J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 317 http://jad.tums.ac.ir Published Online: September 30, 2020 Case Report Gastrointestinal Myiasis Due to Sarcophaga argyrostoma (Diptera: Sarcophagidae) in Mashhad, Iran: A Case Report *Mohsen Najjari1; Bilal Dik2; Gamze Pekbey3 1Department of Parasitology and Mycology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran 2Department of Parasitology, Faculty of Veterinary Medicine, Selçuk University, Selçuklu, Konya, Turkey 3Department of Plant Protection, Faculty of Agriculture, Bozok University, Yozgat, Turkey *Corresponding author: Dr Mohsen Najjari, E-mail: najjarimh@mums.ac.ir (Received 07 Jan 2019; accepted 05 Jul 2020) Abstract Myiasis is infection with a fly larva, usually occurring in tropical and subtropical areas. A 32-years-old immunocompro- mised woman with fever, gastrointestinal pain, cramps, vomiting; and fatigue was referred to Ghaem Hospital in Mash- had in July 2018. Entomological characterisation of cephaloskeletons, posterior spiracles of the excreted larvae and gen- ital dissection of male fly were diagnosed as Sarcophaga (Liopygia) argyrostoma. Accidental intestinal myiasis caused by unplanned intake of dipterous larvae by contaminated food staff or water. Patients with immune deficiency may be more at risk for the threat of maggot’s infestation, so in such cases, hospital standard should be more in attention. To best of our knowledge, S. argyrostoma has not been reported before in the indexed literature from Iran. Keywords: Sarcophaga argyrostoma; Intestinal myiasis; Iran Introduction For many years human body cavities have been attacked by insects’ larvae. The word my- iasis has been derived from ancient Greek lan- guage in which “Mya” means fly and “isasis” means disease (1). Afterward, in year 1840 the term “myiasis” appeared to describe a human ailment that arose from dipterous maggots (2). More recently, it has been more cleared and depicted as invasion of live vertebrate animals and human with fly maggots which in any event for a specific period, feed on the host’s dead or living tissue, liquid body substances, or ingest- ed sustenance (3). In general, it starts when gravid female flies are attracted by the odors of infected wounds, decaying organic matter, feces, urine, and hu- man food, where they deposit larvae or eggs (4) and principally, classified in two groups: ento- mologically and anatomically. From entomo- logical aspect, it can be classified into two major categories named primary and secondary my- iasis. In primary myiasis larvae more found in animals, and rarely found in humans and feed- ing on living tissue in other side, flies could feed on dead tissues and necrotic lesions in patients known as secondary myiasis. It also classified according to the anatomy and position involved in the host body and had classified as oral, na- sopharyngeal ocular, cutaneous, urogenital and intestinal (5). Myiasis can be also classified as obligatory, facultative and accidental. This al- so categorize as entomological point of view (6). Myiasis of the intestinal tract (=intestinal myiasis) caused by accidental ingestion of dip- terous eggs or larvae usually transited and asymptomatic. The flies that cause gastrointes- tinal myiasis usually are the members of the families Sarcophagidae and Muscidae (7). The aim of the study was to report intes- tinal myiasis that is uncommon in Iran though so far there are just three reports of Sarcophaga (Bercae) africa (as S. haemorrhoidalis), Eristalis Copyright © 2020 The Authors. Published by Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by- nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. http://jad.tums.ac.ir/ https://en.wikipedia.org/wiki/Eristalis_tenax https://creativecommons.org/licenses/by-nc/4.0/ https://creativecommons.org/licenses/by-nc/4.0/ J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 318 http://jad.tums.ac.ir Published Online: September 30, 2020 tenax and Lucilia illustris can be seen in lit- erature (8, 9). Case description A 32 years-old woman from Golestan Prov- ince was referred to Ghaem Hospital in Mash- had, northeastern Iran with fever, weakness, gas- trointestinal pain, cramps, vomiting, fatigue and weight loss in July 2018. Her main complica- tion was lasted profound and repeated watery diarrhea started since six months ago. She had a double kidney transplant history seven years ago. Other significant clinical results were: Hb: 8, WBC: 3400, CRP: +++ and ESR: 100, CD4 102, level of cyclosporine in her sera was 3.5. She was before roll out for HIV, HCV, HTLV1, Cryptosporidium spp., Entamoeba histolytica, Toxoplasma gondii and intestinal tuberculosis due to flask like wound in her the large intes- tine appeared in colonoscopy. Complementary diagnostic process was performed and cyto- megalovirus confirmed by real time-PCR. She was treated with Ganciclovir (5% (oral), Hoff- mann La Roche) and using a standard protocol. After ten days of her remedy and subside of her gastric pain and diarrhea due to new complaints of abdominal spasms, gastric pain and diarrhea a new stool sample was sent to parasitology la- boratory. The result was negative for parasite but in macroscopic examination 15 whitish moved worm like observed that later confirmed for maggots of a fly. To investigate whether the feces were infested by larvae from the canteen in which the patient was defecating a sigmoidosco- py was performed in next day and feces directly obtained from the large intestine. The sample was examined and appeared the presence of five live maggots. Due to the threat of maggot tissue penetration, the patient was situated under co- lonoscopy to examine the presence of bare lar- vae in the tissue. There were no larvae although in her biopsy milled inflammatory cells were seen and also evidence of wounds healing showed no additional antibiotic and the extra drug prescribed because of any evidence of con- tinued infestation in her next stool samples ex- amination. Due to the advent of symptoms of healing, get a relative general improvement and disappearance of diarrhea and gastrointestinal symptoms by complete exertion of larvae, af- ter tree week of hospitalization, she was tem- porarily discharged from the hospital regarding her request to continue the treatment at home. In the Laboratory of Parasitology, Ghaem Hospital at first glance and macroscopic ex- amination of feces, the larvae were miss-diag- nosed as pinworms (10) by lab technician while in microscopic examination afterward they were detected as the early stage of unknown fly lar- vae. Obtained wormy like creature was washed using phosphate-buffered saline solution (pH: 7.4). To early diagnosis the larvae one of them cleared by lactophenol and examined again under a light microscope. Five live cylindrical maggots measured they were around 9mm in length and 3mm in diameter and transferred on blood agar medium which usually used for microbiology investigation. After three days the larvae grow as instars III. Three of them saved and fixed by formalin 10% for further larval diagnosis and transferred to Department of Parasitology, Veterinary Faculty of Selçuk University in Konya, Turkey while the re- mained two other transferred in a garden soil glass jar (5cm high), they immediately pene- trated deep into the soil. Five days later, pupas were observable and photographed when they were gently removed from the soil. Finally, after ten days, two adult flies appeared (Fig. 1). The adult flies transferred in a carton box to the Entomology lab in Bozok University, Yozgat, in Turkey for the identification. The other early stage larvae were preserved in eth- anol 70% and save in the collection of Mu- seum of Mashhad University of Medical Sci- ences using assigned voucher numbers. The larvae washed by distilled water, trans- ferred to ethanol 70% and 99% for a few hours in each step, dissected and mounted on the slides in Canada balsam. They were exam- ined, and captured photos of cephaloskeleton, http://jad.tums.ac.ir/ https://www.google.com/search?q=oral&stick=H4sIAAAAAAAAAONgVuLSz9U3MCpPzjXIAwCRHVLMDgAAAA&sa=X&ved=2ahUKEwisntLNqcTfAhVLaBoKHXSJCpQQmxMoATAXegQIChAN J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 319 http://jad.tums.ac.ir Published Online: September 30, 2020 anterior and posterior spiracles with Nikon SMZ camera mounted stereo zoom microscope with Toupcam U3CMOS application unit, and Leica DM750 camera mounted trinocular microscope with Leica DFC295 application unit. The lar- vae were identified as two and third instars of Sarcophaga spp. (Diptera: Sarcophagidae) (11). The body of larva in follows the general pat- tern of Sarcophagidae, i.e., anterior spiracles are seen (Fig. 2). The third instar of S. argyro- stoma was easily recognizable from second instar larva; it has three slits in each one of posterior spiracles by the presence of two slits in posterior spiracles (Figs. 3, 4). The larva had a pair of strong oral hooks and a ceph- aloskeleton (Figs. 5, 6). In the Entomology lab at Bozok Universi- ty, genital dissection of the adult male was per- formed under Leica S8APO stereomicroscope; only the fifth abdominal sternite was softened for 24h in a cold solution of 10% KOH to fa- cilitate the further dissection. Identification, classification, and terminology followed and, the specimen was identified as S. (Liopygia) argyrostoma (Fig. 7) (12). Digital photos of the genitalia were captured with Leica MZ 125 cam- era mounted stereo zoom microscope and Leica application suite (ver. 3.8.0). Fig. 1. Adult fly of Sarcophaga argyrostoma appeared in Parasitology lab, Ghaem hospital, Mashhad, July 20, 2018 Fig. 2. Sarcophaga argyrostoma, third instar larva, anterior stigma, Entomology lab Selçuk University in Konya, August 19, 2018 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 320 http://jad.tums.ac.ir Published Online: September 30, 2020 Fig. 3. Sarcophaga argyrostoma, second instar larva, posterior stigma, Entomology lab Selçuk University, August 19, 2018 Fig. 4. Sarcophaga argyrostoma, third instar larva, posterior stigma, Entomology lab Selçuk University, August 19, 2018 Fig. 5. Sarcophaga argyrostoma, second instar larva -cephaloskeleton and anterior stigma, Entomology lab Selçuk University, August 19, 2018 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 321 http://jad.tums.ac.ir Published Online: September 30, 2020 Fig. 6. Sarcophaga argyrostoma, third instar larva, cephaloskeleton and anterior stigma, Entomology lab Selçuk Uni- versity, August 19, 2018 Fig. 7. Sarcophaga argyrostoma; A- Aedeagus lateral view B- Epandrium with cerci and surstylus C- Fifth abdominal sternite, Entomology lab at Bozok University, August 29, 2018 Discussion It is necessary to consider two distinct sub- jects in the diagnosis of intestinal myiasis; the principal issue considered is the presence of fly larvae in feces does not affirm the significance of intestinal myiasis. Most species of fly eggs or larvae that coincidentally may be intake with http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 322 http://jad.tums.ac.ir Published Online: September 30, 2020 nourishment cannot continue in the gastrointes- tinal environment. In such cases, true host in- festation is never established, despite the fact, the dead larvae might be distinguished on last stool examinations. Such a circumstance is named pseudomyiasis (13). Pseudomyiasis can likewise happen when female flies lay eggs on uncovered fecal samples pot before perform- ing laboratory processing (14). The other en- counter challenge is the coexistence of con- comitant infection as parasites, fungi, and virus- es which may produce common related signs as cramp, gastric pain, vomiting and mislead to fi- nal intestinal myiasis diagnosis. It is important, therefore, for the symptomatic and asympto- matic patient to find live larvae more than once in stool examination and the best way is to ob- tain samples through sigmoidoscopy and direct- ly from the large intestine (15). Intestinal infestations with fly larvae have been rarely reported, especially from develop- ing countries, however, there are such reports as Africa in Zimbabwe (Harare) (16), North America in Laramie, Wyoming (17), Taiwan, Japan, Thailand, China, India, Iran (9) and Tur- key (18). Clinical presentations have been var- ied, including abdominal pain, nausea and vom- iting, or even anal pruritus, and rectal bloodless; moreover, in some cases, it could be asympto- matic (9). To date myiasis agents associated with accidental intestinal myiasis reported as Sarcophaga spp., Fannia canicularis, Hermetia illucens, Eristalis tenax, Muscina stabulans, Fannia scalaris, Musca domestica, Lucilia cu- prina, Stomoxys calcitrans and Phormia re- gina (15). To best of our knowledge, this is the first report of S. argyrostoma reported from the family Sarcophagidae in the review of the lit- eratures revealed for intestinal myiasis. In this case, the patient was admitted to a private room. On the other hand, the patient has been under a special diet by a dietitian during the hos- pitalization period also the consumed food have been served under appropriate catering health conditions. In an interview with the patient, we found that she has a homemade meal [tradition- al dish] which ingredients were starch, sugar and a kind of herbal extract was prepared out of the hospital. We discovered the remaining in her room refrigerator infested by a few tiny flies’ larvae. This myiasis agent can success- fully pass the gastrointestinal tract and over- come the acidic environment of the stomach and enzymatic digestion in the small intestine reported for the first time as human intestinal myiasis, caused by S. argyrostoma in this case. Although cited fly has reported previously in wound myiasis in an old woman in Italy (19), but has a very low occurrence rate and, does not cause any remarkable disorder for patients. Patients with immune deficiency may be more at risk for the threat of maggot’s infestation (20), so in such cases, hospital standards should be more in attention. It is also necessary to moni- tor such patients to use only hospital meal and minimize the consumption of uncared foodstuff with outside origin. The importance of the cur- rent study is hospitalized patients, who encoun- tered to such larvae in their stool samples, are more concerned about; moreover, for labora- tory staff, to avoid misdiagnosis with some other kind of worms in the stool; furthermore, it could be attracted for health professionals to aware that this infestation may happen regard- less of the socioeconomic conditions. Conclusion Accidental Intestinal myiasis regularly hap- pened due to unplanned intake of dipterous lar- vae by contaminated food staff or water. Pa- tients with immune deficiency may be more at risk for the threat of maggot’s infestation so health care professionals should be aware for different routs of such infestations and hospital standards elevation moreover to reach an ear- ly and on time laboratory diagnosis, using En- tomologist collaboration undoubted led to sa- lient decrease of related morbidities not over- looked. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2020, 14(3): 317–324 M Najjari et al.: Gastrointestinal Myiasis Due to … 323 http://jad.tums.ac.ir Published Online: September 30, 2020 Acknowledgements I take this opportunity to express my grati- tude to Mr Seyed Masud Marjani for his sup- port and lab assistance. The authors declare that there is no con- flict of interests. References 1. Khan M, Mehboob B, Noor ULW, Mansoor N (2014) Oral myiasis: a case series of 11 patients treated at Khyber college of dentistry hospital peshawar. Pak Oral Dent J. 34(1): 56–60. 2. 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