(Diptera: Calliphoridae), Sarcophaga

First Record of Human Myiasis Caused by Association of the Species Chrysomya megacephala (Diptera: Calliphoridae), Sarcophaga (Liopygia) ruficornis (Diptera: Sarcophagidae), and Musca domestica (Diptera: Muscidae) Author(s): A.C.P. Ferraz, B. Proença, B. Q. Gadelha, L. M. Faria, M.G.M. Barbalho, V. M. Aguiar-Coelho, and C.S.S. Lessa Source: Journal of Medical Entomology, 47(3):487-490. 2010. Published By: Entomological Society of America DOI: 10.1603/ME09143 URL: http://www.bioone.org/doi/full/10.1603/ME09143

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DIRECT INJURY, MYIASIS, FORENSICS

First Record of Human Myiasis Caused by Association of the Species Chrysomya megacephala (Diptera: Calliphoridae), Sarcophaga (Liopygia) ruficornis (Diptera: Sarcophagidae), and Musca domestica (Diptera: Muscidae) A.C.P. FERRAZ,1,2 B. PROENÇA, B. Q. GADELHA, L. M. FARIA, M.G.M. BARBALHO, V. M. AGUIAR-COELHO, AND C.S.S. LESSA Laboratory of Diptera Studies, Department of Microbiology and Parasitology, UNIRIO, Universidade Federal do Estado do Rio de Janeiro, Rua Frei Caneca, 94, Centro, 20211-040 Rio de Janeiro, RJ, Brazil

J. Med. Entomol. 47(3): 487Ð490 (2010); DOI: 10.1603/ME09143

ABSTRACT We report a rare case of myiasis caused simultaneously by three dipterous species. A 54 yr-old indigent patient was admitted to Andaraõ´ Hospital with painful eruptions on the scalp. The parieto-occipital sulcus showed two lesions caused by scratching associated with deep, odoriferous and exudative pediculosis. Larvae removed with the help of forceps and vaseline produced 153 adults, identiÞed in the laboratory as 114 specimens of Chrysomya megacephala (F., 1794), 38 of Sarcophaga (Liopygia) ruficornis (F., 1794), and one of Musca domestica (L., 1758). KEY WORDS dipteran larvae, pediculosis, parasitic disease

Myiasis has generally been underreported in Rio de Janeiro, but reports of new cases have demonstrated its increasing frequency or greater severity than had previously been found (Marquez et al. 2007, Ferraz et al. 2008, Nunes et al. 2009). This disease is characterized by dipterous larvae that feed on their hostÕs live or necrotic tissue. Several families of Diptera, including the Calliphoridae, Sarcophagidae, Muscidae, and Oestridae, among other less frequent ones, are known to contain species that cause myiasis (Zumpt 1965, Hall and Wall 1995, Guimara˜es and Papavero 1999). In Brazil, the species Cochliomyia hominivorax (Coquerel, 1858) is the most associated with cases of myiasis (Zumpt 1965). The most frequent species that causes primary or obligate myiasis in Brazil is the screwworm C. hominivorax. The screwwormÕs larvae are biontophagous, depositing their eggs in recent wounds or cavities of live hosts (Guimara˜es and Papavero 1999). Necrotic tissue and organic detritus are an entryway for the necrobiontophagous ßies associated secondary or facultative myiasis (Sampaio and Riviti 2001). Infestation of the head by head lice, Pediculus humanus capitis (De Geer) (Downs et al. 1999), in association with poor personal hygiene may cause lesions that attract dipterans and facilitate the estab1 Post-Graduate Program in Animal Biology, UFRRJ, Universidade Federal Rural do Rio de Janeiro. Rodovia BR 465 - Km7, 23890-000 Serope´ dica, RJ, Brazil. 2 Corresponding address: Rua Lucõ´dio Lago, 271/306 Me íer, 20780020 Rio de Janeiro, RJ, Brazil (e-mail: adrianapedroso7@yahoo. com.br).

lishment of myiasis in Argentina (Visciarelli et al. 2003). Marqeuz et al. (2007) described several cases from Rio de Janeiro of patients with both myiasis and pediculosis. They conclude that pediculosis is the disease most frequently associated with myiasis. Here we report a rare association of three families of Diptera with a case of myiasis with pediculose. Materials and Methods To study the bioagents of myiasis, the patientÕs scalp was shaved and the larvae lodged in the lesions were removed with a pair of forceps and Vaseline. The procedure was carried out after obtaining the patientÕs written consent and in adherence of the rules of the research project as approved by the Ethics Committee of the Federal University of the State of Rio de Janeiro (UNIRIO) and by the Andaraõ´ Hospital Research Center. The patient was clinically examined. The larvae were removed from the lesions, placed in sealed jars with nylon fabric containing sterile sawdust and carried to UNIRIOÕs Laboratory of Diptera Studies where they were kept in a climatic controlled chamber set at 28⬚C day/26⬚C night, 60 ⫹ 10% RH and 14 h of photophase until the emergence of adults could be identiÞed. Food was not provided as the larvae were obtained at the third instar stage and therefore, did not require further feeding for pupation. After sorting into families, the Calliphoridae were identiÞed using MelloÕs taxonomic key (Mello 2003). The Sarcophagidae and the Muscidae were identiÞed by specialists from the National Museum of Rio de Janeiro

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Fig. 1. Patient with scalp myiasis. (A) Asepsis of the lesion by shaving of the scalp, showing the two foci of infection. (B) Larger focus (⬇11 cm diameter) with bone exposure.

(Dr. Catia de Mello Patiu and Dr. Marcia Couri, respectively). The specimens were deposited in the taxonomic collection of UNIRIOs Laboratory of Diptera Studies. The medical team decided to hospitalize the patient due to the severity of the lesions. The following medications were prescribed during his internment: dipyrone (analgesic), cephalexin, and gentamicin (antibiotics) because the appearance of the lesion suggested a secondary bacterial infection, and ivermectin (antiparasitic) to eliminate any larvae that were inaccessible during the collection. After 1 wk of hospi-

talization, the patient showed signiÞcant clinical improvement of the lesions. The edges were cleaned, and no areas of necrosis or exudates were detected. The patient was discharged the second week after hospitalization. Results and Discussion The patient, an indigent white 54-yr-old male living on the streets of the city of Rio de Janeiro, entered Andaraõ´ Hospital in April 2008 complaining of “head worms.” He reported feeling symptoms of itching and

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FERRAZ ET AL.: THREE SPECIES OF DIPTERA IN HUMAN MYIASIS

pain in the parieto-occipital region for 15 d and attributed the origin of the lesion to the itching resulting from pediculosis. He did not indicate any previous pathologies. Clinical examination revealed that his overall state of personal hygiene was poor. He displayed a good level of awareness, had a ruddy complexion, was hydrated, acyanotic, not icteric, with good peripheral capital perfusion and with bilateral posterior cervical adenomegaly. The cardiovascular, respiratory, and abdominal examinations showed no signs of disease. An examination of the head revealed myiasis with two foci: the Þrst was ⬇11 cm in diameter, with exposure of the parietal cranium, and the second had a diameter of ⬇1.5 cm. Both lesions were deep, with a fetid odor, bloody serumal exudate, pruritus, and necrotized areas (Fig. 1). A total of 153 Diptera larvae were removed and subsequently reared to adults. Three species were reared from this infestation: 114 Chrysomya megacephala (F., 1794), 38 Sarcophaga (Liopygia) ruficornis (F., 1794), and one Musca domestica (L., 1758). Associated myiasis was diagnosed with pediculosis, which is considered a common infestation, and the main causative species is P. capitis (Downs et al. 1999). This skin disease is a predisposing factor for infestation of myiasis, as well as dermatites, ethylism, malnutrition, immunodepression, inadequate corporal hygiene, low level of education, senility, and family abandonment (Sherman 2000, Martinez et al. 2003, Visciarelli et al. 2003). This is the Þrst report of the association of these three Diptera species in the same case of myiasis. In addition, this is a rare case of the species C. megacephala in humans, which may not have been previously reported in Brazil. One of the reports of C. megacephala in humans occurred in Thailand, where a body was found with a severe lesion infested with larvae dating from before the hostÕs death (Sukontason et al. 2005). Another case of myiasis occurred in two patients from Sri Lanka, during an epidemiological study of cutaneous myiasis (Kumarasinghe et al. 2000). Both cases were cited as being the Þrst occurrences in their respective countries. The species S. ruficornis has been described in the Neotropical, Nearctic, Palearctic, Afrotropical, Oriental, and Oceanian regions (Pape 1996) and has been cited as the cause of myiasis in India in patients with ulcerative lesions (Sreevatsa et al. 1990). However, this species has not been reported to cause myiasis in Brazil, although its presence is frequently noted in forensic entomology studies (Oliveira-Costa and Mello-Patiu 2004, Moretti 2006, Oliveira-Costa 2007). The most common reports of ßesh ßies are the two species that cause myiasis: Wohlfahrtia magnifica (Schiner, 1862), whose larvae are obligatory parasites of warm-blooded vertebrates throughout the Mediterranean basin, Eastern and Central Europe, and Asia Minor (Hall and Wall, 1995, Ç iftiç ioglu et al. 1996), and Wohlfahrtia vigil (Walker, 1849), which causes myiasis in mink, Þsher, fox, rabbits, cats, dogs, and nestlings (Craine and Boonstra 1986).

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M. domestica is reported to cause intestinal myiasis in humans through the ingestion of food or drink contaminated with its eggs or larvae (Zumpt 1963). Intestinal myiasis from M. domestica has been reported in the Indian subcontinent (Shivekar et al. 2008) and Ohio (Ramsy 1952), among other regions. In addition, it has been reported to cause myiasis in a childÕs nasopharynx (Riyaz et al. 2004) and to act as a carrier of Dermatobia hominis (L.) eggs (Ribeiro et al. 1993, Rodriguez and Leite 1997). However, the only report of M. domestica causing cutaneous myiasis involved a deep ulcer in a debilitated diabetic patient (Burgess and Davies 1991). This case, therefore, represents a rare phenomenon of myiasis caused by the infestation of three species, C. megacephala, S. ruficornis, and M. domestica, that had not previously been described as causing human myiasis in Brazil. This report contributes to studies of forensic entomology and emphasizes the need for more in-depth studies of the biology of these dipterans. Acknowledgments The authors acknowledge the Þnancial support of UNIRIO, CAPES, CNPq-PIBIC, and FINEP (Brazil). We are also indebted to Catia de Mello Patiu and Marcia Couri (National Museum of Rio de Janeiro) for their identiÞcation of the species found in this work.

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