- Email: [email protected]
Dermatobia hominis myiasis among travelers returning from South America
630 Brief reports
Administration. According to this report, 47% were cardiovascular symptom such as hypertension, myocardial infarction, and stroke, and 18% were central nervous system events such as seizures. Furthermore, hepatotoxic effects have also been reported.17 As these medicines containing Ephedra Hebra are now popular in the world, NPFDE or other forms of drug eruption caused by Chinese traditional herbal medicines should be taken into consideration in any country. REFERENCES 1. Abramowitz EW, Noun MH. Fixed drug eruptions. Arch Dermatol Syphil 1937;35:875-92. 2. Shelley WB, Shelley ED. Nonpigmenting fixed drug eruption as a distinctive reaction pattern: examples caused by sensitivity to pseudoephedrine hydrochloride and tetrahydrozoline. J Am Acad Dermatol 1987;17:403-7. 3. Alanko K, Kanerva L, Mohell-Talolahti B, Jolanki R, Estlander T. Nonpigmented fixed drug eruption from pseudoephedrine. J Am Acad Dermatol 1996;35:647-8. 4. Quan MB, Chow WC. Nonpigmenting fixed drug eruption after pseudoephedrine. Int J Dermatol 1996;35:367-70. 5. Hindioglu U, Sahin S. Nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride. J Am Acad Dermatol 1998;38:499-500. 6. Vidal C, Prieto A, Perez-Carral C, Armisen M. Nonpigmenting
J AM ACAD DERMATOL APRIL 2003
fixed drug eruption due to pseudoephedrine. Ann Allergy Asthma Immunol 1998;80:309-10. 7. Anibarro B, Seoane FJ. Nonpigmenting fixed exanthema induced by pseudoephedrine. Allergy 1998;53:902-3. 8. Krivda SJ, Benson PM. Nonpigmenting fixed drug eruption. J Am Acad Dermatol 1994;31:291-2. 9. Camisa C. Fixed drug eruption due to pseudoephedrine. Cutis 1988;41:339-40. 10. Hauken M. Fixed drug eruption and pseudoephedrine. Ann Intern Med 1994;120:442. 11. Valsecchi R, Cainelli T. Nonpigmenting fixed drug reaction to piroxicam. J Am Acad Dermatol 1989;21:1300. 12. Desmeules H. Nonpigmenting fixed drug eruption after anesthesia. Anesth Analg 1990;70:216-7. 13. Benson PM, Giblin WJ, Douglas DM. Transient, nonpigmenting fixed drug eruption caused by radiopaque contrast media. J Am Acad Dermatol 1990;23:379-81. 14. Roetzheim RG, Herold AH, Van Durme DJ. Nonpigmenting fixed drug eruption caused by diflunisal. J Am Acad Dermatol 1991;24:1021-2. 15. Garcia Ortiz JC, Terron M, Bellido J. Nonpigmenting fixed exanthema from ephedrine and pseudoephedrine. Allergy 1997;52: 229-30. 16. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343:1833-8. 17. Stickel F, Egerer G, Seitz HK. Hepatotoxicity of botanicals. Public Health Nutr 2000;3:113-24.
Dermatobia hominis myiasis among travelers returning from South America Jeremy Tamir, MD,a Josef Haik, MD,a Arie Orenstein, MD,a and Eli Schwartz, MD, DTMHb Tel Aviv, Israel Dermatobia hominis is the most common cause of myiasis in Central and South America, affecting mammals and humans, causing nonhealing furuncle-like lesions. During the years 1994 to 1999, 14 Israeli travelers returning from South America were diagnosed with D hominis myiasis. The approach consists of correct diagnosis and a proper removal of the larvae, after which the patients heal with no complications. (J Am Acad Dermatol 2003;48:630-2.)
M
yiasis is an infestation of human tissue by larvae of higher flies. Dermatobia hominis (the human botfly) is the most common localized myiasis in tropical America.1 The usual From the Plastic and Reconstructive Surgery Department,a and the Center for Geographic Medicine and Department of Medicine C,b Chaim Sheba Medical Center, The Sackler School of Medicine, Tel Aviv University. Funding sources: None. Conflict of interest: None identified. Reprint requests: Jeremy Tamir, MD, Department of Plastic and Reconstructive Surgery, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel. Email: [email protected]. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.37
host of D hominis is livestock mammals; humans are accidentally infested.2 The fly deposits its packet of eggs on a mosquito or other blood-feeding insect, which unknowingly transfers the eggs to a warmblooded animal. When the mosquito lands on the skin, the eggs hatch and penetrate the feeding site. The larva develops in the skin for 4 to 14 weeks, reaching a length of about 2 cm, exits, and drops to the ground to pupate. After 14 to 30 days the adult fly emerges and the life cycle resumes. In humans the skin lesions are most frequently seen on unprotected areas including the hands, legs, head, and neck. At first the lesions resemble a pruritic mosquito bite, but as the larva begins to move it produces severe pain and itching. The inflammatory
Brief reports 631
J AM ACAD DERMATOL VOLUME 48, NUMBER 4
Fig 1. Anatomic distribution of D hominis lesions in 14 patients.
response around the larva results in the development of a furuncle-like lesion with a central opening. The disease can be fatal in cattle infested with hundreds of larvae, but in humans it is usually an uncomplicated self-limited disease.
MATERIAL AND METHODS We analyzed all cases of D hominis myiasis in Israeli travelers returning from the Americas during a 6-year period (1994-1999). The patients were treated in the Center of Geographical Medicine at Sheba Medical Center, and the final diagnosis was done by The Entomology Department of the central laboratory of the Ministry of Health, Jerusalem.
RESULTS A total of 14 Israeli travelers returning from South America were diagnosed with D hominis myiasis. The mean age was 23 years with a range of 21 to 27 years. Women comprised 64% (9/14) of the total, and 36% were male (5/14). Nine cases (64%) occurred in the year 1999. The distribution of the lesions is depicted in Fig 1. The number of lesions per person ranged from 1 to 4. The mean time from exposure to diagnosis was 1.5 months. All patients presented with unhealed furuncle-like lesions and were unresponsive to antibiotic treatment (Fig 2). The lesions appeared most common on the arms and legs, but also on the buttocks and the abdominal area. Eleven larvae were surgically removed from 7 patients with no complications after the procedure.
Fig 2. Typical lesion of D hominis.
The removal process included injecting the lesion with 1% lidocaine, making a small incision at the opening, and evacuating the larva with a small hemostat (Fig 3). The wound was dressed with synthomycin 5% ointment. One patient had an abscess formation after an attempt to evacuate the larva in Peru. After surgical drainage and a course of IV antibiotics, the lesion healed uneventfully. Seven patients had a successful self-extraction of their larva. In these cases the attempt was done early (⬍1 month) after exposure when the larvae were relatively small.
DISCUSSION Few case reports of myiasis have been published in the medical literature, most related to D hominis in travelers returning from the tropical areas of South and Central America.3-7 Almost all cases originated in the tropical area of Bolivia in the area of Madidi National Park with an estimated attack rate of 1:190 travelers.8 The diagnosis is simple once the physician becomes familiar with the typical skin lesions and the specific anamnesis of traveling to an endemic region. With an inexperienced physician, the lesions are frequently misdiagnosed and confused with impetigo, insect bites, folliculitis, and other skin disorders, as happened to many of our patients who were seen by several doctors without a prompt diagnosis. The treatment can be conservative or surgical. Putting a sealing ointment and occluding the breath-
632 Brief reports
J AM ACAD DERMATOL APRIL 2003
best method of evacuating the larva is by making a small incision through the opening, inserting a small hemostat, and pulling the larva out (Fig 3); the wound usually heals with no complications. Any attempt to probe the wound with nonsterile equipment can result in a bacterial infection, cellulitis, and an abscess formation (as happened to 1 patient). We discourage self extraction of the larva, although it is a legitimate possibility when there is no medical facility nearby. An attempt to seal the opening can lead to the death of the larva in situ and formation of a foreign body granuloma, secondary infection, or calcification.11 Awareness of this skin disorder is the key to correct diagnosis. The treatment is simple and should be done appropriately to evacuate the larva completely. We thank Dr Hedva Pener from the Entomology Department, Ministry of Health, Israel.
Fig 3. Surgical evacuation of D hominis larva.
ing opening causes suffocation of the larva, which causes it to migrate from the skin.1,4 Brewer et al9 applied bacon to the larval apertures and caused them to migrate sufficiently far out of the skin to be removed with tweezers. Nunzi, Rongioletti, and Rebora10 injected lidocaine underneath the larva and produced sufficient pressure to push the larva out of the skin. Olumide11 described a method to extract the larva using pressure applied by two wooden spatulas. We treated a few of our patients with soft paraffin ointment applied to the lesions without success. A reasonable explanation for our conservative treatment failure is having seen the patients at the late stage of the larva. At an early stage, when it is still small and more superficial, it can be removed nonsurgically with no difficulty. As the larva matures, it grows numerous concentric rows of backward projecting spines that lock the larva in place and causes difficulty in dislodging it from the skin.1 From our experience, supported by others,12 the
REFERENCES 1. White GB. Flies causing myiasis. In: Cook GC, editor. Manson’s tropical diseases. London: WB Saunders; 1996. p. 1661-3. 2. Hall M, Wall R. Myiasis of humans and domestic animals. Adv Parasitol 1995;35:257-334. 3. Jelinek T, Nothfurft HD, Rieder N, Loscher T. Cutaneous myiasis: review of 13 cases in travelers returning from tropical countries. Int J Dermatol 1995;34:624-6. 4. Gordon PM, Hepburn NC, Williams AE, Bunney MH. Cutaneous myiasis due to Dermatobia hominis: a report of six cases. Br J Dermatol 1995;132:811-4. 5. Pallai L, Hodge J, Fishman S, Millikan L, Phelps R. Case report: myiasis—the botfly boil. Am J Med Sci 1992;303:245-8. 6. Rubel DM, Walder BK, Jopp-McKay A, Rosen E. Dermal myiasis in an Australian traveller. Australas J Dermatol 1993;34:45-7. 7. Taniguchi Y, Yamazaki S, Ando K, Shimizu M. Cutaneous myiasis due to Dermatobia hominis in Japan. J Dermatol 1996;23:125-8. 8. Schwartz E, Gur H. Dermatobia hominis myiasis among Israeli travelers to South America: an emerging disease in the Amazon basin of Bolivia. J Travel Med 2002;9:97-9. 9. Brewer TF, Wilson ME, Gonzalez E, Felsenstein D. Bacon therapy and furuncular myiasis. JAMA 1993;270:2087-8. 10. Nunzi E, Rongioletti F, Rebora A. Removal of Dermatobia hominis larva. Arch Dermatol 1986;122:140. 11. Olumide YM. Cutaneous myiasis: a simple and effective technique for extraction of Dermatobia hominis larva. Int J Dermatol 1994;33:148-9. 12. Richards KA, Brieva J. Myiasis in a pregnant woman and an effective, sterile method of surgical extraction. Dermatol Surg 2000;26:955-7.
Administration. According to this report, 47% were cardiovascular symptom such as hypertension, myocardial infarction, and stroke, and 18% were central nervous system events such as seizures. Furthermore, hepatotoxic effects have also been reported.17 As these medicines containing Ephedra Hebra are now popular in the world, NPFDE or other forms of drug eruption caused by Chinese traditional herbal medicines should be taken into consideration in any country. REFERENCES 1. Abramowitz EW, Noun MH. Fixed drug eruptions. Arch Dermatol Syphil 1937;35:875-92. 2. Shelley WB, Shelley ED. Nonpigmenting fixed drug eruption as a distinctive reaction pattern: examples caused by sensitivity to pseudoephedrine hydrochloride and tetrahydrozoline. J Am Acad Dermatol 1987;17:403-7. 3. Alanko K, Kanerva L, Mohell-Talolahti B, Jolanki R, Estlander T. Nonpigmented fixed drug eruption from pseudoephedrine. J Am Acad Dermatol 1996;35:647-8. 4. Quan MB, Chow WC. Nonpigmenting fixed drug eruption after pseudoephedrine. Int J Dermatol 1996;35:367-70. 5. Hindioglu U, Sahin S. Nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride. J Am Acad Dermatol 1998;38:499-500. 6. Vidal C, Prieto A, Perez-Carral C, Armisen M. Nonpigmenting
J AM ACAD DERMATOL APRIL 2003
fixed drug eruption due to pseudoephedrine. Ann Allergy Asthma Immunol 1998;80:309-10. 7. Anibarro B, Seoane FJ. Nonpigmenting fixed exanthema induced by pseudoephedrine. Allergy 1998;53:902-3. 8. Krivda SJ, Benson PM. Nonpigmenting fixed drug eruption. J Am Acad Dermatol 1994;31:291-2. 9. Camisa C. Fixed drug eruption due to pseudoephedrine. Cutis 1988;41:339-40. 10. Hauken M. Fixed drug eruption and pseudoephedrine. Ann Intern Med 1994;120:442. 11. Valsecchi R, Cainelli T. Nonpigmenting fixed drug reaction to piroxicam. J Am Acad Dermatol 1989;21:1300. 12. Desmeules H. Nonpigmenting fixed drug eruption after anesthesia. Anesth Analg 1990;70:216-7. 13. Benson PM, Giblin WJ, Douglas DM. Transient, nonpigmenting fixed drug eruption caused by radiopaque contrast media. J Am Acad Dermatol 1990;23:379-81. 14. Roetzheim RG, Herold AH, Van Durme DJ. Nonpigmenting fixed drug eruption caused by diflunisal. J Am Acad Dermatol 1991;24:1021-2. 15. Garcia Ortiz JC, Terron M, Bellido J. Nonpigmenting fixed exanthema from ephedrine and pseudoephedrine. Allergy 1997;52: 229-30. 16. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343:1833-8. 17. Stickel F, Egerer G, Seitz HK. Hepatotoxicity of botanicals. Public Health Nutr 2000;3:113-24.
Dermatobia hominis myiasis among travelers returning from South America Jeremy Tamir, MD,a Josef Haik, MD,a Arie Orenstein, MD,a and Eli Schwartz, MD, DTMHb Tel Aviv, Israel Dermatobia hominis is the most common cause of myiasis in Central and South America, affecting mammals and humans, causing nonhealing furuncle-like lesions. During the years 1994 to 1999, 14 Israeli travelers returning from South America were diagnosed with D hominis myiasis. The approach consists of correct diagnosis and a proper removal of the larvae, after which the patients heal with no complications. (J Am Acad Dermatol 2003;48:630-2.)
M
yiasis is an infestation of human tissue by larvae of higher flies. Dermatobia hominis (the human botfly) is the most common localized myiasis in tropical America.1 The usual From the Plastic and Reconstructive Surgery Department,a and the Center for Geographic Medicine and Department of Medicine C,b Chaim Sheba Medical Center, The Sackler School of Medicine, Tel Aviv University. Funding sources: None. Conflict of interest: None identified. Reprint requests: Jeremy Tamir, MD, Department of Plastic and Reconstructive Surgery, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel. Email: [email protected]. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 ⫹ 0 doi:10.1067/mjd.2003.37
host of D hominis is livestock mammals; humans are accidentally infested.2 The fly deposits its packet of eggs on a mosquito or other blood-feeding insect, which unknowingly transfers the eggs to a warmblooded animal. When the mosquito lands on the skin, the eggs hatch and penetrate the feeding site. The larva develops in the skin for 4 to 14 weeks, reaching a length of about 2 cm, exits, and drops to the ground to pupate. After 14 to 30 days the adult fly emerges and the life cycle resumes. In humans the skin lesions are most frequently seen on unprotected areas including the hands, legs, head, and neck. At first the lesions resemble a pruritic mosquito bite, but as the larva begins to move it produces severe pain and itching. The inflammatory
Brief reports 631
J AM ACAD DERMATOL VOLUME 48, NUMBER 4
Fig 1. Anatomic distribution of D hominis lesions in 14 patients.
response around the larva results in the development of a furuncle-like lesion with a central opening. The disease can be fatal in cattle infested with hundreds of larvae, but in humans it is usually an uncomplicated self-limited disease.
MATERIAL AND METHODS We analyzed all cases of D hominis myiasis in Israeli travelers returning from the Americas during a 6-year period (1994-1999). The patients were treated in the Center of Geographical Medicine at Sheba Medical Center, and the final diagnosis was done by The Entomology Department of the central laboratory of the Ministry of Health, Jerusalem.
RESULTS A total of 14 Israeli travelers returning from South America were diagnosed with D hominis myiasis. The mean age was 23 years with a range of 21 to 27 years. Women comprised 64% (9/14) of the total, and 36% were male (5/14). Nine cases (64%) occurred in the year 1999. The distribution of the lesions is depicted in Fig 1. The number of lesions per person ranged from 1 to 4. The mean time from exposure to diagnosis was 1.5 months. All patients presented with unhealed furuncle-like lesions and were unresponsive to antibiotic treatment (Fig 2). The lesions appeared most common on the arms and legs, but also on the buttocks and the abdominal area. Eleven larvae were surgically removed from 7 patients with no complications after the procedure.
Fig 2. Typical lesion of D hominis.
The removal process included injecting the lesion with 1% lidocaine, making a small incision at the opening, and evacuating the larva with a small hemostat (Fig 3). The wound was dressed with synthomycin 5% ointment. One patient had an abscess formation after an attempt to evacuate the larva in Peru. After surgical drainage and a course of IV antibiotics, the lesion healed uneventfully. Seven patients had a successful self-extraction of their larva. In these cases the attempt was done early (⬍1 month) after exposure when the larvae were relatively small.
DISCUSSION Few case reports of myiasis have been published in the medical literature, most related to D hominis in travelers returning from the tropical areas of South and Central America.3-7 Almost all cases originated in the tropical area of Bolivia in the area of Madidi National Park with an estimated attack rate of 1:190 travelers.8 The diagnosis is simple once the physician becomes familiar with the typical skin lesions and the specific anamnesis of traveling to an endemic region. With an inexperienced physician, the lesions are frequently misdiagnosed and confused with impetigo, insect bites, folliculitis, and other skin disorders, as happened to many of our patients who were seen by several doctors without a prompt diagnosis. The treatment can be conservative or surgical. Putting a sealing ointment and occluding the breath-
632 Brief reports
J AM ACAD DERMATOL APRIL 2003
best method of evacuating the larva is by making a small incision through the opening, inserting a small hemostat, and pulling the larva out (Fig 3); the wound usually heals with no complications. Any attempt to probe the wound with nonsterile equipment can result in a bacterial infection, cellulitis, and an abscess formation (as happened to 1 patient). We discourage self extraction of the larva, although it is a legitimate possibility when there is no medical facility nearby. An attempt to seal the opening can lead to the death of the larva in situ and formation of a foreign body granuloma, secondary infection, or calcification.11 Awareness of this skin disorder is the key to correct diagnosis. The treatment is simple and should be done appropriately to evacuate the larva completely. We thank Dr Hedva Pener from the Entomology Department, Ministry of Health, Israel.
Fig 3. Surgical evacuation of D hominis larva.
ing opening causes suffocation of the larva, which causes it to migrate from the skin.1,4 Brewer et al9 applied bacon to the larval apertures and caused them to migrate sufficiently far out of the skin to be removed with tweezers. Nunzi, Rongioletti, and Rebora10 injected lidocaine underneath the larva and produced sufficient pressure to push the larva out of the skin. Olumide11 described a method to extract the larva using pressure applied by two wooden spatulas. We treated a few of our patients with soft paraffin ointment applied to the lesions without success. A reasonable explanation for our conservative treatment failure is having seen the patients at the late stage of the larva. At an early stage, when it is still small and more superficial, it can be removed nonsurgically with no difficulty. As the larva matures, it grows numerous concentric rows of backward projecting spines that lock the larva in place and causes difficulty in dislodging it from the skin.1 From our experience, supported by others,12 the
REFERENCES 1. White GB. Flies causing myiasis. In: Cook GC, editor. Manson’s tropical diseases. London: WB Saunders; 1996. p. 1661-3. 2. Hall M, Wall R. Myiasis of humans and domestic animals. Adv Parasitol 1995;35:257-334. 3. Jelinek T, Nothfurft HD, Rieder N, Loscher T. Cutaneous myiasis: review of 13 cases in travelers returning from tropical countries. Int J Dermatol 1995;34:624-6. 4. Gordon PM, Hepburn NC, Williams AE, Bunney MH. Cutaneous myiasis due to Dermatobia hominis: a report of six cases. Br J Dermatol 1995;132:811-4. 5. Pallai L, Hodge J, Fishman S, Millikan L, Phelps R. Case report: myiasis—the botfly boil. Am J Med Sci 1992;303:245-8. 6. Rubel DM, Walder BK, Jopp-McKay A, Rosen E. Dermal myiasis in an Australian traveller. Australas J Dermatol 1993;34:45-7. 7. Taniguchi Y, Yamazaki S, Ando K, Shimizu M. Cutaneous myiasis due to Dermatobia hominis in Japan. J Dermatol 1996;23:125-8. 8. Schwartz E, Gur H. Dermatobia hominis myiasis among Israeli travelers to South America: an emerging disease in the Amazon basin of Bolivia. J Travel Med 2002;9:97-9. 9. Brewer TF, Wilson ME, Gonzalez E, Felsenstein D. Bacon therapy and furuncular myiasis. JAMA 1993;270:2087-8. 10. Nunzi E, Rongioletti F, Rebora A. Removal of Dermatobia hominis larva. Arch Dermatol 1986;122:140. 11. Olumide YM. Cutaneous myiasis: a simple and effective technique for extraction of Dermatobia hominis larva. Int J Dermatol 1994;33:148-9. 12. Richards KA, Brieva J. Myiasis in a pregnant woman and an effective, sterile method of surgical extraction. Dermatol Surg 2000;26:955-7.