Abram and Froimson
Myiasis aggot Infection) asa
Complication of Fracture Management
Case Report and Review of the Literature
Leon J. Abram, MD
Avrum I. Froimson, MD
Introduction
Non-iatrogenic human cutaneous myiasis is infre
quently reported in either medicine or dermatology
literature but never to the author’s knowledge in an
orthopedic context. Myiasis refers to tissue infesta
tion by larvae of various dipterous flies, also known
as maggots. Though myiasis is relatively common in
tropical climates, it is a rare occurrence in temperate
zones, ai~d is usually related to recent travel to the
tropics or poor personal hygiene.1-5 A case is
described where myiasis was seen as a complication
of fracture management.
Case Report
In June 1984 a 74-year-old female fell down a
flight of stairs sustaining a closed supracondylar
femur fracture. The patient had a history of psoriasis
which was untreated. She underwent open reduction
of the femur and internal fixation utilizing an eight-
hole, 95° AO blade place. Immediately postopera
tively. a knee immobilizer was used to allow for
dermatological control of her psoriasis. She re
covered and was discharged from the hospital with a
long leg cast and was seen on routine follow up on
weekly intervals. The cast was changed to a plaster
cast-brace and she continued to improve with physi
cal therapy knee motion. X-rays continued to show
adequate fixation and healing. Six weeks following
injury the patient was seen in the emergency room
with complaints of redness of her knee. On inspec
tion, thousands of maggots could be seen living
within and under her cast-brace which was then
From the Mt. Sinai Medical Center, Cleveland, Ohio.
Reprint requests: Leon J. Abram, MD, The Mt. Sinai Medical
Center, One Mt. Sinai Drive, Cleveland, OH 44106.
MYIASIS: FRACTURE COMPLICATION
1 7~? 7
removed. Hundreds more were found, scattering
with exposure to the light. In the emergency room
the maggots were killed with topically applied ether
(Figure). It was noted that her psoriasis had worsened
with thick deposits of epidermal layers, measuring to
3 mm to 5 mm deep. Though the skin was ery
thematous, there were no open wounds and her sur
gical incision had healed and the skin was entirely
intact. The patient was admitted for continued topical
treatment including whirlpool debridement and der
matologic care of her psoriatic lesions. She never
received topical, oral, or intravenous antibiotics.
Since fixation occurred 8 weeks prior to this dis
charge, she was sent home without external support
on the limb and given follow up appointments for
continued derrnatologic and orthopedic care. At 9
months from time of fracture, she continues to ambu
late without problems. Government health depart
ment officials confirmed that the patient’s home was
the source of her infestation and full cleaning and
defestation was accomplished prior to her hospital
discharge.
Discussion
Myiasis is the condition in which fly larvae are
living parasitically on the tissue of humans or ani
mals. Though myiasis is relatively common in trop
ical climates, it is rarely experienced in temperate
areas.6 Myiasis producing flies are of the order dip
tera and are classified on the basis of their oviposi
tioning habits: specific, semi-specific, and acciden
tal. “Specific” species are obligate tissue parasites
while “semi-specific” flies usually deposit eggs in
necrotic organic matter, such as foodstuff. tissue, and
excrement.7’8 Larvae of some families, such as
oestridae (botfly). gasterophilidae (botfly), sar
cophagidae (fleshfly), and others, are capable of
penetrating unbroken skin.2’7 Most cases of myiasis
625
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r spread acceptance, though chloroform is usually
I,
4: , plasters, oils, fats, or ointments to asphyxiate the
--
Figure: Larvae infesting cast, note the exfoliations of
psoriatic, hypertrophied skin.
seen in the United States are caused by species of the
family caliphoridae (blowfly). Blowfly larvae (phor
mia, phaenicia, and lucilia) are specific for necrotic
tissue and historically have been used for debride
ment of wounds and osteomyelitis.9 Phaenicia (pha
enicia serratia, green bottle fly) has also been respon
sible for hospital-acquired myiasis.1°
Clinically, myiasis is recognized by finding larvae
in a wound or within small puncture burrows.
Patients may complain of an “eerie crawling” sensa
tion under the skin.’ Lethargy, malaise, difficulty
sleeping, and occasional fever are frequent associated
complaints. Except for leukocytosis and eosin
ophilia, laboratory examinations are normal.” Sec
ondary bacterial infection can lead to severe disease
and even a fatal outcome.8 Identification of the larvae
is important from both an epidemiologic standpoint
as well as a medical treatment one. Since life cycles
of different species vary, identification can aid in
treatment. Parasitologists or entemologists may be
required to assist in larval identification; raising a
larva to adulthood leads to easier identification by
examining the resultant fly.7 This can be accom
plished by placing the maggot on either meat or even
a blood-agar plate. Commercial preparations for use
as a medium are available.’
Treatment consists of removing all larvae and anti
biotic treatment of secondary bacterial invaders if
present. Surgical therapy includes excision of nec
rotic tissue and irrigation under appropriate anesthe
sia.12 Other treatments include use of toxic sub
stances to directly kill larvae and eggs or indirectly
by localized hypoxia (or anoxia) by occlusion of the
626
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April 1987 Vol 10/No 4
breathing orifice of the organism. Regarding these
treatments, clinical experience, rather than research
findings, seem to dominate the literature. Ether or
chloroform applied directly seems to have a wide
quite painful and causes greater damage to normal
tissue, we therefore recommend ether. Other solu
tions containing peroxides, alcohol, and chlorides
have also been used.1
Occlusive techniques include placement of pastes,
larvae or make them surface for air. This is especially
useful for the maggot types which burrow into deeper
tissues. Pork fat has been touted as being a superior
agent by its ability to cause hypoxia and then entrap
the larva as it surfaces.’
Prevention of myiasis is foremost in eliminating
the disease and can be achieved by proper personal
hygiene and education in techniques for preventing
the contact of flies with skin. Insecticides and erad
ication of infected livestock are of prime importance
in decreasing disease in endemic areas.2
Maggots have been used therapeutically, pri
marily for debriding necrotic wounds and osteo
myelitis. Though this technique has lost its initial
acceptance because of improved antibiosis, it is still
considered a viable option for wound or ulcer
debridement. Maggots have also been used for com
mercial cleaning of flesh from bones and skulls.
Blowfly secretions have been investigated in their
use of enzymatic debridement of burn eschar.9
Human cutaneous myiasis is rarely reported in the
United States and has never been reported as a com
plication of fracture management. A patient is
described with poor hygiene and uncontrolled
psoriasis who developed maggot infestation of her
psoriatic lesions under a long leg cast-brace applied
to support an internally fixed supracondylar femur
fracture. Following removal of all larvae and appro
priate dermatologic treatment her myiasis was elimi
nated. A brief literature review on the topic of
myiasis covering the disease stage, diagnosis, treat
ment, prevention, and therapeutic use has been
described.
References
1. Davis E, Shuman C: Cutaneous myiasis: Devils in the
flesh. Hosp Prac 1982; 17(12):115-123.
2. Domonkos AM, Arnold HL, Odom RB: Diseases Due to
Animal Parasites in Andrew? Diseases of the Skin, ed 7. Phila
delphia, WB Saunders Co. 1982.
3. Everett ED, Devillez RL, Lewis CW: Cutaneous myiasis
~
~
~
I- ~
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Abram and Froimson MYIASIS: FRACTURE COMPLICATION

due to dermatobia hominis. Arch Dermatol 1977; 113:1122.
4. Katz SI. Taylor R: Cutaneous myiasis. South MedJ 1971;
64:759-760.
5. Kave HD, Higgins RP: Human botfly infestation in the
United States. JAMA 1964; 189:64.
6. Guillozet N: Diagnosing myiasis. JAMA 1980;
244:698-699.
7. Moschella SL, Hurley HJ: Parasites and Tropical der
matology, in Dermatology, ed 2. Philadelphia, WB Saunders,
1985.
8. Schreiber MM, Schuckmell N, Sampsel i: Human
myiasis. JAMA 1964; 188:828-829.
9. F~chter EA, Sherman RA: Maggot therapy: The surgical
metamorphosis. Plasi Reconstruct Surg 1983; 72:567-570.
10. Jacobson JA, Kolts RL, Conti M, et al: Hospital-acquired
myiasis. Infection Control 1980; 1:319-320.
11. Hubler WR, Rudolph AH, Dougherty EF: Dermal
myiasis. Arch Dermarol 1974; 110:110.
12. Macias EG, Graham AF, Green M, et al: Cutaneous
myiasis in South Texas. NEngl MedJ 1973; 289:1239-1241.

627

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 Surgical Maggots
To keEdjlor. The historical note, “Surgical Maggots,” by
Chernin ~SouU, MedJ 79:1143, 1986) stirred memories and
prompted this note.
Several yeai~s ago, in writing an autobiography for my
family, I made note of the following among experiences in
my year as a rotating intern in a Salt Lake City hospital
(1923-1924): “1 recall patients with chronic osteomyctitis, the
bane of hospitals in those days, who in addition to sauceriza
tio1~, had an unusual treatment. Dr. Pugh, who had had ex
perience on the Western Front in WW I, Would upon occasion
telegraph for ‘sterile’ maggots which arrived in special con
tainers. We would apply maggots in some instances of chronic
osteornyclitis or infected compound fractures, and they real
ly cleaned up the necrotic tissue so fresh granulation tissue
might form. When one wished to sterilize the wound of mag
gots, one merely poured in ether.”
I recall that Vaselinc dressings were applied at the wound
edges to prevent the maggots from crawling onto the normally
sensitive skin. Quite naturall~- my recollectiojis in this regard
are very vivid because it was the only time I would see mag
got therapy, which seemed very repulsive. The late Walter
Pugh, MD, FACS, chief surgeon for the Utah Copper Com
pany, recounted observations lie had made in the wounded
in France and which led him to use this treatment,
From this experience with maggot therapy, I condude that
in addition to Dr. Baer, who described the treatment, and
0 my mentor, Dr. Pugh, most probably many surgeons of the
AEF made similar observations, l?urthCrmore, the commer
cial availability of “sterile” maggots a decade or so before
l3aer’s publication would indicate that there was a demand
for maggots sufficient to justify their production for the market
before their approval by the Council on Pharmacy and
Chemistry, as documented by Chernin.
What remains an enigma is that the use of maggots to the
point of theircommercial production had goncon foradecade
before it was reported in the literature. This seemed so
unbelievable that I reviewed the Quarterly Cu,nulaiite ladex
Meditus from 1916 to 1932 and found that in truth there was
no documentation of maggot therapy before that by l~aer in
1931, Schmidt,’ in his MedicatDjscoperje~ credits Baer with
the first report, except for a report in 1812 on the therapeutic
use of maggots by Dominique Jean Larry.
One can only repeat the old adage, “there is nothing new
under the sun,”
R. H. Kamprneier, MD
Professor of Medicine, Emeritus
Vanderbilt University School of Medicine
Nashville, TN 37232
Q C Thomas, 1959
Reference
ScI,,njcj~ JE; Mtdiçs,1 Dircop:,jgs: H’ha and W!~i,,. Springfield, Ill, Charles
Acute Water lntoxlcatlo~
To i/ti Editor. During each of the last eight years, I have
seen at least one case of “water intoxication ‘in children less
than 1 year old. These children have come from families head
ed by fathers in the lower eniiste,d ranks. The fattier is usual
ly at sea and the mother is living in either a small one-room
666 May 1987 • SOUThERN MEDICAL JOURNAL
apartment Or a motel Otn. She is young, isolated fro,n ~
extended family, and lacking the financial resources to JitrC
baby-sitters, When the money is depleted she dilutes the for
mula or feeds the child tap water only. After several days, the
child is brought to the emergency room having sci~.~~rcs.
Laboratory studies reveal that the child has hyponatremia,
but usually urine has not been obtained. It becomes diflicult
to prove that these infants have inappropriate secretion of an
tidiuretic hormone (SIADH), I believe the cause (If the
hyponatremia is SIADH secondary to CNS damage from cliiki
shaking.
Borowitz and Rocco’ suggest that salt deprivation leads tO
a readjustment of the arginine vasopressin setting. I measured
the sodium content of tap water in our area and found ii (0
be? mEq/L, which is the same sodium content of breast ~~ilk.
Since these children probably drink more tap water than a
normal child does breast milk, they would have a higher
sodium intake than normal.
Since Caffey~ first described the parent-Infant stress syn
drome in 1946, he has subsequently described CNS awl bone
abnormalities from infant shaking. He pointed out that “shak
ing is widely practiced in all levels of society, by a wide varie
ty of persons, in a wide variety of ways, for a wide variety
of reasons.” It appears to me that a young, isolated mother,
who has to live in a closed room with a crying, hungry infant
might easily be stressed. This could lead to “whip-lash’’ slink
ing of the child and subsequent SIADH secondary in niild
CNS injul-y.
I have not had the opportunity to evaluate the long-ermn
development of these children, but would he concerned ahnttt
permanent damage, which would be not from the seixur~’s or
hyponati-emia, but from the shaking. It is encouraging to see
that in the experience of Borowitz and Rocco, the children
appear to develop normally, at least during the ensuing six
months.
F, R. Etiwatiger, ML)
Department of Pcdin tries
Naval Hospital
Portsmouth, VA 237~8
References
I. Ilorcnvitx SM, R,occo M: Acute waler intoxication in Itealihy itsfj,,,i’~
MedJ79:1156.1158, 1986
2. Caffey J; On die theory and practice of shaking infants. As,,) IJie Child
124:161-169, 1972
To the Editor. I write with enthusiasm about thc Utsiely
clinically useful article of Di’s. Borowitz and Rocco on acu t~
water intoxication in healthy infants, t~ reflect on die fact th51
both infants deScribed were severely hyponatremjc, yci tIic~
rapidity of normalization of the serum sodium was acItievt~<I
in less than 24 houts in both cases. Although in these cases
the outcomes were respectably favàrabte, the hastiness t,Iv~-_
rective treatment carries with it the calculated risk of ecfltt-aI
pontine myclinolysis that surely would be devastating
especially in this age group.
Richard A. Levine, M I)
1420 E Sandpiper Circle
Hollywood, FL 33026
• Vol. 80, No. 5