Re: What is this?!?!

Hi Dvelardi,

Hope you have had good success resolving this infection.

THE QUICK ANSWER:
Your descriptions and some of the images definitely appear to be a type of Myiasis, probably Creeping Myiasis (fly larvae in various stages infecting and tunneling through skin and deeper tissues). It may possibly involve a fly in the Hypoderma or Drosophila (D suzuki) genus or something similar and small. I have seen and read about several other types of myiasis-causing fly infections in many US states.

The most important information to remember about these types of infections:
* All insect bites are to be immediately treated with some type of anti larval & anti microbial.
* Daily use of fly/gnat/mosquito repellents is important.
* The more quickly the infection is recognized and treated the less extensive it becomes and the less time required to resolve it.

Treatments generally involve using a topical anti larval agent with, or without, systemic anti-larval treatment; and/or, the use of occlusion therapies (e.g., "suffocants", drawing agents,...), all of which are followed by manual removal of some sort.


THE LONG ANSWER:
(Information from medical literature, health organizations, news reports, conferences, personal experiences,....)


INFECTION BACKGROUND INFORMATION

Myiasis = a disease of humans originating specifically with dipterous larvae (two-winged insect larvae, e.g. flies) as opposed to other insect larvae. They feed on dead, decaying or living tissue; liquid body substances; blood and ingested food.

Some medical sources imply that only ill, poor or unhygienic people are infected however, many travelers, non-travelers, farmers, country-living people, hikers, campers and other healthy people are commonly infected. Where flies are present infection can occur.

These infection rates are increasing in the US, and other countries, and the flies are not indigenous. Since 2008, Drosophila suzuki, from Asia, has spread throughout the US, and other countries, and is associated with the destruction of healthy produce; however, this fly can infect warm blooded creatures since they are primarily attracted to yeast/fungus and many people have yeast/fungus infections (e.g., Candida).
And, the New World/Old World screwworms, infecting the Keys Deer in Florida, has spread into many US states and infects humans.

Some of the flies that infest humans are very small, light colored & difficult to see. You will simply feel them on the skin or scalp.

Generally, there are over 70 types of flies that can cause human myiasis (more common: Hypoderma, Dermatobia, Wohlfartia, Chrysomyia, Cochliomyia, Oedemagena, Rhinoestrus, Drosophila, Oestrus, Gasterophilus, Cordylobia, Sarcophaga, Muscina, Fannia, Calliphora vicina, Lucilia, Phormia, etc...). Common names include Tumbu Fly, Latrine Fly, Blow Fly, Warble Fly, Cattle Grub, Stomach Grubs, Sheep nasal bot fly, Horse fly, Flesh Fly, Bots, Grubs, Maggots, and the green-, blue- or black-bottled flies.

The different types of Myiasis infections are based on the affected body location (skin - 3 skin types; nose; eye; mouth; ear; intestines; ...), type of symptom or degree of parasitism (i.e., Obligatory, Accidental, Facultative).

Creeping/Migratory Myiasis is one of 3 types of CUTANEOUS MYIASIS (i.e., Furuncular, Wound, Creeping/Migratory) & is the most difficult to diagnose and treat since the flys & larvae can be quite small and the symptoms quite subtle & easily mistaken for other skin conditions. And, even more so if the doctors/culture are not familiar with the infection as exists in the US.

The scalp, ears, nose, mouth, eyes, hairy areas, eyebrows, neck, torso and extremities are common sites of attack. In general, any exposed area can be infected. Disease can also be caused by ingestion or surface contact on which eggs or larvae have infected.

Generally, the eggs or larvae attach to the hair shaft or skin surface and burrow into various layers of the epidermis and connective tissue where they can migrate causing very small to large superficial and deeper masses, nodules & tunnels which can enlarge and deepen overtime. If destroyed by pressure, the larvae can cause large swellings or anaphylaxis.

Larva or eggs can be deposited in, or migrate to, various locations within/without the body - eyes, esophagus (specific for some species), nostrils, ears, throat, chest, brain, hair shafts, skin, intestines (specific for some species), spine, and body cavities. Larvae and eggs can invade wounds, sites of infections, unhealthy skin and unbroken skin. They can enter the body through various orifices (nose, ears, eyes, mouth hair shafts, urogenital). Larvae and eggs can reach the intestines and stomach if ingested or, via migration, and cause intestinal or gastric myiasis.


Examples of Migratory Cutaneous Myiasis:

1. The Fly - Gasterophilus intestinalis
Humans become infected by direct contact with eggs on the horse's coat or the eggs are directly laid onto human skin.
The larva initially produce small papules then burrow deeper and can cause intensely itchy, snake-like, and raised red linear lesions that advance at one end and fade at the other as it searches for a place to develop.
The lesion can travel up to 30cm per day and can continue for several months. The infestation may end spontaneously with or without developing a purulent sore.
Many symptoms can be associated with this infection depending on location, depth and length of burrow. There are many other symptom variations.

2. The Flies - Hypoderma bovis & H. lineatum (note: there are other species that infect humans)
Infections typically occur in rural areas where animals are raised.
The eggs are laid on the body & larvae enter through the skin & migrate in the subcutaneous tissues and can cause slightly red, tender, and ill-defined 1-5 cm raised areas often called warbles.
After several hours to several days the redness subsides, leaving a yellow- pigmented patch, as the larva wanders to another location. A faint, irregular, palpable line connects the old area of redness with the newer one. The larva can migrate 2 to 30 cm per day. The larva can die in the tissues or remain for quite a long time.
There are many other symptoms and their variations. Some cause layers and overlapping thin layers of infection within the skin and subcutaneous tissues which over time slowly swell in size.
Human Hypoderma myiasis can be a mild disease but can cause muscle & joint pain, urogenital swelling, ascites, fluid around the heart, fever and infection of the brain & spinal cord.



MYIASIS SYMPTOMS

Symptoms will depend on what part of the body is affected.

NEURO MYIASIS - example, cats can develop feline ischemic encephalopathy caused by Cuterebra larvae migrating through the brain and humans can develop intracerebral hematoma from various species.

ORBITAL MYIASIS - If affecting the eye, Ophthalmomyiasis externa/interna, it can cause uveitis, glaucoma and retinal detachment. Oestrus ovis, the sheep nasal botfly, often causes this condition in addition to other species: e.g., Rhinoestrus purpureus, Dermatobia hominis, Cochliomyia hominivorax, Chrysomyia bezziana, Wohlfartia magnifica, Oedemagena tarandi and Hypoderma bovis.

AURAL MYIASIS - there can be crawling sensations, buzzing or other noises, smelly discharge, blood or other discharge. If located in the middle ear larvae could reach the brain.

NASAL MYIASIS - there can be obstruction of nasal passages, various irritations, movement sensation, debris/larvae. Sometimes facial edema, sinus edema and fever can develop. Death can occur.


SOME CUTANEOUS MYIASIS SYMPTOMS

The scab-like material is the glue they use to adhere to the hair, skin and deeper tissues.
There are various symptoms & can include: odd scabs, thick clearish or dark scabs, psoriasis-appearing areas, flaky/flaky red areas (painful when removing flakes), incision type wounds; clear fluid, blood or pus can drain; non-healing wounds; small holes/punctums; movement sensations or visual movement; tunneling tracks (linear or irregular); boil- or ulcer-like lesions; very mild to large nodules/lumps/swellings/masses that are roundish or irregular in shape, with or without inflammation or exudations; layers of flaky debris or crusts often bleeding when removed; etc... Lesions typically last for prolonged periods. Sometimes there is a protective coating over the lesions.

The infection starts out with a fly "bite" or "deposit" which can appear as small bleeding wounds, incisions or very small to large pimple-like spots or, burn-like or scraped lesions (all called "fly strikes"). Some can lay hundreds and hundreds of eggs/larvae on the hair shafts which then burrow into the skin & tissues. A roundish, fluid filled dome is typical of some bot fly strikes.



USA INFECTIONS

Some of the flys infecting a number of people in the US are light colored, small, and difficult to see, not your typical house fly variety. A lot of people and animals are being infected in many states across the US. There have been many news reports indicating an increase in these infections throughout the US. Also, you can see most of the flys & the overwhelming majority are not indigenous to the US.

I have seen various myiasis-causing flies in coffee shops, ethnic & non-ethnic grocery stores and other shops where you can see them on produce & pastries.

The US Gov strictly monitors these types of infections due to the severe impact on the agricultural industry and on domestic animal and human health. However, during the past 5-10 years, inspections/treatments/laws are not being strictly followed. It is similar to the lack of enforcement and public education regarding the once well known state health laws banning dogs from beaches (and businesses) in order to protect people, wildlife and sea life from canine parasites and canine vector-borne diseases (e.g., hookworm - contagious & easily contracted through the skin by walking on beaches).



TREATMENT

Insecticides work because it is an arthropod/insect (borax, boric acid, ivermectin,...). Often, there will be itching, burning, etc... after application because you are killing the organisms.

Ivermectin kills them topically though, 3-4 applications, daily, at 1%, or greater, is needed.
The problem is getting the organisms to surface from under the skin, deeper tissues, scab and/or wound so that the medication can reach them and/or so that they can be removed.
The other problem is these organisms are often much smaller than the typical larger and more focal furuncular myiasis masses which can be easily identified and removed.
Under a microscope you will see the organisms turn into an agar-looking mass when ivermectin is used on them whereas, if removed manually without ivermectin, they retain their color and form.

Depending on the species, Diatomaceous earth can kill them if you rub the powder into the skin multiple times a day is best - it causes them to surface & dehydrates & shreds them. Then, you can remove them manually which can be painful and sometimes difficult since they can still be attached to the skin in which case you need to pull them off.
They are easier to remove if ivermectin is applied to the organisms, after they surface, since it kills them and relaxes their grip. DE application, followed by emergence, followed by manual removal, and repeated is the process.

I know of several people infected by some type of tiny flying fly and developed flaky red areas on the face or scalp - nose, ears, brow, cheeks, chin,.... Sometimes the affected area(s) became slightly inflammed, tender, painful with pressure, thickened, scaly, crusty or swelled depending on how long the infection was present. These areas were removed with chemical peels, laser treatments or multiple applications of DE, Ivermection or other salves.
Most of the time the removal procedures were a bit painful but better out then in.

In some other cases, the insect plastered itself to the skin & after it was peeled off one could see larvae emerging after anti-larvals were applied to the superficial wound.


In medical literature the general treatments for Creeping Myiasis include:

A. Ivermectin Therapy:
APPLY 1-3% Ivermectin cream (optional - with DMSO 5-10%) topically, 4 times daily.
And, take oral Ivermectin (1-4x/day) and Albendazole (2x/day) - length and dose vary depending upon severity of infection.
Must manually remove all larvae and organisms to prevent reinfections, secondary infections and allergic reactions.
Repeat process until ALL masses are completely resolved which can take days, weeks, or months.
Also, there is the subcutaneous use of Ivermectin in treating & preventing this condition.

B. Manual Removal Process:

1. Cause larvae to surface using suffocation, sedation or other tactics (liquids, salves, thick oils, waxes, petroleum jelly, "bacon therapy", injected anesthetics, DMSO with ivermectin or other medications, Turpentine packs/stupes, etc.....).
2. Emerged larvae can then be manually removed using serrated forceps, tweezers, needles, hemostats or other instruments. Can save in 70% isopropyl alcohol for ID.
3. Continue this process until ALL organisms and debris are removed.
Some species can lay hundreds and hundreds of eggs & over time, this can add up; hence, the procedure can take days, weeks or months.

C. Surgery is sometimes needed.

D. Antibiotics are often used due to secondary infections (e.g., e coli, mycoplasma, staph, other bacteria and viruses, and even other parasites).

NOTE: another medication used topically and/or systemically is 15% thiabendazole, there are others meds. In animals they use Moxidectin, Doramectin, Ivermectin, Fipronil, Imidacloprid or Selamectin to prevent or treat warble infestations.


A 2012 Entomology Seminar on Myiasis indicated the following treatments:
A. DIAGNOSIS
* Diagnosis of cutaneous myiasis is made primarily on the CLINICAL APPEARANCE of the lesions, associated symptoms, travel history, and a thorough patient history (e.g., odd flys were around, insect bite started symptom onset, visiting a farm, animal contact, etc...).
Note: sometimes an obvious demarcation of the lesion is not visible and only a subtle "swelling" is noticed which leads to one of the classic signs of parasitism, ASYMMETRY, where there is a subtle to obvious asymmetry in the same feature (e.g., one cheek is "puffier" than the other, one brow bone is "swollen" compared to the other, one mid calf is 1/2" larger in circumference compared to the other, ...).
* Dermoscopy and ultrasound may be helpful, diagnostic and can assist during treatment to locate extent/depth of lesion.
* Submerging the lesion under water may confirm the diagnosis – if the larva is alive, bubbling will often occur.
* intestinalis larva can be diagnosed by massaging a thin layer of glycerol or paraffin over the red lesion.
* Under magnification, black transverse bands can be seen that represent spines on the larva's body segments.
* Skin biopsy - will often see the classic myiasis stages: eggs, 3 instar larvae stages, pupae, "husks" and even adult stage.
* Application of "drawing" or "occlusive" agent (may take 24 hours or longer) to cause larvae to surface and thus identified.
* Other imaging exams

B. TREATMENT
1. Occlusion & manual removal of the larva may be used for treatment of cutaneous myiasis.
OCCLUSION
* The larvae require contact with air to breathe; occlusion either kills the larva or induces it to move upwards where it can be removed.
* A variety of occlusive substances have been used including: glycerol, paraffin, clays, petroleum jelly, ....
* The occlusive substance is placed over the pore of the furuncle, or over the area of wound myiasis, other lesions or affected area for up to 24-48 hours - as long as needed.
* Once the larvae have migrated to the skin surface, they can be removed with forceps. This can be difficult as the larvae resist extraction using their spines to anchor themselves to the host. D hominis is one of the most difficult larva to extract due to its tapered shape.
* Depending on the severity of the infection and the fly species, this process can take hours, days or months.

C. MIGRATORY MYIASIS - examples
1. Hypoderma larvae can be extracted through a surgical incision if there is no warble formation, but can be difficult to capture since they can dig deeper into skin or move.
2. Gasterophilus can be extracted by making a small surgical incision over the leading edge of the advancing lesion and using the tip of a sterile needle to remove.

D. PREVENTION
* Use window screens, mosquitoe netting, insect repellents and insecticides, adequate protective clothing, good skin & wound hygiene to keep flies/mosquitoes and ticks from reaching the skin.
* Cover all open wounds and change dressings daily.
* Hang clothes to dry in bright sunlight and/or iron them (the heat destroys both the eggs and larvae).
* Improve hygiene and sanitation (e.g., remove rubbish from around living areas, do not leave food out, sanitize bathroom frequently, no smelly areas, ....



MYIASIS RX HISTORY

During the 1800s - early 1900s the old timers and cowboys used various thick salves applied to the myiasis-affected areas and left on the skin roughly 3 days after which, the debris/wound was cleaned out and the process repeated until the often deeply embedded infection cleared. This was actually one of the main sources of cowboy labor - treating myiasis infections in cattle and other animals and humans.

The thick drawing/occlusive salves were often variations of pine salve - pine tar, pine resin, pine resin oil (turpentine), pine oil, etc.... These were often mixed with sulfur and petroleum jelly and/or with other drawing, antimicrobial and/or insecticidal herbs or elements. These salves caused the larvae to surface and die.


I have read of other natural treatments used topically and/or systemically - all of which are followed with manual removal:

* Various traditional herbs used for myiasis infections, taken orally and/or applied topically to kill them.
* Borax (saturated solution) + 1% Hydrogen Peroxide - topical. And, both can be taken internally in minute amounts. (Ted, EarthClinic).
* 10% Ammonia chloride + 10% Tetrasodium EDTA in distilled water, topical - Ted, EC
* Lavender and/or Tea Tree essential oils, multiple applications daily - Ted, EC
* Oregano oil - multiple applications daily until infection completely drawn out. Or other anti-myiasis, anti-larval essential oils mixed with an insecticidal carrier oil.
* Salt packs sometimes mixed with anti-myiasis/larval oils, baking soda & Epsom Salts .
* Stupes (turpentine stupes used in India and other countries)
* Salt soakings, twice daily, 30-45 minutes each time.
* Other drawing, dessicant & antifungal solutions.
* Daily or twice daily applications of natural insecticidals for as long as needed, generally 3 months.

Other products or procedures causing suffocation & surfacing:
* Frequent applications of some anti-myiasis/larval essential oils (e.g., Turpentine causes suffocation)
* BEST - sulfur/pine oil/petroleum jelly blend (leave on 3 days, debride, wash, repeat
* Medical - Laser treatments, various chemical peels,...
* Adding DMSO or other non-toxic solvents/penetrants to medications or other products could cause deeper tissue penetration and potential surfacing.
* Using something to destroy the yeasts/fungus in the skin and blood can make a difference since yeast/fungus can feed & attract some species (e.g., D. suzuki).

Finding proper medical care is difficult since most Americans and US doctors are not familiar with myiasis infections since the government did a great job at eradicating myiasis-causing flys (especially New World/Old World Screwworm) in the US during the 1940s-1960s; and, there is gross lack of public education or warnings. Also, until around 5-10 years ago, the US government maintained strict monitoring & treatment protocols & laws in every state.

In the 1940s the US government developed a sterilization technique that is now used worldwide to eradicate myiasis-causing flys in the environment. During the 1960s and even up to the 1990s, several European countries eradicated the Warble Fly (Hypoderma genus and its species) and several South and Central Amerian countries use this technique today.

Currently, Myiasis is increasing worldwide, especially in industrialized countries.

One wonders if we actually live in an industrialized nation because third world countries easily recognize, diagnose and treat myiases and they are not in denial.
In addition, they actually have access to effective medications or medical treatments and the price is significantly less.

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