Surgical management for the case of scrotal myiasis in a 7-day-old neonate: a case report

Abstract

Introduction

Neonatal myiasis is a rare condition, with few reports available on the subject. Surgical management is recommended in some cases. In this study, we present the case of a 7-day-old male neonate with larvae in his scrotum who underwent surgery.

Case presentation

A full-term 7-day-old male infant (Aryan race) was referred to a children’s hospital. On the sixth day after birth, three 3–4 mm long larvae crawled out from his scrotum, with the number increasing over time. He was given intravenous antibiotics and topical mupirocin to combat secondary infections. The surgical treatment involved two steps: first, the larvae were extracted, and then the infection site was washed with betadine and hydrogen peroxide to help remove any possible remaining larvae.

Conclusion

Scrotal myiasis is a rare disease that occurs in infants and requires immediate treatment. Surgical treatment is effective in removing dead or decaying larvae from a deep-seated location and washing the infection site to prevent secondary infection.

Introduction

Myiasis is the infestation of live humans and vertebrate animals with dipterous larvae [1]. Neonatal myiasis is a disease caused by fly larvae [2] and often occurs on exposed skin, such as the face, scalp, arms, and legs, though it can also invade the scrotum, spermatic cord, penis, and pelvic organs [3].

A higher incidence of myiasis is more common in rural areas, particularly in tropical and subtropical regions of Africa and the Americas [1, 2]. A total of 26 cases of human myiasis were reported In Iran from 2013 to 2020, with four of them occurring in the age group of 0–9 years [3].

The extent of the disease and host immune response depends on the fly species responsible for the disease, the host (for example, species, concomitant disease), and the breeding conditions (for example, environment) [2].

Local antiseptics and systemic antibiotics for combating secondary infections have been recommended as treatment options in neonatal myiasis [4]. A surgical approach to remove live and dead larvae and complete washing of the infection site with betadine and hydrogen peroxide is recommended as the final treatment used to help remove any possible remaining larvae and prevent recurrence of the disease [5].

Although adult cases have been reported, neonatal myiasis is a rare condition and there are few reports about this subject [6,7,8,9,10,11].

In this study, we report a 7-day-old male neonate referred to Abuzar Hospital (a pediatric center in the southwest of Iran) due to larvae in his scrotum. He was infected with myiasis larvae and underwent surgery and received proper antibiotics.

Case presentation

A full-term 7-day-old male infant of Aryan descent was born via normal vaginal delivery at 36 weeks gestation. He weighed 3800 g at birth and did not experience any medical issues at that time. However, on the sixth day after birth, larvae were discovered in his scrotum, prompting a referral to a children’s hospital.

There was no significant family history of medical issues, but the infant’s parents had a low socioeconomic status and struggled with maintaining proper hygiene practices. Consequently, the newborn was not consistently kept in clean diapers.

The patient was admitted to the Neonatal Care Unit. Upon admission, he had a heart rate of 142 beats per minute, blood pressure of 70/35 mmHg, body temperature of 36.3 °C, and a respiratory rate of 40 breaths per minute. He weighed 4000 g, had a head circumference of 34 cm, and an Apgar score of 8. The percentile for weight was 78th and for height was 60th.

During a physical examination, the skin, head, neck, heart, lungs, and abdomen appeared normal. However, swelling, redness, and the excretion of numerous small larvae were observed under the base of the penis and from the scrotum. Three larvae measuring 3–4 mm in length crawled out from his scrotum (see Fig. 1). On the basis of these findings, he was referred to Abuzar Hospital for further evaluation and treatment. In the neurological examination, muscle tone and the ability to move arms and legs were normal. Rooting reflex, suck reflex, Moro reflex, and grasping reflex were also normal.

Fig. 1

A Larvae emerging from the scrotum on admission. B Larvae emerging from the scrotum before surgery

Laboratory investigations showed a white cell count of 13,500/mm³ with 20% lymphocytes and 80% polymorphonuclear leukocytes, hemoglobin of 15.8 g/dL, and platelets of 231,000/mm³. His serum urea was 11 mmol/L and creatinine was 0.8 mmol/L. Urine analysis revealed a white cell count of two per high-power field, red cell count of zero per high-power field, and no organisms present. Liver function tests showed Alanine Transaminase (ALT) at 12 U/L, Aspartate Transaminase (AST) at 26 U/L, Alkaline Phosphatase (ALP) at 543 U/L, direct bilirubin at 0.3 mg/dL, and total bilirubin at 3.3 mg/dL, all within normal ranges. His C-reactive protein level was negative. Four maggots preserved in 70% alcohol were sent to the Medical Entomology Unit for study and identification following standard procedures.

He was treated with intravenous ampicillin (100 mg/kg/day, four times a day) and intravenous gentamicin (5 mg/kg/day, three times a day) for sepsis, and topical mupirocin 2% for 2 days before undergoing surgery to combat secondary infections. The surgical procedure involved first completely removing the larvae, followed by washing the infected area with betadine and hydrogen peroxide to help remove any possible remaining larvae and prevent recurrence of the disease (Fig. 2). Four maggots in 70% alcohol were sent to the Medical Entomology Unit. The specimens were processed for study and identification according to standard procedures. They were examined under a microscope at 400× magnification. On the basis of the presence of two respiratory slits each in the posterior spiracles, the four maggots were identified as second-stage maggots of the fly family Sarcophagidae.

Fig. 2

A Extracted larvae during surgery. B Scrotal view after surgery

After surgery, he was given intravenous ampicillin (100 mg/kg/day, four times a day) and intravenous gentamicin (5 mg/kg/day, three times a day) for 8 days (duration of hospitalization: 10 days). He was discharged with Susp (100 mg/5 mL) cephalexin (25 mg/kg/day, four times a day) for 7 days after being in good general condition with stable vital signs. The neonate was followed up 1 week, 1 month, 3 months, and 6 months after discharge. The general condition, wound healing, and surgical site infection were evaluated by a pediatric surgeon and neonatologist in these follow-ups, which were normal.

Discussion

We reported a case of rare scrotal myiasis in a full-term, 7-day-old male infant. The infant responded successfully to treatment with intravenous antibiotics, topical mupirocin, and surgical intervention.

Myiasis is a rare condition in infancy that is typically found in tropical areas [1]. There have been a few reported cases of neonatal myiasis in the literature, most of which involved the ear, mouth, and umbilical regions [6,7,8,9,10,11].

Myiasis is an extremely rare condition in infancy that is almost always found in tropical areas [1]. To date, there have been only a very few neonatal myiasis cases reported in the literature, most of which were otic, oral, and umbilical [6,7,8,9,10,11]. As far as we know, no cases of scrotal myiasis have been reported in infants in our region. This study is the first report. Neonatal myiasis is only briefly mentioned in two or three pediatric textbooks, with very few reported cases [2, 3].

Blowflies (Calliphoridae) and flesh flies (Sarcophagidae) can cause myiasis, a condition of short duration, by acting as obligatory and/or facultative parasites. They typically mature within 4–7 days, often found in the host’s body orifices and wounds. Common species involved in causing myiasis include Lucilia cuprina, Lucilia sericata, Cochliomyia hominivorax, and Wohlfahrtia magnifica [7].

The Lucilia blowfly genus consists of obligatory and/or facultative ectoparasites that belong to the Calliphoridae family and are commonly found in meat and animal corpses [6]. They are known to cause myiasis in both humans and domestic herbivorous animals. The Calliphoridae family is divided into two subfamilies: Calliphorinae and Chrysomya. The Calliphorinae subfamily includes the Lucilia, Calliphora, Cordylobia, and Auchmeromyia genera. Adult Lucilia flies typically have a metallic-green or copper-green color, with a diameter ranging from 8 mm to 10 mm, and are commonly found around butcher shops and slaughterhouses [10]. Samples have been sent to the parasitology laboratory, and we are currently awaiting the results for the determination of the species [2].

Myiasis may also be accompanied by inflammatory reactions, secondary bacterial infections, massive destruction, and life-threatening consequences, as consistent with the results of the present study and other studies [5,6,7,8,9,10,11]. Rural agricultural areas, crowded conditions, and poor personal hygiene are other predisposing factors for myiasis. Mechanical removal of maggots is an important step in the management of myiasis [4].

Myiasis is common in areas with poor hygiene, where flies breed [9], similar to the results of our study. The neonates in the present study also had a low socioeconomic status. Reports of human myiasis have decreased with improving living standards.

Conclusion

Overall, scrotal myiasis is a rare disease that can affect infants and should not be overlooked. Following antibiotic therapy, surgical intervention is necessary to remove any dead or decaying larvae from a deep-seated site. This is crucial to prevent serious complications such as secondary infections or sepsis.