J Arthropod-Borne Dis, June 2016, 10(2): 268–271 F Demirel-Kaya et al.: A Case of Extensive … 268 http://jad.tums.ac.ir Published Online: January 05, 2016 Case Report A Case of Extensive Wound Myiasis Caused by Lucilia sericata (Diptera: Calliphoridae) in a Patient with Maxillary Sinus Squamous Cell Carci- noma, in Turkey *Filiz Demirel-Kaya 1, Ömer Orkun 2, Ayşe Çakmak 2, A Çağkan İnkaya 3, Murat Öcal 1, Sibel Erguven 1 1Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey 2Department of Parasitology, Ankara University Faculty of Veterinary Medicine, Ankara, Turkey 3Department of Internal Medicine, Infectious Diseases Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey (Received 8 Apr 2014; accepted 10 Aug 2014) Abstract The larvae causing myiasis can lead extensive tissue destruction, invasion into deep tissues and secondary infec- tions. Poor hygiene, low socioeconomic condition and presence of open wounds are the most important predisposing factors. This case report describes destructive wound myiasis in a 58-year-old male patient diagnosed with maxillary sinus squamous cell carcinoma who lives in a rural area in Ankara, Turkey. Approximately 200 larvae were collected and identified as Lucilia sericata by morphological examination. Myiasis should be considered especially when the patient has open extensive lesions such as malignant wounds. Keywords: Myiasis, Squamous cell carcinoma, Lucilia sericata Introduction Myiasis is defined as the parasitic infes- tation of tissues and organs in living verte- brates with dipterous larvae which at least for a certain period, feed on the host’s living or dead tissue, mucosa, liquid body substance or digested food (Hope 1840, Zumpt 1963). Myiasis is seen more typically in tropical and subtropical countries. Low socioeconomic status, poor sanitation, advanced age and vas- cular disorders are the most important risk fac- tors for myiasis (Francesconi and Lupi 2012). The clinical manifestation of myiasis de- pends on the genus and species of fly, the degree of invasion by larvae, the stage of the fly, number of larvae and the site of inva- sion. Skin involvement is the most seen clin- ical manifestation. Cutaneous myiasis includes furuncular, migratory and wound myiasis (Zumpt 1963, Francesconi and Lupi 2012). A broad range of flies can cause myiasis in humans, especially members of Oestridae, Calliphoridae and Sarcophagidae families are reported (Scholl 2002). Lucilia sericata flies belonging to the Calliphoridae family are very common flies in the temperate zone of North- ern hemisphere. They can cause myiasis in humans and domestic animals (Lane and Crosskey 1993). Diagnosis of myiasis depends on the demonstration of larvae on the patient’s tis- sues or organs. It is important to make the correct identification of the larvae for plan- ning the treatment and promoting preventing measures (Francesconi and Lupi 2012). Case presentation In this report, a case of maxillary sinus carcinoma complicated with myiasis was presented. A 58-year-old male patient living *Corresponding author: Dr Filiz Demirel Kaya, E- mail: filiz.kaya@hacettepe.edu.tr J Arthropod-Borne Dis, June 2016, 10(2): 268–271 F Demirel-Kaya et al.: A Case of Extensive … 269 http://jad.tums.ac.ir Published Online: January 05, 2016 in a rural area with low socioeconomic con- dition, admitted to the Hacettepe University Department of Emergency Medicine, Ankara, Turkey in July 2013, because of a suppu- rated, massive destructive lesion containing numerous larvae covering left half of his face. The patient had poor general condition. He was diagnosed maxillary squamous cell carcinoma five years ago, and catatonic schizophrenia. He had been operated four times because of his tumour before. The tumoural lesion of the patient was covered the left maxillary-orbital region and nose and there were a great number of larvae moving in his tumour lesion (Fig. 1). Ap- proximately 200 larvae were removed from his wound by mechanical and the lesion was rinsed using hydrogen peroxide solution. Some of the larvae delivered to the parasi- tology laboratory. After morphological ex- amination the larvae washed in distilled wa- ter and killed in alcohol 70 % and they were taken to the Ankara University Veterinary Faculty Department of Parasitology for iden- tification. The morphological characters of cephalo-pharyngeal skeleton, anterior spira- cles and slits of the posterior spiracles were examined. Measured length of 10–15 larvae were about 12 to 16 mm (Fig. 2). The anterior spiracles with 7–9 lobes, the posterior spira- cles with narrow and complete peritreme, straight and parallel 3 slits and cephalo- pharyngeal skeleton without accessory oral sclerite were observed by microscopically (Fig. 3). We also observed inner, median, outer and anal tubercles on the posterior segment of the larvae and the distance be- tween the tubercles on the top side of the posterior cavity was equal. The larvae were identified as 3rd instar of L. sericata. Be- cause of all the larvae were dead we could not rear the larvae to adult stage. The patient’s white blood cell count and C-reactive protein values were found high so meropeneme therapy was started. He had se- vere protein-energy malnutrition because of unabling to eat and a dietary supplement was intended. The patient was taken to the De- partment of Otorhinolaryngology for pal- liative operation for his tumour. Excision of mass, total left maxillectomy, total parotidec- tomy, partial mandibulectomy and rinectomy was performed. Fig. 1. Extensive destructive lesion of the maxillary- orbital region of the face with a lot of larvae inside Fig. 2. Macroscopic aspect of a larva J Arthropod-Borne Dis, June 2016, 10(2): 268–271 F Demirel-Kaya et al.: A Case of Extensive … 270 http://jad.tums.ac.ir Published Online: January 05, 2016 Fig. 3. A) Cephalopharyngeal skeleton, B) Anterior spiracle, C-D) Posterior spiracle Conclusion Lucilia sericata flies belong to Cal- liphoridae family which can cause myiasis in humans and domestic animals. The adult flies of the L. sericata species are metallic green and they are known as greenbottles. Females can deposit their eggs in neglected and suppurating wounds. The larvae hatch in a few days and feed on the tissues and exu- dates (Lane and Crosskey 1993). In humans, first case of myiasis due to L. sericata was reported in 1826 by Magen from mouth, eyes and paranasal sinuses of a patient. In literature there are several reports of cases with myiasis by L. sericata. Talari et al. (2004) reported a wound myiasis in a heroin addicted patient. Kılıç et al. (2011) presented a postoperative wound myiasis caused by L. sericata in a woman who had breast cancer surgery. Myiasis is one of the most undesirable conditions in cancer pa- tients with malignant cutaneous wounds and a rare complication of squamous cell carci- noma. Sesterhenn et al. (2009) reported a case of wound myiasis in an extensive skin metastasis of oral squamous cell carcinoma and they identified the larvae as Lucilia sp. Gabriel et al. (2008) presented a case of myiasis in a patient with extensive head and neck squamous cell carcinoma. Pessoa et al. (2011) reported myiasis infestation in a pa- tient with invasive oral squamous cell carci- noma with ulcerated necrotic wound. In all of these patients, open neglected wounds and poor hygiene are the most important predis- posing factors leading the infestation with larvae. Living in a rural area, advanced age and low socioeconomic conditions are also risk factors (Demirel-Kaya et al. 2014). Psychiatric disorder, low socio-economic level and poor hygiene are the most impor- tant predisposing factors that lead to the de- velopment of myiasis in this patient as well as the presence of an open, extensive ne- glected wound. It should be kept in mind that the cancer patients with open wounds may develop myiasis especially in the sum- mer months and larvae can cause progres- sive wound infection. Sometimes the presence of larvae is use- ful for the wounds. Maggot therapy is the medically use of sterile fly larvae in treat- ment of resistant wounds. Larvae can de- bride and clean wounds and promote heal- ing. L. sericata is usually used for the mag- got therapy (Falch et al. 2009). It has been also demonstrated that some of the enzymes and substances secreted by 2nd and 3rd in- star of the L. sericata larvae have bacterio- static and bactericidal effects and by this way the larvae can disinfect the lesions. (Polat et al. 2012). Acknowledgements The authors declare that there is no con- flict of interest. References Demirel Kaya F, Orkun O, Cakmak A, Inkaya AC, Erguven S (2014) Human cutanous myiasis caused by larvae of J Arthropod-Borne Dis, June 2016, 10(2): 268–271 F Demirel-Kaya et al.: A Case of Extensive … 271 http://jad.tums.ac.ir Published Online: January 05, 2016 Sarcophaga spp. in a diabetic patient. Mikrobiyol Bul. 48(2): 356–361. Falch BM, de Weerd L, Sundsfjord A (2009) Maggot therapy in wound management. Tidsskr Nor Laegeforen. 129(18): 1864– 1867. Francesconi F, Lupi O (2012) Myiasis. Clin Microbiol Rev. 25(1): 79–105. Gabriel JG, Marinho SA, Verli FD, Krause RG, Yurgel LS, Cherubini K (2008) Extensive myiasis infestation over a squamous cell carcinoma in the face. Med Oral Patol Oral Cir Bucal. 13(1): E9–11. Hope FW (1840) On insects and their larvae occasionally found in the human body. Trans R Soc Entomol. 2: 256–271. Kılıç K, Arslan MÖ, Kara M (2011) A post- operative Wound Myiasis Caused by Lucilia sericata (Diptera: Calliphori- dae) in a Woman in Kars. Turkiye Pa- razitol Derg. 35: 43–46. Lane RP, Crosskey RW (1993) Diptera causing myiasis in man In: Lane RP and Crosskey RW (Eds): Medical In- sects and Arachnids, Chapman and Hall, London, pp. 429–451. Pessoa L, Galvao V (2011) Myiasis infesta- tion in advanced oral squamous cell carcinoma. BMJ Case Rep. doi:10.1136/ bcr.04.2011.4124. Polat E, Cakan H, Aslan M, Sirekbasan S, Kutlubay Z, Ipek T, Ozbilgin A (2012) Detection of anti-leishmanial effect of the Lucilia sericata larval secretions in vitro and in vivo on Leishmania tropica: first work. Exp Parasitol. 132(2): 129– 134. Scholl PJ, Catts EP, Mullen GR (2002) Myi- asis.In: Mullen GR and Durden LA (Eds): Med Vet Entomol. 2nd ed. El- sevier, USA, pp. 309–338. Sesterhenn AM, Pfutzner W, Braulke DM, Wiegand S, Werner JA, Taubert A (2009) Cutaneous manifestation of my- iasis in malignant wounds of the head and neck. Eur J Dermatol. 19(1): 64–68. Talari SA, Sadr F, Doroodgar A, Talari MR, Gharabagh AS (2004) Wound myiasis caused by Lucilia Sericata. Arch Ira- nian Med. 7(2): 128–129. Zumpt F (1963) The problem of intestinal myiasis in humans. S Afr Med J. 37: 305–307.