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American Journal of  Medical 
Science and Innovation (AJMSI) 

Cutaneous Furuncular Myiasis in a Rural Kenyan Hospital: A Case Report
Noi J. Joseph1, James N. Kariithi1, Vonwicks C. Onyango2* 

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.2257
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: October 25, 2023
Accepted: November 27, 2023
Published: November 30, 2023

Myiasis is a neglected tropical disease caused by infestation by the larval stages (maggots) 
of  many species of  flies, which occur worldwide but are more prevalent in the tropical and 
subtropical regions. The two main types of  flies causing human myiasis are Dermatobia 
hominis (bot fly) and Cordylobia anthropophaga (tumbu fly). Cases of  human myiasis in 
Kenya are not well documented, but some epidemiological studies show the tumbu fly 
to be the most prevalent. Transmission and infestation occur in cases of  poor personal 
and environmental hygiene, especially in spaces shared with wild and domestic animals. 
Cutaneous myiasis, presenting as a furuncular, wound, and migratory disease, is the most 
common clinical phenotype that may be associated with secondary pyogenic infection and 
cellulitis, especially when not treated promptly. In this study, we present a case of  cutaneous 
furuncular myiasis in a patient from rural Kenya. We share our experience managing the 
patient and also provide a literature review on the clinical case management of  myiasis, 
with a call for more epidemiological and clinical work to be done to better understand this 
neglected disease.

Keywords
Myiasis, Cutaneous Myiasis, 
Furuncular Myiasis, Tumbu Fly, 
Bot Fly, Dermatobia Hominis, 
Cordylobia Anthropophaga, 
Kenya

1 PCEA-Tumutumu Mission Hospital, Karatina, Nyeri County, Kenya
2 St. Joseph Rift Valley Hospital, Gilgil, Nakuru County, Kenya
* Corresponding author’s e-mail: drvonczelo@gmail.com

INTRODUCTION
Myiasis is the term applied to the disease produced by 
infestation by the larvae (maggots) of  the species of  
flies of  the arthropod order Diptera, that invade and live 
parasitically in human tissues (‘myia’ is a Greek word 
for fly). Myiasis is a neglected disease. It is sporadically 
distributed worldwide, and the flies infest many animals 
and humans. The most common flies causing human 
infestation are Dermatobia hominis (bot fly), which is 
endemic in Central and South America and the Caribbean; 
and Cordylobia anthropophaga (tumbu fly), which  is 

endemic to sub-Saharan Africa and is responsible for the 
furuncular form of  cutaneous myiasis (Kuria & Oyedeji, 
2020; Robbins & Khachemoune, 2010). In Kenya, there 
is no robust data that captures the prevalence of  myiasis 
in humans, though some surveillance epidemiological 
studies report that myiasis is endemic in the south-eastern 
counties, e.g., Kitui. Most human cases are anticipated to 
closely follow the prevalence in domestic animals, e.g., in 
dogs, sheep, and goats. A cross-sectional study done on 
canine cutaneous myiasis in Kitui County, Kenya, revealed 
an overall prevalence of  45%, with all the larvae isolated 

Figure 1: The life cycle of  myiasis larvae (Man et al., 2022)



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Am. J. Med. Sci. Innov. 2(2) 202-205, 2023

being C. anthropophaga (tumbu flies) (Mutinda et al., 2022). 
The flies prefer warm and humid environments and 
are thus restricted to the summer months in temperate 
zones, but are prevalent year-round in the tropics and 
subtropical countries. The mechanism of  transmission 
varies depending on the species of  fly. The adult fly may 
deposit its eggs on a wound, which hatches to produce the 
larva that burrow into the skin, or it may deposit the eggs 
directly into the nostrils, the conjunctiva, on the lips, or 
on an intact skin with subsequent larva invasion into the 
tissues. The D. hominis species is usually found in humans, 
cattle, swine, cats, dogs, horses, sheep, other mammals, 
and bird species. It is especially interesting because it 
deposits eggs on a mosquito, tick, or other fly. When the 
mosquito or tick bites a human, the warmth of  the skin 
induces the eggs to hatch, and the larvae enter the skin 
at the site of  the bite. C. anthropophaga is hosted by wild 
rats (the main hosts), mice, monkeys, squirrels, dogs, cats, 
rabbits, guinea pigs, goats, chickens, and humans. The 
flies lay their eggs on the ground or dump clothes and 
bed linens hung out to dry. People get infected when they 
contact the hatched larvae (Francesconi & Lupi, 2012). 
Figure 1 panel from Pharmaceutical Research (2022) 
shows the life cycle of  myiasis larvae (Man et al., 2022). 
Infestation may be classified based on parasite-host 
interaction as obligatory, facultative, or accidental myiasis. 
More commonly, it is classified based on the body parts 
affected, e.g., cutaneous, nasopharyngeal, intestinal, and 
urogenital myiasis, etc. (Dires et al., 2022). Cutaneous 
myiasis is the most common type and may have three 
different clinical forms: furuncular, migratory, or wound 
myiasis. The furuncular subtype is the most commonly 
encountered, often presenting with nodular and cystic 
cutaneous lesions (Dires et al., 2022).
The diagnosis of  myiasis is clinical with direct observation 
of  the larvae, and laboratory testing is not routinely 
required. Manual removal of  the larva is the most 
common mode of  treatment, while surgery may rarely 
be used, especially where there are associated pyogenic 
infections or the occurrence of  myiasis in body cavities 
or unusual sites.

Case Summary
History and Physical Examination
A 76-year-old man, a father of  four adults from Sagana, 
Kirinyaga County, Kenya, was admitted with a 2-week 
history of  acute-on-chronic left lower limb septic 
venous ulcers and generalized painful boil-like swellings 
predominantly distributed on both his arms and back. He 
was a widower who lived alone and worked as a subsistence 
farmer, cultivating food crops and rearing a few sheep and 
goats. He had a significant history of  smoking (about 40 
pack years) and ethanol use, especially of  the traditional 
local brews. He had no other comorbidities.
The boil-like swellings on his body had been recurrent 
over several months (>10 months), affecting his legs, 
arms, groin, torso, and neck. They were painful and 
itchy, with an associated feeling of  creeping movements 

within the lesions. He reported that occasionally “whitish 
worms” would come out of  the lesions spontaneously 
or whenever he squeezed some of  the lesions. He lived 
in a one-bedroomed semi-permanent house, which he 
shared with the lambs and kids of  his sheep and goats, 
respectively. He denied coming into direct physical 
contact with someone with similar lesions. The systemic 
inquiry was unremarkable.
On physical examination, he was an elderly male in 
chronic poor health with features of  general neglect and 
poor overall sanitary condition. He was sick-looking, 
poorly groomed, and dull in appearance and disposition. 
His vital signs were unremarkable. He was mildly pale and 
dehydrated but had no scleral jaundice, finger clubbing, 
pedal edema, or peripheral lymphadenopathy. 

Figure 2: Upper and lower panels showing multiple 
furuncles appearing as nodular and nodulo-cystic lesions 
on the back of  the patient. On the lower panel, some 
furuncles are noted to have healed spontaneously (see the 
associated hyperpigmented scars).

Figure 3: Upper panel showing a furuncle with a maggot 
being manually removed by gentle squeezing. The lower 
panel shows a live maggot extracted from a furuncle on 
the patient



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Am. J. Med. Sci. Innov. 2(2) 202-205, 2023

The patient had multiple tender skin lesions, worse on the 
bilateral forearms and the back. They were mixed lesions, 
i.e., nodular, cystic, and nodulo-cystic, with surrounding 
skin induration and scratch marks. Both new and old lesions 
in different stages of  healing were noted. Serosanguinous 
and purulent discharge was noted in some of  the lesions. 
Dramatically, live maggots could be squeezed from some 
of  them, i.e., one live whitish maggot per lesion. See 
Figures 2 and 3 panels.
His left lower limb was swollen up to the knee level, was 
hyperpigmented, and had an approximately 8cm by 10cm 
ulcer on the dorsum of  the foot with foul-smelling sero-
purulent discharge and concomitant severe cellulitis. The 
neurovascular exam was normal. The right lower limb was 
grossly normal. The rest of  the systemic exam was grossly 
normal.

Basic Work-Up
His complete blood count showed neutrophilic leukocytosis 
with a total leucocyte count of  28.2 x103 cells/l (4-11) 
with 83.5% neutrophils; hemoglobin was 10.7g/dl (12-16) 
with a mean corpuscular volume of  81fl (mild anemia); a 
normal renal function test with creatinine of  73.6 mmol/l, 
a normal random blood sugar of  5.6mmol/l, and a 
negative rapid test for the human immunodeficiency virus. 
A compression doppler ultrasound scan of  both lower 
limbs showed features of  bilateral venous insufficiency 
with no deep venous thrombosis and marked soft tissue 
swelling of  the left leg up to the mid-thigh level (consistent 
with the cellulitis).

Patient Management and Follow-Up
A clinical diagnosis of  cutaneous furuncular myiasis in 
a patient with a septic chronic venous left leg ulcer with 
associated cellulitis was made. The maggots were physically 
removed by squeezing and plucking them out using non-
toothed tissue forceps and surgical gauzes at the bedside. 
The wounds and furuncles were cleaned and dressed daily 
with topical antiseptics. A seven-day course of  intravenous 
flucloxacillin and acetaminophen analgesics was also 
administered. The outcome was the complete resolution 
of  all the lesions in about two weeks. The septic venous 
ulcer was debrided serially, cleaned, and dressed daily, and 
is currently scheduled for split-thickness skin grafting later 
on. The patient and his family members were educated on 
the importance of  personal and environmental hygiene to 
prevent the recurrence of  the myiasis infestation.

DISCUSSION
The typical clinical encounter with human myiasis in 
temperate countries is the returning traveler from endemic 
areas presenting with predominantly cutaneous myiasis 
(Chang & Donaghy, 2021; Dalton & Chambers, 2009; 
Oliva et al., 2020; Song et al., 2017; Suárez et al., 2018; Uslu 
et al., 2018). In tropical countries, e.g., Kenya, the disease 
is observed in endemic regions. The most common 
etiological species are C. anthropophaga and D. hominis. 
Patients typically present with cutaneous myiasis in the 
clinical forms of  furuncular, i.e., boil-like lesions (the most 

common), wound type, or migratory phenotypes (Dires 
et al., 2022). Furuncular myiasis is typically diagnosed 
clinically during patient encounters, sometimes aided by 
pictorial taxonomical keys (Dires et al., 2022). Whereas 
routine dermoscopy and ultrasound may aid in accurate 
diagnosis and speciation (Bakos & Bakos, 2007), they 
often offer no additional therapeutic value in the eventual 
definitive management of  the infestation. Our patient had 
myiasis caused by C. anthropophaga (tumbu fly) based on its 
predominant endemicity, multiple furuncles, and typical 
appearance when matched to pictorial taxonomical keys. 
We believe our patient acquired the infestation during 
direct contact with the tumbu fly larvae in the unsanitary 
living environment at home shared with domestic animals.
The larvae penetrate the skin, causing intense pruritus, 
pain, skin erythema, and a dramatic sense of  crawling 
underneath the skin. This results in single or multiple 
furuncles, which may be nodular, cystic, or nodulo-cystic, 
and of  varying sizes, and are associated with surrounding 
cellulitis in some cases. They are distributed in the arms, 
legs, buttocks, torso, neck, and sometimes in the body 
orifices or unusual sites like the eyes, nose, ears, or around 
surgical devices (Dalton & Chambers, 2009; Das et al., 
2021; de Souza Barbosa et al., 2008; Dires et al., 2022; 
Huang et al., 2020). The lesions have a central opening 
(punctum) that allows the larvae to breathe. The latter 
can be seen as bubbles when the body part is immersed 
in water (Francesconi & Lupi, 2012). Secondary bacterial 
infection of  the furuncles may cause purulent discharge 
from some of  them (as was the case with our patient) and 
significant cellulitis and/or abscesses. Typically, symptoms 
develop within 2 days of  the fly bite as itchy lesions, with 
the furuncles developing over 6 days. After 8-12 days, the 
mature larvae leave the skin and fall to the ground, where 
they pupate and soon become adult flies. Treatment is 
aimed at the complete eradication of  the maggots from 
the skin and the prevention or management of  secondary 
infections. If  the larvae or maggots are visible, manual 
extraction can be performed using clippers, artery forceps, 
etc., taking care to extract the maggots whole. If  the larva is 
not visible, the central pore can be covered with petroleum 
jelly, liquid paraffin, or turpentine oil, which suffocates the 
larva and causes it to migrate to the surface, where it can 
be manually extracted (Francesconi & Lupi, 2012). Topical 
(1% solution) or systemic ivermectin is toxic to all forms of  
myasis and may rarely be used. Surgical removal of  the larva 
may be needed for eradication of  the maggots, especially 
in unusual locations (e.g., in body orifices and cavities), 
and for drainage of  associated abscesses or debridement 
of  devitalized tissues (Bani Hani et al., 2019; Dires et al., 
2022). This is followed by thorough daily wound care. In 
our patient, the maggots were all manually removed, with 
subsequent wound management (including antibiotics) 
leading to complete healing of  the furuncles over a period 
of  two weeks, albeit with scars that are already fading.

CONCLUSION
Human myiasis can be a debilitating disease with significant 
personal and psychological trauma associated with the 



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ensuing complications of  cutaneous disease, especially in 
the more common furuncular myiasis, e.g., pain, cosmetic 
aberrations, secondary pyogenic infections, intense 
foreign body reactions during inadequate extractions, 
secondary tetanus (consider tetanus booster vaccination in 
all cases), etc. (Francesconi & Lupi, 2012). The focus of  
management should be the prevention of  infestation by 
limiting exposure to flies, especially in tropical areas, such 
as by wearing clothing that covers the extremities, using 
mosquito nets, and using insect repellants. Other general 
measures include covering wounds with clean dressing to 
prevent flies from reaching the skin, avoiding spreading 
clothes on the ground, ironing clothes dried on the line 
(the heat destroys the eggs and the larvae), and improving 
general personal hygiene and environmental sanitation 
(Diaz, 2006).

RECOMMENDATIONS
Myiasis is a neglected disease, yet it has associated 
significant personal and psychological burdens related 
to the larval infestation. Although not well documented, 
human myiasis does occur in Kenya. Cases of  myiasis are 
likely to be misdiagnosed due to a lack of  prior clinical 
experience with similar cases. The authors recommend 
more epidemiological studies be done in Kenya to 
properly map the prevalence of  this neglected disease, as 
well as deliberate training of  health workers on the case 
management of  myiasis.

Acknowledgements
The authors acknowledge Dr. Mawenzi Ramadhan, 
Consultant Dermatologist at Egerton University, School 
of  Medicine, Kenya, for his technical advice during the 
writing of  the manuscript. Additionally, the authors 
acknowledge the nursing staff  and students at the surgical 
wards of  PCEA Tumutumu Mission Hospital, Karatina, 
Nyeri County, Kenya, for their direct participation in the 
management of  the patient.

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