Neglected Myiasis Wound Presenting With Septic Shock: A Case ReportAbstractMyiasis is larval infestation of tissues, particularly common in tropical, and subtropical regions; especially in pre-existing wounds. Poor hygiene, inadequate wound care, exposed wounds, can predispose to secondary bacterial infection. We report a case of neglected myiasis wound in laborer from rural Nepal, presenting with septic shock; who was managed with intravenous fluids, antibiotics, and wound care.Key Clinical MessageNeglected wounds can be infested by insect larvae, and can have secondary bacterial infection; hence, early treatment should be done to prevent complications of secondary bacterial infection.KeywordsCase report, myiasis, neglected wound, sepsis, septic shockIntroductionMyiasis, the infestation of live vertebrate by dipterous larvae(1), is a significant health problem in tropical and subtropical regions, particularly in resource-limited settings(1,2). Myiasis primarily affects skin and wounds, however it can also involve mucosal surfaces and internal organs. (1) Poor hygiene, inadequate wound care, close vicinity with domestic animals, can result in secondary bacterial infection of myiasis wound. (1,3)Case History and ExaminationA 54 years male, laborer by occupation, with no known comorbidities, was brought to the emergency department with fever for 7 days, and decreased level of consciousness for 3 days. The patient reported that he had burn injury over his right leg, by cooking oil sustained while working in the kitchen 2 months ago. However, due to financial constraints, he had not sought medical care for the wound, and continued working with wounded leg. The wound progressively increased in size over time. He started having malaise since 2 weeks, followed by febrile sensation since 7 days. Since 3 days, he started feeling sleepy and could not go work. Police officers found him unconscious beside the road, and brought him to the emergency department. He used to consume around 500ml of local alcohol daily for last 10 years, and smoke 5 cigarettes daily for 10 years. At the time of admission, his Glasgow Coma Scale was 11/15, temperature 101°F, blood pressure 70/40 mm Hg, pulse 110/min, and respiratory rate 18/min. A large, circumferential full thickness wound was observed on his lower right leg, which was infested with maggots, foul-smelling, with pus, and necrotic tissues. Figure 1Investigations and TreatmentLaboratory investigations revealed total leukocyte count of 18000/mm³ with 92% neutrophils and 5% lymphocytes, blood urea level of 90mg/dl, and serum creatinine of 2mg/dl. 1000ml intravenous fluid bolus of Ringer’s Lactate, followed by another 500ml of Ringer’s Lactate was given in the emergency. However, his blood pressure was only 76/44 mm Hg after 1500ml fluid administration, following which Noradrenaline infusion was started at 0.1 mcg/kg/min. Empirical antibiotic therapy was initiated with intravenous Ceftriaxone 2gm immediately, followed 1 gm twice daily for 10 days followed by oral Cloxacillin for next 2 weeks. He regained full consciousness on 2nd day of admission. On 3rd day of admission, his Mean Arterial Pressure was consistently above 65mm Hg, so Noradrenaline infusion was stopped.Initially, the wound was irrigated with sterile saline, and maggots were manually removed using forceps and Turpentine oil. This procedure was repeated multiple times to ensure complete removal. Figure 2 The wound was initially cleansed with Povidone-iodine. All necrotic and infected tissue were excised to create a clean wound bed. Hemostasis was achieved using simple ligation and pressure dressings. Figure 3 Wound dressing was done daily with sterile gauze soaked in paraffin and Mupirocin. Healthy wound bed with granulation tissue was achieved only after 3 weeks, following which split-thickness skin graft, harvested from the patient’s thigh, was placed over the wound.Outcome and Follow-upThe graft uptake was good, and patient had full functional recovery. Follow up visit after 1 month, 3 months, and 6 months was normal.
