Human myiasis is a rare condition. It is more common in tropical regions. Umbilical cord myiasis has not previously been reported from a temperate climate, for example, New Jersey. We report a 9-day-old infant with umbilical cord myiasis. The maggots were identified by the entomologist as the larvae of Sarcophagidae, more commonly known as flesh flies.
Neonatal myiasis is extremely rare in a temperate climate, and the practitioner in these regions is unlikely to see a case. The existing case reports of neonatal myiasis are exclusively from the tropical climates and from areas in which people live close to livestock, mostly in the rural areas and villages of India, Brazil, Malaysia, Australia and Argentina.1, 2, 3, 4, 5 We described herein a case of umbilical myiasis occurring in a neonate living in an urban area in New Jersey, USA.
A full-term female infant was born in late September 2013 via spontaneous vaginal delivery at a central New Jersey hospital. Meconium-stained amniotic fluid was noted at delivery, and Apgar scores were 9 and 10 at 1 and 5 min, respectively. Birth weight was 3370 g. The baby was discharged home on day 2 of life, and the umbilical cord separated 2 days later. She was seen at an outside clinic on day 4 of life and the umbilicus was reportedly unremarkable.
On day 9 of life, the baby presented to the emergency room at Robert Wood Johnson University Hospital with a history of non-bilious vomiting and history of something coming out of the umbilicus. Clinical examination revealed a well-nourished happy baby with normal clinical exam except for erythema around the umbilical stump with a whitish exudate (Figure 1a). Within an hour, worm-like movement was noted in the umbilicus.
Petroleum jelly was applied to the umbilicus to force the larvae to come out for air. Over the next few hours, six 5-mm wriggling larvae that popped their head through the petroleum jelly were extracted with forceps under direct visualization from the umbilical stump (Figure 1b). Ultrasonographic study of the umbilicus and anterior intraperitoneal space showed no abnormality. The infant was unaffected by the process. The baby remained stable and was discharged home after 5 days.
The collected larvae were sent for identification to the Department of Entomology at Rutgers University. Two of the larvae were desiccated and too shriveled to be analyzed, and a third had ruptured midway down its body. Hence, only 3 larvae could be analyzed. Their length ranged between 5 and 6 mm, and based on the number of slits present in the posterior spiracle, they were identified as second instars. Owing to the shape of the posterior spiracles and presence of a spiracular cavity, it was determined that the larvae belonged to the family Sarcophagidae, commonly known as flesh flies.
The term myiasis (from the Greek word 'myi’ meaning fly) refers to the infestation of living tissue of animals or humans by the fly larvae. Myiasis in the neonatal period is a rare occurrence and almost exclusively found in the tropical areas.6,7 Although umbilical cord myiasis is a well-recognized type of myiasis in animals, it is rare in humans. Natural mummification of fetal tissue during the umbilical separation process is not well described in literature as a risk factor for myiasis, and similarly, the best means to protect this process are still not clear.
Identification of the species of the larvae may be crucial for determining pathogenesis and potential for invasiveness. Therefore, an entomologist should be included in the list of consultants for anything that crawls or flies.7,8
True flies (two-winged flies) belong to the order Diptera (from the Greek di=two, and ptera=wing). True flies are written as two words (for example, crane fly, moth fly, flesh fly) in contrast to non-dipteran insects that have ‘fly’ in their name written in one word (for example, butterfly, stonefly). Three dipteran families are the main cause of myiasis in livestock, and sometimes in humans: Calliphoridae, Oestridea and Sarcophagidae.1,9
The most common larvae causing myiasis in North America are the screwworms (Cochliomyia hominivorax), common cattle grubs (Hypoderma lineatum), sarcophagid flies (Wohlfahrtia vigil), house flies (Musca domestica) and rabbit box flies (Cuterebra cuniculi).8 Human cases of facultative myiasis caused by members of family Sarcophagidae have been reported throughout the world.5
Treatment consists of extraction of larvae and provision of lots of reassurance to the parents.9 Mechanical removal of the larvae under local anesthesia is the traditional treatment for myiasis, but the use of systemic ivermectin can produce favorable results in more severe cases.1 Another suggested therapy is blocking the passages where the larvae reside with petroleum jelly, which forces them to surface because of oxygen deprivation. An alternative is oil of turpentine, routinely used in many Indian veterinary hospitals.10
Prevention of human myiasis involves control of the fly population and general cleanliness, reduction of decomposition odors and cleaning as well as covering wounds. It also includes drying all clothes in the sun, adequately covering the exposed skin, using insecticides and good sanitation. The public should be informed that individuals living in locations without basic sanitation are more predisposed to infestation.1
We can only speculate as to how the larvae got into the baby’s umbilicus. The flies may have deposited their larva on the flesh of the recently separated umbilical stump or the clothing that was worn. Between 28 September and 3 October 2013, the ambient temperature ranged from 12 to 30 °C (53 to 86°F). This unusually warm weather could have contributed to the presence of flies in central New Jersey.
In summary, to the best of our knowledge, this is the first report of a case of umbilical myiasis in a US newborn.
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The authors thank the Department of Entomology at Rutgers University, for identifying the larvae. We acknowledge the assistance of Christopher Duffy, librarian at Somerset Medical Center. We are also grateful to Sylvia, Christina and Chrystal Puvabanditsin for supporting this effort and helping with the manuscript.
The authors declare no conflict of interest.
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Puvabanditsin, S., Malik, I., Weidner, L. et al. Neonatal umbilical cord myiasis in New Jersey. J Perinatol 34, 718–719 (2014). https://doi.org/10.1038/jp.2014.69
Frontiers in Medicine (2020)
Journal of Dr. NTR University of Health Sciences (2020)