Otolaryngology–Head and Neck Surgery (2010) 143, 595-596

CASE REPORT

Myiasis of facial wounds by Cochliomyia

hominivorax sustained in a natural disaster in Haiti

Robin Lindsay, MD, Jeffrey Stancil, PhD, and J. Michael Ray, DDS, Bethesda,

MD; and Jacksonville, FL

No sponsorships or competing interests have been disclosed forthis article.

On January 12, 2010, the nation of Haiti was rocked bya 7.2 magnitude earthquake that devastated the already

struggling nation. In the relief effort that followed, weencountered two patients with open facial lacerations thatwere infested with Cochliomyia hominivorax or New Worldscrewworms. The Institutional Review Board aboard theUSNS Comfort approved this report.

Case 1

A 16-year-old female injured in the earthquake was trans-ferred to USNS Comfort from a field hospital ashore 13 dayslater with multiple facial fractures, an open laceration of theright face, and an anoxic brain injury. Blood cultures onarrival were positive for Acinetobacter, and she was placedon imipenem for treatment. The patient was taken to theoperating room (OR) on hospital day seven for washout andclosure of her facial laceration and treatment of her facialfractures. During exploration of her wounds, three dead flylarvae measuring approximately 10 to 12 mm in length eachwere found in the right medial orbit (Fig 1), later identifiedby the ship’s entomologist as Cochliomyia hominvorax. Thewound was thoroughly debrided, the fractures were treatedwith open reduction and internal fixation, and the lacerationwas primarily closed. Tissue from the open wound near thelarvae was sent for culture, which grew Pseudomonasaeruginosa.

Postoperatively, ciprofloxacin was added to her antibi-otic regimen for the remainder of her hospitalization, andshe was later discharged to a long-term care facility in Haiti.The patient healed uneventfully from her wounds but un-fortunately had not recovered from her brain injury at thetime of this publication.

Case 2

A 10-year-old male sustained a right facial laceration duringthe earthquake on January 12, 2010. Twenty-seven days

Received March 30, 2010; revised April 8, 2010; accepted April 29, 2010.

0194-5998/$36.00 © 2010 American Academy of Otolaryngology–Head and Necdoi:10.1016/j.otohns.2010.04.273

after injury, he was transferred to the USNS Comfort from afield hospital ashore where he had undergone local wounddebridement and three days of oral antibiotics without res-olution of his facial edema. He presented with right midfa-cial edema, postseptal orbital cellulitis, and ophthalmople-gia. Computerized tomography (CT) of the face wasnegative for abscess. He was started on intravenous piper-acillin-tazobactam and taken to the OR on hospital day twofor wound exploration and debridement. Intraoperatively,he was found to have seven dead screwworms located in thesoft tissue of the midface and along the orbital floor andlateral orbital wall (Fig 2). Also present were several smallpockets of purulent drainage that grew Pseudomonasaeruginosa. The larvae were removed, and the wound wasdebrided. He returned to the OR on postoperative days two,four, seven, 10, 13, and 16 for repeat debridement andgradual wound closure. Additional larvae were found deepwithin the soft tissue of the midface and near the medialcanthus during subsequent debridements. The wound grad-ually healed, and his extraocular movements improved.

Figure 1 Intraoperative photo of patient 1 showing the screw-worm present medial to her orbit.

k Surgery Foundation. All rights reserved.

596 Otolaryngology–Head and Neck Surgery, Vol 143, No 4, October 2010

Discussion

The primary screwworm has been eradicated from theUnited States by the Department of Agriculture1 but is stillfound in several countries in the Western Hemisphere, in-cluding Haiti. Unlike its close relative Cochliomyia macel-laria, which feeds exclusively on necrotic tissue and occurscommonly in the United States, primary screwworm larvaefeed on living tissue, with egg deposition occurring on theperiphery of new wounds. Additionally, primary screw-worms demonstrate a predilection for eyes and nasal andoral mucosa. By nature, these larvae will burrow or “screw”themselves into deeper tissues where they will feed onliving tissue.2

Treatment of myiasis, or infestation of fly maggots, con-sists of supportive antibiotic therapy and debridement of theaffected tissues with delayed primary closure being per-formed when tissues are healthy.2 Oral and topical ivermec-tin as an adjunct in the treatment of screwworm myiasis hasbeen described.3-5 Although a potent antiparasitic, ivermec-tin has no antimicrobial activity, so supportive antibioticsare recommended to treat superinfections that may be

Figure 2 Intraoperative photo of patient 2 showing a screw-worm present in the soft tissue of the midface.

present. Retained larval fragments may cause an inability to

heal, and further exploration and debridement may be war-ranted in these cases.

Additionally, both of our patients had pre- and postop-erative CT scans that did not reveal any evidence of myiasis.Therefore, CT, although vital for the management of com-plex facial fractures, did not provide information as to thelocation of the screwworms. Therefore, patients presentingwith nonhealing facial wounds in developing nations de-spite the use of proper antibiotics and wound care shouldhave myiasis included in the differential diagnosis.

Author Information

From the Department of Surgery, Uniformed Services University of theHealth Sciences (Dr. Lindsay), Bethesda, MD; Department of Otolaryn-gology Head and Neck Surgery (Dr. Lindsay), Department of Oral Max-illofacial Surgery (Dr. Ray), National Naval Medical Center, Bethesda,MD; and the Navy Entomology Center of Excellence (Dr. Stancil), Jack-sonville, FL.

Corresponding author: Robin Lindsay, MD, Department of OtolaryngologyHead and Neck Surgery, National Naval Medical Center, 8901 WisconsinAve, Bethesda, MD 20889.

E-mail address: Robin_lindsay@meei.harvard.edu or robin.lindsay@med.navy.mil.

Author contributions

Robin Lindsay, concept and acquisition of data, drafting article, finalapproval; Jeffrey Stancil, acquisition of data, revising article, final ap-proval; J. Michael Ray, concept and acquisition of data, drafting article,final approval.

Disclosures

Competing interests: None.

Sponsorships: None.

References

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3. De Tarso P, Pierre-Filho P, Minguini N, et al. Use of ivermectin in thetreatment of orbital myiasis caused by Cochliomyia hominivorax. ScandJ Infect Dis 2004;36:503–5.

4. Osorio J, Moncada L, Molano A, et al. Role of ivermectin in thetreatment of severe orbital myiasis due to Cochliomyia hominivorax.Clin Infect Dis 2006;43:e57–9.

5. Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: pharma-

cology and application in dermatology. Int J Dermatol 2005;44:981–8.