A rare case report of penile myiasis in a catheterized patient

Abstract

Introduction and importance

Penile myiasis is the infestation of the penile area with larvae of certain fly species, especially diptera. It is rare but can be a serious parasitic infestation that typically occurs in individuals with poor hygiene or those living in unsanitary conditions. Due to the non-specific and vague clinical presentation, it holds diagnostic difficulty.

Presentation of case

A 76-year-old male with a prior history of benign prostatic enlargement, diabetes mellitus, and hypertension presented with a painless penile wound and sanguineous discharge. Debridement of the wound and an attempt to expel the larvae using turpentine oil were performed. Cystoscopic examination revealed larvae inside the urinary bladder, for which bladder irrigation with 0.9 % NaCl solution and administration of ivermectin were carried out. During a follow-up visit, circumcision was performed. Subsequent cystoscopy showed no larvae inside the urinary bladder.

Case discussion

Penile myiasis is rare with only few cases reported globally and no any cases reported from Nepal till now. Penile myiasis is associated with different risk factors like poor personal hygiene, debilitated patients, genital piercing, etc. but the exact incidences of each of the associated factors is not mentioned in the literature. Due to its rare occurrence, diagnosis and proper treatment of penile myiasis is challenging.

Conclusion

Proper history and clinical examination of the genitalia is vital in debilitated patients, if they present with swellings or discharge especially those with prolonged catheterization or a history of immunocompromised conditions such as diabetes.

Highlights

• •Myiasis usually occurs in individuals with poor personal hygiene and in areas with high fly populations.
• •Immunocompromised conditions, such as diabetes with open wounds, significant increase the risks for myiasis.
• •Penile myiasis is a rare presentation, with no prior recorded cases from Nepal, as suggested by literature.
• •Urogenital myiasis is a possible finding in patients with a history of prolonged catheterization.

1. Introduction

Myiasis refers to the invasion of living vertebrate animals by the larvae of flies, specifically those belonging to the diptera family [1]. The dipterous flies, primarily Dermatobia hominis, Cordylobia anthropophaga, and Chrysomya bezziana, are drawn to necrotic, pus-filled, or blood-stained wounds where they deposit their eggs [2]. Several factors contributing to myiasis include rising fly populations, inadequate hygiene, untreated open wounds, and foul-smelling discharges from natural body openings [3]. Most maggots feed on decaying organic matter, but there are wide differences in the food preferences of different flies. In mammals, including humans, dipterous larvae can consume living or dead tissue, bodily fluids, or ingested food from the host, leading to various types of infestations depending on the body location and the interaction between the larvae and the host [1]. The distribution of human myiasis is global, with more species and higher abundance in poor socioeconomic regions of tropical and subtropical countries [4]. It is frequent in rural areas where people are in close contact with domestic animals [4]. Urogenital myiasis occurs when fly larvae infest the urinary tract or genital areas, such as the vaginal or penile openings [5]. Infestations of male or female genitalia are most likely occurs when eggs or larvae get deposited near these organs. This can happen when female flies are attracted by foul discharge, pre-existing wounds or other conditions such as Carcinomas [5]. Another potential route of infestation is through contaminated medical instruments, such as catheters or syringes used for douching. These instruments, if exposed to urine or pus, can attract female flies looking to lay their eggs [5]. Although cases of urogenital myiasis have been reported worldwide, occurrences involving the glans penis are particularly uncommon. Our literature review found no previously reported cases of penile myiasis from Nepal. This absence of documented cases prompted us to present this case, highlighting the need for awareness and consideration of this rare condition as a differential diagnosis when evaluating genital lesions, especially in debilitated patients. This awareness is crucial for healthcare providers who might encounter such cases. We present a case of penile myiasis in a debilitated patient with a history of hypertension, type 2 Diabetes Mellitus, and stroke, which appears to be the first reported case of penile myiasis from our country. This case report has been reported in line with the SCARE Criteria [6].

2. Case presentation

A 76-year-old heterosexual married male, who worked as an overseer in a manufacturing company in India in the past but is currently retired and stays in western Nepal, presented with a 4-day history of periurethral discharge. There was a positive history of hematuria, but burning micturition, flank pain and fever were absent. He has a past history of benign enlargement of the prostate for which he had a Foley catheter in place for the past 2 years, type 2 diabetes mellitus, hypertension and stroke. Two years ago, he suffered a cerebrovascular attack resulting in left-sided hemiparesis which made him dependent on his wife for personal hygiene.

On primary physical examination, the patient general condition was found to fair, conscious, with stable vital signs. Local examination of his genitalia revealed a penile swelling, a wound with sanguinous discharge (Fig. 1) and multiple maggots. He also had a Foley catheter in place. Abdomen was soft, non-distended, non-tender, and normal bowel sounds were heard on auscultation. Chest examination revealed bilateral normal vesicular breath sounds, and cardiovascular examination showed normal heart sounds.

Fig. 1.

A penile wound showing sanguineous discharge.

In laboratory tests, urine microscopy revealed plenty of RBCs and 2–4 pus cells per high power field. Hematological analysis showed decreased hemoglobin concentration of 10.2 g/dl; Differential leukocyte count revealed increased neutrophil (84 %) and decreased lymphocytes (12 %); total RBC count of 3.72 million and Packed Cell Volume of 32 %, all other parameters of urine microscopy were normal. Biochemical tests showed random blood sugar of 167 mg/dl, blood urea level of 49 mg/dl, and serum creatinine of 1.7 mg/dl. Under liver function tests, total bilirubin was 1.7 mg/dl, direct bilirubin of 0.4 mg/dl and ALT level of 94 Unit/Litre. Other parameters of biochemical tests were normal. The coagulation assay revealed a slightly prolonged prothrombin time (PT), but with a normal International Normalized Ratio (INR), suggesting that this finding was not clinically significant. Serological exams were negative for Hepatitis B surface antigen (HBsAg), Hepatitis C antibody (HCV Ab), and HIV antibody, ruling out these viral infections. An ultrasonography (USG) of abdomen and pelvis revealed grade-3 prostatomegaly with intravesical protrusion and mildly thickened Urinary bladder walls.

Patient went dorsal slit incision and debridement and removal of maggots were performed under regional anesthesia, along with an attempt to expel the larva using turpentine oil. During debridement, maggots were seen crawling through the urethra towards the penile meatus, raising the concern for the presence of larvae within the bladder. There were no any other signs and symptoms of upper urinary tract involvement besides hematuria. Consequently, a cystoscopic examination was done. On cystoscopic examination, larvae were also found in the urinary bladder (Fig. 2), there were trabeculations in the urethra and narrowing of urethra due to prostate enlargement.

Fig. 2.

Cystoscopy showing a maggot inside bladder cavity.

Consequently, a bladder irrigation with NaCl solution was done for expelling the larvae. A single dose of ivermectin tablet, 12 mg was given orally. He was put on a 3-way Foley catheter and was discharged after 11 days of hospital stay. He was stable at the time of discharge and was asked to follow up after 1 week. On follow-up visit the patient underwent circumcision for decreasing the risk of another infection. A repeat cystoscopy was done which revealed no larvae in the Urinary bladder. Ivermectin was not given this time.

3. Discussion

Myiasis occurs when larvae of dipterous insects, infest the live vertebrates [1]. Furuncular, wound associated, or migratory are the three forms in which cutaneous myiasis presents clinically [7].

While myiasis is not so common, some reports can be found in the medical literature. Penile myiasis is even rare among urogenital myiasis, with only a few cases reported globally [8]. However, no previously documented cases of penile myiasis in Nepal could be found in the literature review. Penile myiasis is more common among people with poor personal hygiene, debilitated patients, high fly populations, neglected open wounds, and foul-smelling discharge from natural body orifices [3].

In the literature, we found a case of genital myiasis associated with genital piercing, a case of penile myiasis in association with penile carcinoma, and myiasis as a rare complication of male circumcision, however myiasis in our patient was neither associated with risk factors such as genital piercings, circumcision nor accompanied by any carcinomas [[9], [10], [11]]. A patient with penile myiasis may also present with inguinal lymphadenopathy and severe local pain [12]. However, the exact percentage of incidences of each of the associated factors is not documented in the literature.

Infestations of male or female genitalia most likely occur when eggs or larvae get deposited near genital organs. This happens when female flies are attracted by foul discharge or previously present wounds [5]. In this patient's case, the use of a Foley catheter for an extended period, coupled with his inability to maintain personal hygiene due to hemiparesis, might have created an ideal environment for fly attraction and subsequent infestation. The discovery of maggots in both the penis and urinary bladder is an uncommon and alarming occurrence. Although urogenital myiasis is not uncommon, but infestation of bladder is very rare, and it indicates the severe and invasive nature of the disease. In this patient, the detection of larvae inside the urinary bladder during cystoscopic examination is an unusual finding and the contributing factors were likely prolonged catheter use and poor personal hygiene of genital area.

Evaluation of the patient's laboratory results revealed an increased neutrophil count, suggestive of ongoing acute inflammatory response, and anemia, which may have been contributed by his underlying chronic conditions and poor nutrition.

There is a practice of trying to eliminate larvae through petroleum Vaseline and turpentine oil [13]. Applying pressure at glans penis to remove larvae is also a method of practice [14]. Examination of catheter for presence of any eggs or larvae is also essential and a practical approach in patients of prolonged catheterization, as in this patient. Turpentine oil was used in the given scenario. Turpentine oil blocks the access of oxygen to the larvae causing them to suffocate, thus they seek air in distress and come out from the wound, facilitating their manual removal. 50 ml of turpentine oil was applied directly, without any dilution and no any skin reactions were noted. Adequate precautions were taken while applying turpentine oil to prevent its contact with normal tissue around the wound. The patient was closely observed for any skin reactions like local irritation, redness or burning sensation at the site of application. He was treated with the multifaceted approach of a wound debridement, manual larvae removal, bladder irrigation with the help of NaCl solution and use of Ivermectin, an antiparasitic agent, which is known for its effective treatment of myiasis. Through this approach a complete removal of maggots from the patient was successful. When the patient came for follow-up after a week, cystoscopy was performed which revealed no maggots. Circumcision was performed for the sake of hygiene and to prevent future recurrence. The patient was satisfied with the treatment he got in the hospital.

The patient's susceptibility to myiasis is likely influenced by prolonged catheterization, contamination of the catheter and inadequate hygiene. Due to its rare occurrence, diagnosis and proper treatment of penile myiasis is challenging.

4. Conclusion

This case report highlights that clinician must think of urogenital myiasis as a differential diagnosis if patients have a history of prolonged catheterization or catheter associated complications, especially in resource-limited settings. It also highlights that severe complications can be prevented if the problem is detected early and managed comprehensibly. Although rare, myiasis should be considered as a possibility in any debilitated patient who presents with abnormal genital discharge or swelling, particularly when sanitation or hygiene practices are compromised. Raising awareness about the condition and maintaining personal hygiene are essential for preventing myiasis. Above all, controlling the fly population is also crucial.

Author contribution

PA and SG = data collection, conduction of diagnostic tests, writing and editing of the manuscript.

SM = writing the initial draft, senior author and supervisor.

NS, BL and PRC = surgical care of the patient, analyzing the case, literature review, coordination among the authors.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal on request.

Ethical approval

Not required.

Guarantor

Sagar Mandal (the senior author and the corresponding author) take the full responsibility of the work.

Research registration number

Not applicable.

Note: no patient and author details are included in the figure.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of Generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used ChatGPT in order to paraphrase and correct the grammar of the manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Funding

None.

Conflict of interest statement

The authors declare that they have no competing interests.

Appendix A. Supplementary data

Supplementary video