoresy phenomenon in which the fly uses hematophages as vectors.1Ting P.T. Barankin B. Cutaneous myiasis from Panama, South America: case report and review.J Cutan Med Surg. 2008; 12: 133-138PubMed Google Scholar Flies attack, attracted by infected wounds.2Chan J.C. Lee J.S. Dai D.L. Woo J. Unusual cases of human myiasis due to Old World screwworm fly acquired indoors in Hong Kong.Trans R Soc Trop Med Hyg. 2005; 99: 914-918Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Prevalence is greater in tropical-subtropical areas. Incidence is subestimated because most cases occur in rural areas and are not registered. Generally, the manifestations in humans occur in undernourished individuals with poor hygiene and/or individuals who are mentally incapable of avoiding attacks from flies. The genitourinary infestation have been related to psychiatric disorders, use of urinary catheters, cystocele, and uterine prolapse in association with precarious genital hygienic conditions.4Shaunik A. Pelvic organ myiasis.Obstet Gynecol. 2006; 107: 501-503Crossref PubMed Scopus (11) Google Scholar Damages vary from superficial infestations of simple diagnosis and treatment, to massive infestations that are difficult to diagnose and present sequelae. Mortality is inferior to 5%, associated to lesions of the central nervous system.5Sesterhenn A.M. Pfützner W. Braulke D.M. Wiegand S. Werner J.A. Taubert A. Cutaneous manifestation of myiasis in malignant wounds of the head and neck.Eur J Dermatol. 2009; 19: 64-68PubMed Google Scholar The differential diagnosis with pyogenic staphylococcal furunculosis, abscesses, epidermal cyst, cellulites, granulomas, tungiasis, reaction to foreign bodies, allergic reactions, and lesions due to sarcoptes scabiei.6Nordlund J.J. Cutaneous ectoparasites.Dermatol Ther. 2009; 22: 503-517Crossref PubMed Scopus (12) Google Scholar We conducted an exhaustive literature search, consulting PubMed-MEDLINE databases (without time limits and including all languages and types of publications) for uterine myasis, cavitary myasis, genital myasis, and pelvic myasis. We used the keywords and all the MeSH terms. We included SciELO-database (Latin American literature). Our revision found 3 case reports of uterine myasis,7Szendi B. Fly larvae in the uterus (myiasis of the uterus cervix).Zentralbl Gynakol. 1952; 74: 1063-1068PubMed Google Scholar, 8Chen D.X. A case of myiasis in uterine cavity.Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi. 2006; 24: 401Crossref PubMed Scopus (2) Google Scholar, 9Lopes-Costa P.V. dos Santos A.R. Pereira-Filho J.D. da Silva B.B. Myiasis in the uterine cavity of an elderly woman with a complete uterine prolapse.Trans R Soc Trop Med Hyg. 2008; 102: 1058-1060Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar predominantly in underdeveloped countries; the first report from 1952 and the last 1 from 2008 by Lopes-Costa, who reported a similar case of Cochliomyia hominivorax in an elderly Brazilian woman uterine prolapse. A search of local nonindexed literature revealed 2 cases.10Rojas L. Cantillo J. Osorno-Mesa E. Uterine myasis: a case of Uterine myasis for American Callitroga.Rev Col Obstetr Gin CoI. 1974; 25: 51-56Google Scholar, 11Alarcon M. Perez A. Uterine myasis: second case in Colombia.Rev CoI Obstetr Gin CoI. 1988; 39: 130-133Google Scholar In our case, we report the use of ivermectin with scientific support of its usefulness in cavitary myasis.12Fox L.M. Ivermectin: uses and impact 20 years on.Curr Opin Infect Dis. 2006; 19: 588-593Crossref PubMed Scopus (90) Google Scholar No report on uterine myasis reviewed in literature has used this drug. During treatment, it is important to bear in mind the type of lesion, location, time of evolution, superinfection, and general conditions of the patient. The aim is to remove the larvae and control the superinfection. Occlusion of the nodule to diminish oxygen concentration force the larvae to come out to breath; local application of paralyzing substances; and mechanical methods to extract the larvae (eg, using forceps) are available methods in treating this condition. Antibiotics are used according to the size of the wound and its location. To avoid and/or control superinfection and favor scarring, antibiotics should cover Gram-positive, Gram-negative, and anaerobic bacteria. Ivermectin, indicated for use in external parasitosis, is efficient, safe, low cost, easily administered, with minimal collateral effects, and scientific evidence of its usefulness; reports have been made, especially, of successful treatment of myasis in some natural cavities but not in the uterus.12Fox L.M. Ivermectin: uses and impact 20 years on.Curr Opin Infect Dis. 2006; 19: 588-593Crossref PubMed Scopus (90) Google Scholar Given the rarity of the condition described, we contribute with this report, integrating current evidence onto a more holistic and suitable option to approach the pathology with short-term satisfactory results and avoiding complications.