Beyond the usual etiology: Acute balanoposthitis revealing preputial myiasis: A case report

Abstract

Acute balanoposthitis is a common inflammatory condition in children, typically caused by infectious agents. Penile infestation by fly larvae is an extremely rare etiology, imposing difficulty with diagnosis and treatment in endemic areas. We describe the case of severe acute balanoposthitis in a toddler from Ambo town, Ethiopia, as a result of myiasis caused by tumbu fly larva. The larva was completely removed, and circumcision was done. This instance emphasizes how crucial it is to take myiasis into account in the differential of balanoposthitis in endemic areas.

1. Introduction

Bacteria and Candida are the main culprits of inflammation of the prepuce and glans in boys who are not circumcised.^1,2 The Jegadish et al. study found that over 77 % of balanoposthitis cases were infectious, with Candida being the most common agent.¹ Rare parasitic etiologies like myiasis must be considered, particularly in tropical areas like Ethiopia, where myiasis is endemic with prevalence rates of 50–55 %.3, 4, 5, 6, 7 Myiasis, the infestation of living tissue by dipterous fly larvae, is uncommon in the genital region, particularly the prepuce or glans penis.6, 7, 8, 9, 10, 11 One of the primary causes of furuncular myiasis in sub-Saharan Africa is the tumbu fly, Cordylobia anthropophaga, which is often associated with trauma, inadequate sanitation, or remote regions.^4,5,7, 8, 9 The geographical significance of genital myiasis is highlighted by cases reported by Petersen and Zachariae, Jesuyajolu et al., Talwar et al., and Kelbore et al., which outline the condition in various communities, notably in Ethiopia.^6,7,10,11 Treatment is frequently delayed due to erroneous assessment as cellulitis, abscesses, or STDs.^3,6,7,12 To illustrate diagnostic difficulties and treatment approaches, we report a case of preputial myiasis in a 3-year-old Ethiopian boy that was first misdiagnosed as bacterial balanoposthitis.

2. Case presentation

In Ambo, Ethiopia, a toddler aged three who had not been circumcised arrived at Ambo University Referral Hospital after experiencing pain, swelling, and redness of his penis for four days. It started as a tiny, itchy lump on the foreskin, which developed into excruciating pain and made him sleepless. Fly contact was increased because the household resided in poor hygiene close to domestic pets.^4,5,7,8 No reports of insect bites or injury were made. Upon evaluation, the foreskin and head of the penis were found to be extremely swollen, erythematous, and tender, and the foreskin couldn't be retracted back on the glans penis (Fig. 1). Vital signs showed a temperature of 37.8 °C, a respiratory rate of 28 breaths per minute, and a pulse of 124 beats per minute. The biological parents gave their informed consent for the management and consideration for publication in accordance with the Declaration of Helsinki because, per organizational regulations, this one case report wasn't subject to a formal ethics committee evaluation.

Fig. 1.

Grossly swollen and erythematous prepuce and glans penis at re-evaluation, showing signs of inflammation.

Laboratory tests on arrival revealed a hemoglobin level of 13.6 g/dL, a platelet level of 235,000/μL, a leukocyte count of 13,000/μL (73 % neutrophils), and a normal urine analysis. He was prescribed intravenous ceftriaxone (50 mg/kg/day) after his diagnosis with acute suppurative balanoposthitis. There was no noticeable change in patients' symptoms and clinical findings after one day of treatment. A revised diagnosis of balanoposthitis secondary to preputial myiasis was established by re-evaluation, which showed a five-millimeter by five-millimeter opening on the anterior aspect of the foreskin, which had a visible moving larva (Fig. 2).^3,7,8,10

Fig. 2.

Ventral prepuce with a 5 mm × 5 mm opening revealing a motile larva.

3. Management

Six milliliters of 1 % lidocaine for an anesthetic were used in a sterile setting. The genital area was cleaned with 10 % povidone-iodine and 0.9 % normal saline. Manual compression yielded 3 mL of pus but failed to extract the larva. A small incision along the opening, followed by manual pressure, removed one 2 cm, serrated, motile larva (Fig. 3), presumed to be Cordylobia anthropophaga based on its appearance (cylindrical shape, backward-pointing spines) and regional prevalence in southwestern Ethiopia.^4,8,10 We did not have experts or the facility for entomological identification to confirm the species, consistent with challenges reported in other Ethiopian cases.⁷ The wound was irrigated with 0.9 % normal saline, left open, and dressed with sterile gauze. The patient received cephalexin at a dosage of 25 mg/kg/day, administered twice daily, and Paracetamol syrup at 15 mg/kg, given four times daily for five days to treat the secondary infection and alleviate pain.6, 7, 8^,12

Fig. 3.

Third-stage larva of Cordylobia anthropophaga extracted from the prepuce.

4. Follow up

After daily wound treatment for two days, when the patient got better, he was sent home. Wound healing progress was assessed at one-, three-, and six-week follow-up visits at the outpatient department. Circumcision was performed two months after. At 6 months, the circumcision site was well-healed with no complications (Fig. 4).

Fig. 4.

Healed circumcision site at 6 months post-procedure.

5. Discussion

Preputial myiasis is an exceedingly rare cause of Balanoposthitis, with few reported cases globally.^3,6, 7, 8, 9, 10, 11, 12 This case adds to the limited literature on urogenital myiasis worldwide and in Ethiopia, where a similar case in Wolaita Sodo involved a nodular lesion on the glans penis misdiagnosed as a furuncle.⁷ Given that Myiasis may resemble the usual illnesses like cellulitis or abscesses, an earlier incorrect assessment of our patient as bacterial Balanoposthitis highlights the diagnostic difficulty.^3,6,7,12 The general public's understanding of myiasis varies in Ethiopia, and misunderstandings (such as the idea that it is caused by contact with moist soil) may hinder early diagnosis.⁴ Since we lacked the expertise and resources for a proper entomological analysis, we identified the larva as Cordylobia anthropophaga through its physical characteristics (2 cm length, serrations) and geographic region endemicity—a constraint also observed in a study from southern Ethiopia.^4,7,8 In areas where the disease is prevalent, comparable cases—like the ones reported by Jesuyajolu et al., Petersen and Zachariae, Talwar et al., and Kelbore et al.—emphasize the necessity of maintaining a high degree of suspicion, especially in individuals who have poor sanitation or have been exposed in remote regions.6, 7, 8^,10 The predisposing conditions that correspond with the patient's history include clothing that is laid outside to dry and not ironed properly, living in rural areas, and a lack of sanitation.4, 5, 6, 7, 8 Since they may behave likewise, differential diagnoses such as Leishmaniasis of the skin ought to be taken into account.^13,14 As with other genital Myiasis instances, immediate surgical extraction—like the one done here—is essential, and secondary bacterial infections are treated with antibiotics.6, 7, 8^,12 As observed in instances like this, post-recovery circumcision probably decreased the risk of recurrence.^8,10 In order to fill in knowledge gaps and encourage preventive practices like ironing clothes, healthcare providers in tropical areas should take Myiasis into account when treating uncommon genital infections, aided by health education in the community.^4,7

6. Conclusion

Penile Myiasis infestation is an uncommon but significant cause of acute Balanoposthitis in individuals who live in or have visited endemic areas. This case, one of the few reported in Ethiopia alongside a similar urogenital case in Wolaita Sodo,⁷ underscores the importance of a broad differential diagnosis, thorough re-examination, and prompt larval extraction to achieve favorable outcomes. With the help of community-based initiatives to raise understanding and encourage safeguard measures, healthcare professionals in areas that are endemic should keep a high index of suspicion for parasitic infestations in order to avoid errors in diagnosis and adverse outcomes.^4,7

CRediT authorship contribution statement

Amanuel Mesfin Oljira: Writing – review & editing, Supervision, Investigation, Data curation, Conceptualization. Samuel Kefiyalew Kelbessa: Supervision. Berhanu Nigusse Bikila: Conceptualization. Bekele Abera Mekonen: Data curation. Dereje Gurmessa Geleta: Conceptualization. Boka Imiru Shoro: Investigation.