|Year : 2015 | Volume
| Issue : 1 | Page : 50-53
Cicatricial alopecia as a sequel to furuncular myiasis of the scalp in an immunocompetent child
Aditya Kumar Bubna, Sudha Rangarajan, Sankarasubramanian Anandan, Mahalakshmi Veeraraghavan
Department of Dermatology, Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India
|Date of Web Publication||16-Jan-2015|
Aditya Kumar Bubna
Department of Dermatology, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Furuncular myiasis (FM) is a type of cutaneous myiasis, a human infestation by maggots of Diptera flies. Our patient presented with scalp lesions closely mimicking pyoderma of the scalp, only to reveal crawling larvae of Lucilia sericata. Though the patient was promptly managed, cicatricial alopecia as a tell-tale sign of FM remained.
Keywords: Cicatricial alopecia, furuncular myiasis, Lucilia sericata
|How to cite this article:|
Bubna AK, Rangarajan S, Anandan S, Veeraraghavan M. Cicatricial alopecia as a sequel to furuncular myiasis of the scalp in an immunocompetent child. Indian J Paediatr Dermatol 2015;16:50-3
|How to cite this URL:|
Bubna AK, Rangarajan S, Anandan S, Veeraraghavan M. Cicatricial alopecia as a sequel to furuncular myiasis of the scalp in an immunocompetent child. Indian J Paediatr Dermatol [serial online] 2015 [cited 2019 Dec 9];16:50-3. Available from: http://www.ijpd.in/text.asp?2015/16/1/50/149435
| Introduction|| |
Myiasis refers to larvae of Diptera flies invading living, necrotic or dead tissue.  Cutaneous myiasis is of two types, wound myiasis and furuncular myiasis (FM). This infestation predominantly occurs in rural areas in individuals with poor standards of hygiene. Immunosuppression is another predisposing factor in acquiring this condition. If not promptly diagnosed and treated, these maggots can notoriously complicate things owing to tissue invasion and destruction.
| Case report|| |
A 2-year-old child presented to the Department of Dermatology with matted hair and a foul smelling discharge from the scalp for the past three months, associated with intermittent fever. There was a history of poultice application over the scalp for three months with no improvement of the condition. Treatment was taken in the village only to complicate issues further. Inspection of the scalp revealed matted hair with multiple edematous ulcers discharging a sero-purulent fluid [Figure 1]. On closer examination, sensations of movement could be clearly visualized within the ulcers from one end to the other, showing the motile fly larvae [Figure 2]. The maggots were sent to the entomologist who suggested it to be the larvae of Lucilia sericata (Green bottle fly) [Figure 3]. The important findings in the diagnostic panel were a total leucocyte count of 33,700/mm 3 , pus culture from the discharge growing Staphylococcus aureus with sensitivity to cephalexin, a negative HIV, hepatitis C virus and HBsAg status and a nonreactive venereal disease research laboratory test. A skull X-ray did not show any bone involvement and a computerized tomography with contrast of the brain revealed multiple superficial filling defects of varying sizes in the right high parietal and mid post parietal region of the scalp with loss of the normal skin integrity of that area. The skull vault and the brain parenchyma were normal [Figure 4] and [Figure 5]. The patient was aggressively managed with daily turpentine dressings and maggot removal along with appropriate antibiotics and anti-histaminics. Patient gradually improved with closure of the scalp ulcers, though leaving behind cicatricial alopecia (CA) as a sequel to the infestation [Figure 6].
|Figure 2: A close up view of the first figure demonstrating a deep pocket within the ulcer. Maggots were seen in these pockets. However because of the light used for photography, the maggots have crawled inside|
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|Figure 4: Contrast CT of the skull showing linear filling drfects depicting multiple sinus tracts over the right parietal region of the scalp. These filling defects correspond to the areas occupied by maggots|
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|Figure 5: Another section of the contrast skull CT. To note here are the intact skull bones with no involvement of the underlying brain|
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|Figure 6: Cicatricial alopecia as a sequel to furuncular myiasis of the scalp|
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| Discussion|| |
FM also referred to as warble, occurs after the fly larvae penetrate into the healthy skin of the host. The predisposing factors in our patient were poor hygiene and a low socioeconomic status, two important variables in acquiring FM, , along with existing suppurative lesions that could have attracted the female insect fly to deposit her eggs, thus perpetuating the assault. FM is most commonly caused by the bot fly (Dermatobia hominis) or the tumbu fly (Cordylobia arthrophagia)  , though in our case the culprit was the green bottle fly (L. sericata). Once the eggs hatch, the larvae quickly detach themselves delving into the subcutaneous tissue because of the increased temperature there, where they feed and grow for a period of 50-60 days, after which they pupate and emerge as adult flies thus continuing the cycle  . The infested maggots grow and produce a swelling in the subcutaneous tissue with a central punctum or pore, through which the larvae performs the function of respiration and excretion. Clinically the presentation is characterized by episodes of pruritus, bouts of severe lancinating pains and expression of a serosanguinous discharge. ,, On examination, the hallmark lesion in warble is a nodule resembling a furuncle from which a sensation of movement can be perceived. Though, other variants, well documented, include the vesiculobullous type, pustular variant, ulcero-erosive variant, and the ecchymotic type. However, these presentations are more common in the malnourished and the immune-compromised individual. By the time we received our patient, the furuncular morphology was not at all evident, rather it was the ulcerations teeming with maggots, which was striking. Generally complete healing of the lesions is a rule without any sequel after appropriate treatment. In occasional cases scarring may be a complication as seen in our patient. Treatment is directed toward complete maggot removal along with symptomatic treatment for the symptoms like pain and pruritus. Conventional modalities to extract the offending larvae are surgical excision or occluding the punctum to suffocate the maggots, thus prompting its exit from the sinuses. ,, Materials advocated for this purpose include mineral oils, petrolatum jelly, pork fat, nail polish and chewing gum.  10% lignocaine injection into the cavity containing the larvae may prove effective also, though larval trauma and secondary inflammation could follow and thus, should be considered only as a last resort.  However, these techniques may not be sufficient to cause complete larval extrusion and must be therefore complemented with mechanical removal like grasping the maggots with forceps and extracting it out. A venom extractor has also been found to be useful for this purpose.  Topical 1% ivermectin has been applied over the lesions, though after its usage there is a high probability of the dead larvae to get trapped within the subcutaneous tissue  and there could be a hypersensitivity reaction so it would be prudent to avoid this. Surgical treatments are also available for the same. However, they are seldom warranted, except in recalcitrant cases, wherein a cruciate incision may be employed for maggot removal.  Along with this, debridement of the necrotic debris from the maggot containing pockets would be essential in the management of such cases.  Systemic treatment with Ivermectin is usually not recommended for FM, as owing to larval death within the subcutaneous tissue a localized tissue reaction could occur along with inflammatory symptoms.  In our patient turpentine oil was used for maggot suffocation followed by forcep extraction of the larvae. To treat the secondary bacterial infection cephalexin was the antibiotic employed. Our patient responded exceedingly well to the above treatment with complete clinical remission. However, CA as a sequel persisted. We present this case because of the unusual presentation in an immune-competent child, L. sericata (Green bottle fly) a rare agent in FM and the possibility of FM being a very rare cause of CA.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]