carmen Rodriguez-Cerdeira

Miguel Carnero Gregorio

Roberto Arenas Guzman

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267ACTA DERMATOVENEROLOGICA CROATICADermatobia Hominis Infestation Misdiagnosed as  Abscesses in a Traveler to Spain Dear Editor, A 29-year-old woman presented with abscesses on her buttock and leg attributed to flea bites inflict-ed 5 days earlier on return to Spain after 2 months in Guinea-Bissau. Ciprofloxacin was ineffective after 7 days, and she was referred for dermatologic evalu-ation. Examination revealed 4 round, indurated, ery-thematous-violet furunculoid lesions with a 1.5-2 mm central orifice draining serous material. She reported seeing larvae exiting a lesion, and we extracted sever-al more (Figure 1). Parasitology identified Dermatobia (D.) hominis (Figure 2). Biopsy revealed intense dermal eosinophilic in-flammatory infiltrate with a deep cystic appearance, surrounded by acute inflammatory infiltrate and necrotic material. Dermoscopy identified a foramen surrounded by dilated blood vessels and desquama-tion. A yellowish structure with a luminescent cen-tral ring was noted. Ultrasonography identified oval, hypoechoic, and hypovascular structures with inner echoic lines corresponding to cavities with debris and/or larval remains. Larvae were extracted before ultrasonography (Figure 1, b).  Recommended treatment included topical anti-septic, occlusion of the infected area with paraffin, and 1% topical ivermectin; treatment resulted in in-complete resolution after 7 days. Furunculoid myiasis is more common in develop-ing countries (1). Cases in Spain are usually imported, since the flies that produce this type of myiasis are not found locally. The species most frequently involved are D. hominis from Central and South America (bot-fly) and Cordylobia anthropophaga from the sub-Sa-haran region (tumbu fly) (2). We believe this was the first case in Spain imported from Guinea-Bissau.Figure 1. (a) Indurated, hyperpigmented lesions with bloody, purulent exudate on the buttock and thigh. (b) Larvae were extracted before ultrasonography. Lesions involved the hypodermis and dermis, with increased surrounding echogenicity, probably due to edema and inflammation.Acta Dermatovenerol Croat                              2018;26(3):267-269                               LETTER TO THE EDITOR268 ACTA DERMATOVENEROLOGICA CROATICA Several cases have been reported in Spain. Marco de Lucas et al. (3) reported a case in a Colombian male emigrant with multiple subependymal and intraven-tricular lesions, concentric blooming artifacts, and moderate hydrocephalus due to intracerebral myia-sis. Another case was described by Arocha et al. (4). Central European countries continue to report new cases of imported furunculoid myiasis (5). D. hominis is a fly of the Oestridae family, approxi-mately 1.5 cm long, yellowish-white in color, with a plumose edge (6). Larvae induce erythematous papules that sometimes ulcerate and resemble oils or large pustules, with a central orifice of about 1 mm, representing the larval respiratory pore. The le-sions are usually painful (especially when larvae are still present) and pruritic, and produce sensations of movement under the skin. Lesions are located pre-dominantly in exposed areas (7) and areas of contact with clothing and footwear, such as feet, buttocks, and external genitalia. Histopathology is not necessary for diagnosis, but usually reveals intense inflammatory infiltrate with abundant eosinophils surrounding larvae. (2) In our patient, ultrasound confirmed absence of living larvae within the cavity. D. hominis larvae show spontaneous movement in positive lesions and can be detected with ultrasound. Lesions in the hypoder-mis and dermis showed increased echogenicity of surrounding tissue, probably due to edema and in-flammation (8). Diagnosis is established by comparing the lesion appearance with images of boils, abscesses, and in-clusion of foreign body reaction cysts. Based on failed antibiotic therapy and travel to an endemic zone, my-iasis should be considered in the differential diagno-sis. Treatment consists of larval extraction through the respiratory orifice using pressure or a fine forceps or punch (9). Topical or oral ivermectin (10) can short-en the time to larval elimination. Physicians should be aware of this condition when travelers from endemic regions present with furuncu-lar lesions, especially if movement is felt within the lesions or if lesions fail to heal. Myiasis is easily diag-nosed based on clinical suspicion and epidemiologi-cal history, and is simple to treat.References:1. Kuria SK, Kingu HJ, Villet MH, Dhaffala A. Human myiasis in rural South Africa is under-reported. S Afr Med J. 2015;105:129-33.2. Hasegawa M, Harada T, Kojima Y, Nakamura A, Yamada Y, Kadosaka T, et al. An imported case of furuncular myiasis due to Cordylobia anthro-pophagi which emerged in Japan. Br J Dermatol. 2000;143:912-4.3. Marco de Lucas E, Díez C, Gutiérrez A, Montiaga F, Arnáiz J, Mandly AG, et al. Unusual MRI findings in a patient with history of frontal fracture and skin infestation by fly larvae, as a possible sign of intracerebral myiasis. Clin Neurol Neurosurg. 2008;110:725-8.4. Arocha J, Moreno A, Díaz J, Valladares B, Batista N, González A. Myiasis caused by Dermatobia homi-nis. Enferm Infecc Microbiol Clin. 1996;14:453.5. Totkova A, Jakubovsky J, Totka A, Bohmer D, Stan-kovic I, Holeckova K, et al. The first imported hu-man infestation with furuncular myiasis in man in the Slovakia and current knowledge of myiasis. Bratisl Lek Listy. 2016;117:321-7.6. Solomon M, Lachish T, Schwartz E. Cutaneous myiasis. Curr Infect Dis Rep. 2016;18:28. 7. Gaci R, Delord M, Parola P, Brouqui P, Lagier JC. Ex-tended perineal Dermatobia hominis myiasis in a traveler returning from South America. JAMA Der-matol. 2015;151:1389-90. 8. Bouer M, Rodriguez-Bandera AI, Albizuri-Prado F, Lobos A, Gubeling W, Wortsman X. Real-time high-frequency colour Doppler ultrasound detec-tion of cutaneous Dermatobia hominis myiasis. J Eur Acad Dermatol Venereol. 2016;30:e180-e181. 9. Pascoal G, Oliveira FQ, Siqueira RR, Lopes MG, Martins MPN, Gamonal AC. Excision of furuncular myiasis larvae using a punch: a simple, practi-cal and aesthetic method. An Bras Dermatol. 2016;91:358-61. Figure 2. Morphology of D. hominis larva after mechanical extraction.Letter to the editor Acta Dermatovenerol Croat2018;26(3):267-269269ACTA DERMATOVENEROLOGICA CROATICA10. Puthran N, Hegde V, Anupama B, Andrew S. Iver-mectin treatment for massive orbital myiasis in an empty socket with concomitant scalp pediculosis. Indian J Ophthalmol. 2012;60:225-7.Carmen Rodríguez-Cerdeira1,2, Miguel Carnero Gregorio1,3, Roberto Arenas Guzman41Efficiency, quality and costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain2Dermatology Service, Hospital do Meixoeiro and University of Vigo, Vigo, Spain3Department of Biochemistry, Genetics and Immunol-ogy, University of Vigo, Vigo, Spain4Mycology and Parasitology Service, Hospital Manuel Gea González, Mexico City, MexicoCorresponding author:Carmen Rodriguez Cerdeira, MDDermatology Service, Meixoeiro HospitalCHUVI, C/Meixoeiro S/N 36200VigoSpaincarmencerdeira33@gmail.comReceived: August 26, 2017Accepted: July 11, 2018Letter to the editor Acta Dermatovenerol Croat2018;26(3):267-269

Dermatobia Hominis Infestation Misdiagnosed as Abscesses in a Traveler to Spain

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