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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 797-799 |
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| Myiasis as a rare complication of neglected pemphigus vulgaris: Two cases |
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Ajeet Singh, Tamil S Kumar, Satyaki Ganguly, Meghana P S. Reddy
From the Department of Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Ajeet Singh
Department of Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_681_22
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How to cite this article:
Singh A, Kumar TS, Ganguly S, S. Reddy MP. Myiasis as a rare complication of neglected pemphigus vulgaris: Two cases. Indian J Dermatol 2022;67:797-9 |
How to cite this URL:
Singh A, Kumar TS, Ganguly S, S. Reddy MP. Myiasis as a rare complication of neglected pemphigus vulgaris: Two cases. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:797-9. Available from: https://www.e-ijd.org/text.asp?2022/67/6/797/370339 |
Sir
A 35-year-old female, with a known case of pemphigus vulgaris with a history of receiving systemic steroids presented with multiple, clear fluid-filled blisters over the body and oral ulcers for four months. The patient did not have any other co-morbidity. On cutaneous examination, multiple, flaccid, clear fluid-filled bullae along with crusted erosions were present mainly over the back, chest, face, and proximal limbs [Figure 1]. There were multiple oral and genital erosions associated with candidiasis. Few maggots were seen crawling out of the vaginal orifice [Figure 2]. Her laboratory investigations showed anemia, leukocytosis, hypoalbuminemia, and 5 to 10 pus cells per high-power field on urine microscopy. Blood culture and urine culture were sterile while pus culture from the erosions showed Pseudomonas aeruginosa growth. A diagnosis of wound myiasis complicating pemphigus vulgaris was made. Turpentine oil-soaked gauze was kept in the vaginal cavity followed by manual removal of maggots. The patient was started on intravenous (IV) piperacillin-tazobactam and systemic steroid followed by pulse steroid therapy. She improved significantly over the next 4 weeks with the healing of most of the erosions [Figure 3]. | Figure 1: Extensive erosions of pemphigus vulgaris over the back and upper extremities in case 1
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 | Figure 3: Healed erosions with post inflammatory hyperpigmentation after one month of treatment in case 1
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The second patient was a 62-year-old male belonging to a lower socio-economic status, neglected by his family members, and a known case of pemphigus vulgaris presented with few bullae and multiple, painful cutaneous and oral erosions for 1 month. He was hemodynamically stable at the time of presentation. His mucocutaneous examination revealed oral erosions with candidiasis and multiple erosions of varying sizes, involving the trunk, extremities, and the bilateral gluteal region. Multiple sinuses were present over the ulcers on bilateral gluteal region with maggots crawling in and around the sinuses [Figure 4]. Turpentine oil-soaked gauzes were kept over bilateral gluteal regions followed by manual removal of maggots. Laboratory investigations showed anemia, leukocytosis (17,000/mm3), urea 86 mg/dL along with hyponatremia and hypoalbuminemia. Urine routine microscopy showed the presence of pus cells. Blood, pus, and urine culture were sent. The patient was started on IV dexamethasone 8 mg daily, IV piperacillin-tazobactam and metronidazole empirically. Unfortunately, on the second day of admission, the patient went into septicemia, had a cardiac arrest, and succumbed. | Figure 4: Multiple erosions over the back and buttocks with maggots seen over the erosions on the gluteal region in case 2
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Myiasis is derived from the Greek word “myia” meaning fly. It is defined as the infestation of humans and vertebrate animals with dipterous (two-winged) larvae which feed on the living or dead necrotic tissue of the host.[1] Poor hygiene, low socioeconomic status, negligence, and debilitated patients are the common predisposing factors for this condition.[2]
Based on the host-parasite relationship, myiasis caused by fly larvae can be classified into three types- obligatory, facultative, and accidental type. Myiasis can also be classified according to the site of involvement as cutaneous, nasopharyngeal, ophthalmic, intestinal, urogenital, etc., Cutaneous myiasis includes furuncular, migratory, and wound myiasis (as in the cases of Pemphigus vulgaris).[3]
Diagnosis of myiasis can be done by morphological identification of maggots. Dermoscopy plays an important role in the species identification of myiasis.[4] Skin ultrasound can also be used to identify the deeper tissue invasion. Treatment of myiasis includes manual removal of the visible larvae, debridement of necrotic tissue, irrigation with an antiseptic solution, and daily dressing. Various agents used to suffocate and paralyze the larvae include chloroform in olive oil, turpentine oil, petroleum jelly and liquid paraffin.[5] Broad-spectrum antibiotics are frequently used to prevent secondary infection.
Myiasis can be seen in various dermatological conditions such as giant squamous cell carcinoma, Bowen's disease, large genital seborrheic keratosis, ulcers in leprosy, and diabetic ulcers, etc.[5] However, myiasis in association with pemphigus vulgaris has rarely been reported with only two cases reported to date to the best of our knowledge.[3],[6]
Our cases highlight that myiasis can occur in neglected pemphigus erosions, further complicating the disease course and can lead to septicemia or even death as in one of our patients. Its early diagnosis and treatment are vital to improve the overall prognosis of pemphigus and as a dermatologist, the suspicion of a maggot infestation in cases of long-standing pemphigus ulcers in debilitated patients is warranted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Robbins K, Khachemoune A. Cutaneous myiasis: A review of the common types of myiasis. Int J Dermatol 2010;49:1092-8.  |
| 2. | Ramana KV. Human myiasis. J Medical Microbiol Diagnosis 2012;1:e105. |
| 3. | Robbins K, Khachemoune A. Cutaneous myiasis: A review of the common types of myiasis. Int J Dermatol 2010;49:1092-8. |
| 4. | Jakhar D, Misra A, Dabas S. Myiasis under dermatoscope: The hidden story. Indian Dermatol Online J 2018;9:220-1. [ PUBMED] [Full text] |
| 5. | Patil P, Zambare U, Tambe S, Aderao R, Nayak C. Myiasis in a neglected case of generalized erythrodermic pemphigus foliaceus. Indian J Dermatol Venereol Leprol 2017;83:350-2. [ PUBMED] [Full text] |
| 6. | Vinay K, Handa S, Khurana S, Agrawal S, Dipankar De. Dermatoscopy in diagnosis of cutaneous myiasis arising in pemphigus vulgaris lesions. Indian J Dermatol 2017;62:440. [ PUBMED] [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4] |
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