Hrev_master Emergency Care Journal 2023; volume 19:11505 [Emergency Care Journal 2023; 19:11505] [page 79] Question Given the patient’s history, what is the most likely diagnosis? 1. Marjolin’s ulcer 2. Diabetic foot ulcer 3. Infected neoplastic ulcer 4. Kaposi sarcoma Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044. E-mail: poggiali.erika@gmail.com Key words: skin lesions, neoplastic ulcer, squamous cell carcinoma, foot lesions, myiasis. Contributions: Both the authors cared for the patient, collected details of the case, drafted the manuscript, approved the final version and stated the integrity of the whole work. Conflicts of interest: EP is member of the editorial board of Emergency Care Journal. The other author declares no potential conflict of interest, and all authors confirm accuracy. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it. Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: The patient provided consent for the access to med- ical records at the time of admission. Received: 2 June 2023. Accepted: 20 June 2023. Early access publication 11 June 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11505 doi:10.4081/ecj.2023.11505 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. What lies beneath a maggot infestation of an ulcerated foot wound? Irene Triggia, Erika Poggiali Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy We present here the case of a 55-year-old male patient with a past medical history of HIV infection on appropriate antiretroviral therapy (Bictegravir/Emtricitabine/Tenofovir Alafenamide), pre- viously treated for hepatitis C with sustained viral response, who was diagnosed with squamous cell cancer of his right hand 2 years before, and treated with carboplatin and taxol, and surgery (partial amputation) for cancer progression and recurrent infec- tions. He presented to our emergency department for worsening pain (NRS 10/10) of a suppurative and foul-smelling interdigital ulcerated lesion of his left foot, that had been present for 3 months. He reported 100% adherence to his HIV therapy and denied fever or chills. Initial work-up showed 10,690/mm3 leukocytes (8,240/ mm3 neutrophils, 1,560/mm3 lymphocytes), and a C-reactive protein of 2.89 mg/dL (normal value 0-0.5). CD4 count on presentation was 225 cells/µL. The patient was immediately treated with morphine (10 mg iv) and piperacillin/tazobactam (4.5 gr iv). The lesion presented erythe- matous ulcerated bleeding surface with serous and fetid secretion on which mobile larvae were found inside (as showed in the video). We removed about 20 maggots with blunt pliers, identi- fied as larvae of Musca domestica (housefly). Non -co mmerc ial us e o nly Images in Emergency [page 80] [Emergency Care Journal 2023; 19:11505] Answer The patient was admitted to the Infectious Disease Unit and was treated with ivermectin 12 mg was given orally in a single dose with complete cure of the myiasis. A broad-spectrum intra- venous antibiotics, which included Linezolid, ciprofloxacin and metronidazole, were infused for a total of 3 weeks, without improvement. A skin biopsy was done, and it revealed well-differ- entiated squamous cell carcinoma (SCC). After a combined onco- logical and orthopaedic consultation, he underwent surgical ampu- tation of the foot. The final diagnosis was skin myiasis in ulcered SCC of the left foot. Myiasis is an ectoparasitic infestation by Diptera larvae of higher flies of the genus Dermatobia. It can be a complication of malignant lesions, particularly those affecting the head and neck;1,2 of these, epidermoid carcinoma is one of the most frequently asso- ciated with this complication, particularly in patients with large, ulcerated, and necrotic SCC.3,5 Female flies have a strong visual and olfactory attraction to blood and decaying tissue, particularly tumour cell metabolites, which may explain the propensity of ulcerated malignant tumours to be parasitized. The goal of treat- ment is to mechanically remove with forceps all larvae to avoid deep invasion and bleeding. To date, no treatment guidelines for wound myiasis exist. Patel et al. recommend using ivermectin, albendazole, and clindamycin to eradicate the infestation.6 Large, ulcerated, necrotic, myiasis-burdened SCC lesions in the head and neck area still remain a challenge for treatment, par- ticularly in patients with aggressive malignancies in the hospice and palliative medicine settings.7 Grinblat et al. proposed a four- pillar protocol to rapidly improve wound condition through disin- fection, pain relief, and malodour and discharge eradication as a bridge to surgery.8 References 1. Villwock JA, Harris TM. Head and neck myiasis, cutaneous malignancy, and infection: A case series and review of the lit- erature. J Emerg Med 2014;47:e37–41. 2. Kondoh A, Ota M, Tokuyama M, et al. Case of Wound Myiasis in a Squamous Cell Carcinoma Lesion of the Scalp. Tokai J Exp Clin Med 2022;47:44-6. 3. Fukaura R, Terashima-Murase C, Mori S, et al. Myiasis on a spindle cell squamous cell carcinoma: A scanning electron microscope observation of Lucilia sericata larvae [online ahead of print]. J Dermatol 2023;10.1111/1346-8138.16833. 4. Gonçalves KKN, de Araújo ESM, Barbirato DS, et al. Head and neck cancer associated with myiasis. Int J Oral Maxillofac Surg 2022;51:847-53. 5. Jain A. Myiasis in patients with oral squamous cell carcinoma- a systematic review and protocol for management. Oral Maxillofac Surg 2019;23:265-9. 6. Patel BC, Ostwal S, Sanghavi PR, et al. Management of Malignant Wound Myiasis with Ivermectin, Albendazole, and Clindamycin (Triple Therapy) in Advanced Head-and-Neck Cancer Patients: A Prospective Observational Study. Indian J Palliat Care 2018;24:459-64. 7. Waidyaratne G, Zhou S, O'Neil T, Marks A. Management of Wound Myiasis in the Hospice and Palliative Medicine Setting. J Palliat Med 2021;24:797-800. 8. Grinblat G, Frenkel Y, Shochat I, et al. Myiasis in Neglected Cutaneous Squamous Cell Carcinoma of the Head and Neck: Review of Management and Current Protocol Recommendations. Adv Skin Wound Care 2021;34:372-8. Online supplementary material: Video. Mobile larvae in the wound. Non -co mmerc ial us e o nly