|Year : 2017 | Volume
| Issue : 1 | Page : 55-58
A rare case of genital myiasis in a woman with psychiatric disturbance
Upreti Purnima1, Umesh Varshney2, Mavish Jahan1
1 Department of Obstetrics and Gynaecology, Government Medical College, Haldwani, Nainital, Uttarakhand, India
2 Department of Microbiology, Government Medical College, Haldwani, Nainital, Uttarakhand, India
|Date of Web Publication||19-Dec-2016|
Department of Microbiology, Government Medical College, Haldwani, Nainital - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
A middle-aged psychiatric woman was brought to the casualty by national health ambulance. The patient was a destitute and had psychiatric illness. Local examination revealed irreducible third-degree uterovaginal prolapse with necrotic ulcerated areas infested with maggots. The patient was managed conservatively with the removal of maggots with 100% turpentine oil, culture-sensitive antibiotics, and local antiseptics. With treatment, the prolapsed mass got free of maggots, the ulcerated areas healed, and prolapsed mass became reducible.
Keywords: Maggot infestation, myiasis, uterovaginal prolapse
|How to cite this article:|
Purnima U, Varshney U, Jahan M. A rare case of genital myiasis in a woman with psychiatric disturbance. CHRISMED J Health Res 2017;4:55-8
|How to cite this URL:|
Purnima U, Varshney U, Jahan M. A rare case of genital myiasis in a woman with psychiatric disturbance. CHRISMED J Health Res [serial online] 2017 [cited 2019 Dec 13];4:55-8. Available from: http://www.cjhr.org/text.asp?2017/4/1/55/196069
| Introduction|| |
Myiasis is derived from Greek myia which means fly.  Myiasis is the infestation by dipterous larvae (maggots) of various fly species which feed on living or necrotic tissue of the host. Cutaneous, nasopharyngeal, auricular, and ophthalmic myiases are common. Genital myiasis is a rare condition. We report a case of genital myiasis in a psychiatric woman with irreducible uterovaginal prolapse.
| Case report|| |
A middle-aged woman was brought to the casualty of Dr. Susheela Tiwari Government Hospital, Haldwani, by National Health Ambulance (108). The woman was a destitute. She was mentally unsound. She did not respond to the verbal commands; hence, history of her illness could not be elicited. Her personal hygiene was very poor. She was of poor built and nutrition. Her vitals were stable. She was severely anemic. There was no significant lymphadenopathy. Her abdomen was soft and nontender. Bowel sounds were present. On local examination, there was third-degree uterovaginal prolapse. There were ulcerated areas over the prolapsed mass with numerous yellowish maggots [Figure 1]. These areas were covered with necrotic tissue. There was foul-smelling discharge. The tissue surrounding the ulcerated areas was edematous. The prolapsed mass was irreducible. Uterine size could not be ascertained. The patient was admitted in the Department of Gynecology.
|Figure 1: (a and b) Prolapsed uterine mass with large ulcerated areas infested with maggots|
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She was investigated. Her hemoglobin was 3.5 g%. Total leukocyte count was 22,540 cells/cubic mm, and differential leukocyte count was P76 L23 E1; blood sugar, renal function test, liver function test, coagulation profile, and urine analysis were within normal limit. Venereal disease research laboratory, hepatitis C virus, hepatitis B surface antigen, and human immunodeficiency virus were negative. X-ray of the chest (PA) and ultrasonography of the whole abdomen and pelvis did not reveal any abnormality. Culture and sensitivity of discharge from ulcerated area showed growth of Gram-negative bacteria ( Escherichia More Details coli and Klebsiella spp.) which were found sensitive to the third-generation cephalosporins (cefotaxime, ceftriaxone) and amikacin.
Patient's personal hygiene was taken care of. She was catheterized. Initially, she was not taking anything orally, so she was put on intravenous fluids. She was treated with injection cefotaxime 1 g intravenously 12 hourly and metronidazole 500 mg intravenously 8 hourly for 7 days. Antipsychotic treatment was started as per the advice of psychiatrist. Four units of packed cells was transfused for correction of anemia.
On the 1 st day, hundreds of maggots were removed using nontoothed forceps, and the prolapsed mass was cleaned with normal saline. From the 2 nd day onward, the ulcerated areas were irrigated daily with turpentine oil. Deep-seated maggots would swarm up after irrigation and were then washed away with saline. At the end of the 7 th day, the prolapsed mass was free from maggots. As the patient's mental condition improved, she gradually started taking food orally. She was put on high protein diet, hematinics, and multivitamins.
Glycerin and acriflavine dressing was done daily. By the end of the 15 th day, the ulcerated areas healed; by the 21 st day, the prolapsed mass could be reduced [Figure 2]. Thereafter, definitive surgery was planned for uterovaginal prolapse.
| Discussion|| |
The term "myiasis" was coined in 1840 by Reverend Frederick William Hope to refer to diseases resulting from dipterous larvae.  Even though the term myiasis was first used in 1840, such conditions have been known since ancient times. Ambroise Pare, the chief surgeon to King Charles IX and King Henry III, observed that maggots often infested open wounds. 
The distribution of myiasis is worldwide, with more cases being commonly reported from subtropical, tropical, and warm-temperate regions. The condition is uncommon in the USA and European countries. However, the rapidity of international travel permits this exotic tropical infestation to present in any region. 
German entomologist Fritz Zumpt describes myiasis as "the infestation of live human and vertebrate animals with dipterous larvae, which at least for a period, feed on the host's dead or living tissue, liquid body substances, or ingested food."
There are two forms of myiasis:
- Obligate, in which the maggots feed themselves on living tissues of the host
- Facultative, where the maggots opportunistically take advantage of wounds or degenerative necrotic conditions to feed themselves. 
There are three families of flies encountered in myiasis and can be divided into two groups for comparison of host location strategies:
- Oestridae - They are obligate parasites; they deposit their eggs or larvae directly onto the host
- Calliphoridae and Sarcophagidae - They are obligate parasite and primary facultative parasite; they deposit their eggs or larvae directly onto the host at some predisposing site, such as caused by wounding or necrosis. 
These parasites can be identified either by microscopic examination or by developing these larvae to adult flies for entomological classification.
The classical description of myiasis is according to the part of the host that is infected.  Most common type of myiasis is mucocutaneous type. Urogenital myiasis can be external or internal based on anatomical site that is affected.  External genital myiasis is common in women. The practice of not wearing undergarments, cervical carcinoma, or sexually transmitted diseases predisposes women to external genital myiasis. In women, clitoris, urethra, vulva, vagina, and uterus have been found affected. Internal urogenital myiasis is rare and occurs when larvae reach internal genitourinary organs. Our case is of external genital myiasis affecting prolapsed uterus and vagina. Baidya reported a case of genital myiasis in a woman with uterovaginal prolapse and vaginal malignancy.  Dhakne and Gupta reported a case of genital myiasis in a woman with irreducible uterovaginal prolapse with squamous cell carcinoma of the cervix.  Lopes-Costa et al. reported a case of myiasis in the uterine cavity of an elderly woman with a complete uterine prolapse.  Passos et al. reported a case of vulvar myiasis during the pregnancy.  Cilla et al. described a case of vulvar myiasis in a diabetic 86-year-old woman. 
Human genital myiasis is usually associated with poor general health and personal hygiene, lower socioeconomic status, extremes of age, psychiatric illness, diabetes mellitus, vascular occlusive diseases, restricted mobility, and ulcerative lesions.  In our case, the woman was of poor built and nutrition; her personal hygiene was very poor, and she had psychiatric illness. She had third-degree uterovaginal prolapse with decubitus ulcer. All these factors predisposed her to genital myiasis. da Silva et al. also reported vulval and perineal myiasis in a woman with psychiatric disturbance.  Our patient was a destitute. In a multicenter study of American patients who had myiasis, 38% were homeless. 
The treatment involves usage of anti-larval measures (turpentine oil or mixture of turpentine oil and chloroform), followed by the removal of the larvae. Other agents such as ether, chloroform, or surgical debridement have been used for removal of the larvae.  We used 100% turpentine oil, local antiseptics, and culture-specific antibiotics. Our treatment made the prolapsed mass free of maggots. The ulcerated areas healed and the prolapsed mass became reducible.
Multiple surgical techniques have been described in the past, but no single standardized technique for surgical extraction of larvae has been adopted. It is interesting to note that fly larvae, or maggots, can be used to cleanse necrotic debris from a wound as they feed on the necrotic tissue of the wound.
| Conclusion|| |
Myiasis of the genitals is rare. However, when infestation occurs at these sites, it is usually associated with previous lesions, precarious health conditions, and poor personal hygiene and often with aural environment. Social evaluation of these individuals is the key to promote health. The physician's role in educating patients (especially those living in a rural area) about good personal hygiene is important.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]