CASE PRESENTATION ON

MAGGOT INFESTATION WITH

DIABETIC FOOT ULCERS

PRESENTED BY:
SYED MOHAMMED HASAN RAZVI
170715882016
PHARM.D V/VI YEAR

DECCAN SCHOOL OF PHARMACY

DARUSSALAM, AGHAPURA, HYD, T.S.
 INTRODUCTION
Myiasis is an infestation of skin by developing larvae (maggot) of a variety of fly
species within the arthropod order Diptera. The classification of myiasis is based on the
localization within the host body i.e. cutaneous, subdermal, nasopharyngeal, internal organs,
or urogenital (or) based on the type of host-parasite relationships i.e. obligatory, facultative,
or pseudomyiasis.[1]
The most common type of myiasis involves the skin. Cutaneous myiasis can manifest as
furuncular, inflamed skin, wounded skin, myiasis linearis (larvae migrans) and traumatic
myiasis. 
Myiasis in diabetic patients falls into the wound myiasis group where it can be caused
by the larvae of Cochliomyia hominivorax, Chrysomya bezziana, Lucilia sericata, Phormia
regina, Sarcophaga, Calliphora and Stomoxys.

[1]. María Sofía Olea et al. First Report of Myiasis Caused by Cochliomyia hominivorax (Diptera: Calliphoridae) in
a Diabetic Foot Ulcer Patient in Argentina. Korean J Parasitol. 2014; 52(1): 89–92.
 The risk factors that potentially cause myiasis are the exposure of ulcers and
hemorrhoids, diabetes mellitus and alcohol abuse, bacterial infection of wounds or natural
cavities, poor personal hygiene, alcohol-related behaviours such as lack of sensitivity and
sleeping outdoors, lesions resulting from itching in patients with pediculosis, and extreme
lack of personal hygiene.
Although diabetes mellitus is a risk factor for myiasis, diabetic foot is quite rare among
myiasis cases.
The differential diagnosis between infesting larvae is usually based on the clinical
picture, exploration findings, and entomologic analysis on the stage of the larvae. Often,
however, the maggots must be raised on culture media or meat until pupation, at which time
the adult fly morphology allows an easier diagnosis.
 TREATMENT
 The Pharmacologic treatment of myiasis is species specific. An alternative treatment
for all types of myiasis is oral ivermectin or topical ivermectin (1% solution)
 Application of chloroform, chloroform in light vegetable oil, or ether, with removal of
the larvae under local anesthesia, has been advocated for wound myiasis.
 The recommended treatment goals for the management of myiasis is to collect all
visible larvae directly from the wound and to perform active debridement and daily
dressing with antiseptic solutions; if possible, the infested area should be removed
completely.
 If necessary, excisions can also be made to reach the larvae. First, larvae and eggs are
forced to the surface by triggering regional hypoxia with a toxic substance; then, the
larvae on the surface are mechanically cleaned.
 These procedures are the only active treatment protocols.
SOAP NOTES
 SUBJECTIVE

A 50 year old male patient was admitted in the General Surgery department in
Owaisi Hospital and Research Centre in the month of November 2019
complaining of pain, swelling and ulcer on bilateral foot over plantar aspect with
continuous pus discharge.
The examination revealed bilateral symmetrical trophic ulcers of size 2x2x4 cm
seen with edge, irregular borders, bony base containing the number of maggots.

Above pictures shows the infested maggots over bilateral foot at the time of admission
 History of present illness: Small worms seen inside the wound since 4 months.

 Past medical history: HTN (Not on medications since 2 months)

T2DM since 10 yrs on (Tab. Glimepride 1mg and
Tab. Metformin 500mg)

 Personal history: Tobacco chewer since 20 yrs

Chronic alcoholic

 Socio-economic status: Poor

 OBJECTIVE
 CBP:-
TEST LAB FINDINGS NORMAL RANGE
Haemoglobin 8.0 11 – 17 gm/dl
RBC 3.18 3.7 – 6.5 millions/cumm
WBC 16.10 4000 – 11000 cells/cumm
Neutrophils 77.9 40 – 80 %
Lymphocytes 11.9 20 – 40 %
Monocytes 9.0 2 – 10 %
Eosinophils 0.6 1–6%
Basophils 0.6 0–2%
Platelets 2.32 1.5 – 4.5 lakh/cumm

Interpretation: Increased WBC levels and decreased lymphocytes indicates bacterial infection
 Sr. Electrolytes:-
TEST LAB FINDINGS NORMAL RANGE
Sodium 124 mmol/lit 135 – 145
Potassium 4.4 mmol/lit 3.5 – 5.0
Chloride 92 mmol/lit 95 – 105

 Biochemistry:-
TEST LAB FINDINGS NORMAL RANGE
RBS 187 mg/dl 95 – 105
Blood Urea 43 mg/dl 10 - 45
Creatinine 1.5 mg/dl 0.6 – 1.5

 Fasting Blood Sugar: 201 mg/dl (70-110)

 HbA1c: 6.6 % (<6.5)

 ECG: Normal

 Doppler Study of Left LL: Mild short segment wall thickening of GSV below
knee till mid leg

 Doppler Study of Right LL: Diffuse subcutaneous edema seen in right leg &
foot region

 2D Echo Doppler: Normal cardiac valves & chamber, No

RWMA/MR/TR/PR/PAH, Good LV/RV function

 Pus culture sensitivity test: Found the growth of Klebsiella Pneumoniae,

Acinetobacter in culture. And the prescribed antibiotics were found sensitive.
 FINAL DIAGNOSIS
MAGGOT INFESTATION WITH
DIABETIC FOOT ULCERS
 ASSESSMENT
Problem 1: Chronic wound with maggot infestation over bilateral foot
Treatment: Debridement and Fasciotomy
Problem 2: Bacterial Infection
Medication: Inj. Clinzucia 600mg/IV/BD (Clindamycin) and
Inj. Piptaz 4.5g/IV/TID (Pipperacillin+Tazobactum)
Problem 3: Diabetes Mellitus
Medication: Inj. HAI acc. to scale IV/TID (Human Actrapid Insulin)
Problem 4: Hypertension
Medication: Tab. Cinod 10mg/PO/BD (Cilnidipine)
Problem 5: Pain
Medication: Inj. Tramadol IV/BD
For wound healing: Tab. Chymoral forte TID (Tripsin Chymotripsin)
 DAY NOTES
DAY 1 :- DAY 3 :- DAY 5 :-
O/E :- Trophic ulcers, Maggots + POD :- 1 (Debridement + Fasciotomy) POD :- 3
Temp :- Afebrile C/o :- Mild dry cough, no other complaints C/o :- No fresh complaint, no fever spikes
BP :- 110/80 mmHg Temp :- Afebrile Temp :- Afebrile
PR :- 88 b/min PR :-82 b/min PR :-88 b/min
RR :- 16/min Vitals :- Stable Vitals :- Stable
GRBS :- 210 mg/dl GRBS :- 233,225 mg/dl GRBS :- 113, 395 mg/dl
ADVICE :- Doppler B/L foot, 2D Echo, ADVICE :- Dressing intact ADVICE :- Blood transfusion, ASD
x-ray, fbs, rbs, hba1c.
DAY 4 :- DAY 6 :-
DAY 2 :- POD :- 2 POD :- 4
O/E :- Trophic ulcers, Maggots + C/o :- Pain in right leg, Fever, Cough C/o :- Cough, No fresh complaint, no
Temp :- Afebrile decreased fever spikes
BP :- 130/100 mmHg Temp :- Afebrile Temp :- Afebrile
PR :- 94 b/min PR :-82 b/min PR :-76 b/min
RR :- 20/min Vitals :- Stable BP :- 170/100 mmHg
GRBS :- 261,280 mg/dl GRBS :-147, 266 mg/dl GRBS :- 330, 228 mg/dl
ADVICE :- Pus CST, Sr. electrolytes, ADVICE :- CBP, Dressing intact, no soakage ADVICE :- ASD, no soakage
Sr. Creatinine.
DAY 7 :- DAY 9 :-
POD :- 5 POD :- 7
C/o :- No fresh complaint, no fever C/o :- No fresh complaint
spikes, wound healthy Temp :- Afebrile
Temp :- Afebrile Vitals :- Stable
PR :-8 b/min GRBS :- 186 mg/dl
Vitals :- Stable ADVICE :- ASD
GRBS :- 270, 150 mg/dl
ADVICE :- ASD PATIENT GETS DISCHARGED

DAY 8 :-
POD :- 6
C/o :- No fresh complaint
Temp :- Afebrile
Vitals :- Stable
GRBS :- 529, 132, 384 mg/dl
ADVICE :- ASD
 PLAN
 The Initial management included application of turpentine oil, manual removal of maggots and
intact dressing.
 On third day, the patient underwent wound Debridement and Fasciotomy. The trophic ulcer
over right limb debrided and multiple fasciotomy incisions given over plantar and dorsal aspect of
foot. The trophic ulcer over left plantar aspect of foot debrided. Haemostasis secured and dressing
done.

Before After Before After

The above pictures shows the progression of wound healing from the day of surgery to 30
days after the surgery.
MEDICATIONS:-
 Before Surgery

DAY 1
DRUG GENERIC NAME DOSE ROA FREQUENCY DAY 2

Inj. Clinzucia Clindamycin 600 mg IV BD  

Inj.
Tramadol
Tramadol 1 amp IV BD  

Tab. Pan Pantoprazole 40mg PO OD  

Acc. to
Human Actrapid
Inj. HAI
Insulin
scale IV TID  
(6u)
  After Surgery
FREQU POD POD POD POD POD POD POD
DRUG GENERIC NAME DOSE ROA ENCY 1 2 3 4 5 6 7
Inj. Clinzucia Clindamycin 600 mg IV BD       
Piperacillin +
Inj. Piptaz
Tazobactum
4.5 g IV TID       

Tab. Pan Pantoprazole 40mg PO OD       

Tab. Chymoral Tripsin
forte Chymotripsin
1 tab PO TID       

Inj. Tramadol Tramadol 1 amp IV BD   X X X X X

IVF NS Normal Saline 60 ml/hr IV   X X X X X

Human Actrapid Acc. to

Inj. HAI
Insulin scale (6u)
IV TID       

Tab. Cinod Cilnidipine 10 mg PO BD X X X    

 The patient gets discharged from the hospital after 7 days of surgery.

DISCHARGE MEDICATIONS:-

 Tab. Pan 40 mg OD (before breakfast) x 5 days

 Tab. Chymoral forte x 5 days
 Tab. Ultranise (SOS)
 To take antihypertensive and antidiabetic medications as previously prescribed
 Alternate day ASD

 The case was followed in OPD.

 Cleaning of the wound and dressing changes were conducted every other day.
 No post-operative complications were observed and the progress of wound
healing was noted.
 No parasite-specific pharmacologic treatment was used because no recurrence
of the myiasis was detected after the initial management.
 PATIENT COUNSELLING
The Patient was counselled about:
 The care and protection of chronic and untreated wounds is highly important.
 Foot, wound and skin care is an essential practice that needs to be performed
carefully and systematically in patients with chronic wounds such as diabetic
foot ulcers.
 The wound site may need to be aerated to avoid conditions like maceration.
 If the wound is left open for aeration, it must be covered with a thin layer of
sterile gauze. The pores of the gauze must be small enough to prevent flies
from penetrating while allowing airflow.
 Chronic wounds should be treated at least once a day and should be closed
well. 
 The wound site should be inspected and cleaned regularly, so that formation of
myiasis again is less likely.
 The patient was counselled about the medication adherence and to maintain
glucose levels under control.
 DISCUSSION

 In our case report, the patient was residing in a rural area by working as a painter
and had low standards of living. We agree with the hypothesis that the exposed
ulcer was a conditioning factor that, in combination with the patient's poor personal
hygiene, alcoholism, rural tasks and insensibility associated with diabetes
determined the degree of evolution of the myiasis in the patient.
 The differential diagnosis between infesting larvae is usually based on the clinical
picture, exploration findings, and entomologic analysis on the stage of the larvae.
 The recommended treatment of myiasis is to collect all visible larvae (maggots)
directly from the wound and to perform active debridement and daily dressing with
antiseptic solutions.
 The most important recommendation is related to the prevention of myiasis.
Therefore, the care and protection of chronic and untreated wounds is highly
important.
 CONCLUSION

The Myiasis in this case was a complication of an open, neglected wound mainly
due to uncontrolled diabetes. The treatment of myiasis requires debridement of
the necrotic tissue and removal of the larvae in the wound. A multidisciplinary
approach with entomologic diagnosis, adequate medical and surgical treatments,
and excellent revascularization and reconstructive procedures allows a favorable
outcome.

Although myiasis is not a lethal disorder, knowledge of this disease is necessary

from a preventive, diagnostic and curative standpoint.
 REFERENCES

• María Sofía Olea et al. First Report of Myiasis Caused by Cochliomyia hominivorax (Diptera:
Calliphoridae) in a Diabetic Foot Ulcer Patient in Argentina. Korean J Parasitol. 2014; 52(1): 89–
92.
• Serhat Uysal et al. Human myiasis in patients with diabetic foot: 18 cases. Ann Saudi Med. 2018;
38(3): 208–213.
• R Franza et al. Myiasis of the tracheostomy wound: case report. Acta Otorhinolaryngol Ital. 2006;
26(4): 222–224.
• Kwok Hang Lam et al. Myiasis of the Foot and Leg Caused by Chrysomya bezziana. The Journal of
Foot & Ankle Surgery. 2014; 53(1): 88–91.
• Jose M. Villaescusa et al. Infestation of a diabetic foot by Wohlfahrtia magnifica. Journal of Vascular
Surgery Cases and Innovative Techniques. 2016; 2(3): 119-122
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