Human genital myiasis: A rare case from Western Thar region.

Sir,

Human myiasis is the infestation of human tissues by dipterous larvae (maggots) of various fly species. Arms, legs, nasal sinus, auditory canal, and ocular globes are common sites for human myiasis. Cases of myiasis occur around the globe, with higher reporting rates in tropical, subtropical, and warm temperate regions.[1] Injury, immunodeficiency, unhygienic conditions, and psychiatric disturbances are risk factors for acquiring ectoparasitic infections.[2] Genital myiasis is a rare condition with very few published reports.

The authors hereby present a rare case of genital myiasis in an 18 years young, mentally sound, college-going female with painful swelling and itching in her genitalia for the past 10 days. The patient informed having normal menstrual cycle. No psychological abnormality was noted in the patient. In spite of itching and pain for the past 10 days, she did not inform anyone about it until the pain became intolerable for her. She told her elder sister about the painful swelling who accompanied her to the hospital.

The patient reported using clothes during menstrual periods. She also informed that after washing clothes she hang them outside in the compound area of her house where there is a toilet as well as a cowshed present which may attract flies. These flies can come in contact with the hanged cloth which the patient uses during her menstrual period.

There was no history of injury, sexual involvement, insect bite, or any other condition. No antibiotic, painkiller, immunosuppressive, or steroids was taken by the patient. General physical examination revealed good physical and mental status.

After obtaining the informed consent from the patient, local examination was performed by the attending doctor in the presence of female chaperone. The labia majora of the patient were found erythematous, tender with swelling and had a single discharging sinus with 2–3 mm in size near clitoris [Figure 1]. The sinus was observed to contain black headed maggots with creamy-white body. Her labia minora were normal and had intact hymen. Her blood sample was collected and sent for laboratory investigations. Hemoglobin level was normal (10.2 g%), total and differential leukocytes count was within normal range. Complete urine examination was within normal limits. Her blood sugar was 98 mg/dl. She was tested negative for human immunodeficiency virus (HIV) and syphilis (by Rapid Plasma Reagin card test) serological tests. The patient was hospitalized and was injected ceftriaxone, Tiniba with gentamicin. Her empirical treatment also included serratiopeptidase and cetirizine through oral route as tablets.

Figure 1

Single discharging sinus in the genitalia

The attending physician removed 5 maggots from the discharging sinus near the clitoris of the patient, using a nontoothed forceps on the 1st day. After removing the maggots, the wound was cleaned with betadine. On the 2nd day, the wound was irrigated with turpentine oil, the deep seeded maggots swarmed up after irrigation and two more maggots were removed. On the 3rd day, no maggot was found even after applying turpentine oil. The wound healed in next 5 days and the patient was discharged with an advice to improve her personal hygiene to avoid reinfestation.

The morphology of maggots was read, and on the basis of body length and appearance of posterior spiracles, it was identified as 3rd instar larvae of blowfly [Figure 2]. The details of morphology along with photographs were sent for confirmation to an entomologist expert in Diptera identification.

Figure 2

Larva surgically removed from the discharging sinus and sent for identification

The classical description of myiasis is according to the infected site of the host's body.[3] External genital myiasis is more common in women compared to men. Depending on the infested anatomical site of genitourinary organ, the myiasis can be divided into external urogenital myiasis and internal urogenital myiasis.[4] Some predisposing factors for external genital myiasis in women include cervical carcinoma, sexually transmitted diseases, or the practice of not wearing undergarments. Clitoris, urethra, vulva, vagina, and uterus are found to be affected in women. Internal urogenital myiasis is a rare event and crop up only after the larvae intrude internal genitourinary organs.

Myiasis of vulva constitutes only 0.7% of total human myiasis.[5] The present case is of vulvar myaisis as the maggots have invaded the labia majora (vulvar tissue). The eggs of the flies can be the possible source in the present case. The flies might have laid eggs on the undergarment or the cloth which the patient was using during the menstrual period as those were used to hang outside after washing. The soiled undergarment or the cloth might have transmitted eggs to the vulva.

The use of turpentine oil has been suggested in many cases of cutaneous myiasis around the globe, but only Kataria et al. have mentioned its use in vulvar myiasis.[6] The turpentine oil was used in this case, and excellent results were observed. In the present case, there was no history of any preexisting genital lesion or seropositivity to HIV which are seen as a precipitating cause of myiasis. The compromised personal hygiene is an important contributing factor for the cause of myiasis, especially with the genital myiasis. Cases of genital myiasis in India are reported by Baidya in women with genital prolapsed,[7] Upreti et al. in middle-aged psychiatric women,[8] and Kataria et al. in unmarried women having multiple discharging sinuses.[6]

Very few cases are reported from other parts of the world. Passos et al. reported a case of vulvar myiasis during the pregnancy.[2] A case of vulvar myiasis in an 86-year-old women suffering with diabetes was reported by Cilla et al.[9] Soulsby et al. have described the first case of human genital myiasis from the United Kingdom, caused by northern blowfly, in a 79-year-old female with the previous history of multiple spinal fractures who was found unconscious in the garden and remained unnoticed for 2 days.[10]

As per the knowledge of authors, this is the first case of human genital myiasis reported from Rajasthan. A through genital examination is recommended to diagnose such rare conditions, and use of turpentine oil can be helpful in complete surgical excision of maggots hiding in the lesion. The important role is of the attending physician in educating the patients in keeping good personal hygiene.

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.