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Miranda No. Prevention of nosocomial myiasis, or hospital-acquired larvae infestation, should be an essential part of all hospital infection control programs. This report describes a case of nosocomial myiasis of a year-old boy who was admitted to a pediatric intensive care unit for congestive heart failure, anemia, uremic encephalopathy, hypertension, and severe respiratory distress. Ten days after admission, the pediatrician and the nurse perceived an increase in the volume of the gingival mucosa of the upper buccal vestibule and the presence of fly larvae. The maggots were sent to the Instituto de Diagnostico y Referencia Epidemiologicos for identification and were found to be Lucilia sericata larvae. This report highlights the need to educate medical and paramedical personnel, as well as creation and implement protocols in hospitals to avoid nosocomial myiasis and improvement of general sanitation.

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Miranda No. Prevention of nosocomial myiasis, or hospital-acquired larvae infestation, should be an essential part of all hospital infection control programs. This report describes a case of nosocomial myiasis of a year-old boy who was admitted to a pediatric intensive care unit for congestive heart failure, anemia, uremic encephalopathy, hypertension, and severe respiratory distress. Ten days after admission, the pediatrician and the nurse perceived an increase in the volume of the gingival mucosa of the upper buccal vestibule and the presence of fly larvae.

The maggots were sent to the Instituto de Diagnostico y Referencia Epidemiologicos for identification and were found to be Lucilia sericata larvae. This report highlights the need to educate medical and paramedical personnel, as well as creation and implement protocols in hospitals to avoid nosocomial myiasis and improvement of general sanitation.

Nosocomial myiasis is an infestation of larvae during or after hospitalization that was not present or incubating at the time of hospital admission [ 1 , 2 ]. Of the various types of myiasis, only secondary accidental or facultative myiasis can be nosocomial [ 3 ]. As nosocomial myiasis is a strong indicator of negligence in medical care, there is evidence that hospitals underreport this type of infestation to avoid associated legal and political implications [ 4 ].

These guidelines do not include the prevention of arthropod infestation, especially infestations by common flies that can easily pass into intensive care units ICUs [ 5 ]. We report a case of oral nosocomial myiasis caused by Lucilla sericata L.

This case report is the first evidence of this species in a pediatric patient in Mexico, although this species is probably responsible for most reported cases of nosocomial myiasis [ 6 ]. The patient described in this case is a year-old boy originally from the state of Guanajuato, residing in the state of Queretaro, two neighboring states in central Mexico.

The boy was raised in a lower-middle-class household and environment. The patient had a history of chronic renal failure controlled with hemodialysis. On April 8, , the patient presented with severe respiratory distress, seizures, and generalized edema and was taken to a private hospital where he began treatment with mechanical ventilation, anticonvulsants, and hemodialysis. Once stabilized, he was immediately referred to a public specialty hospital and entered their Pediatric Emergency Department in critical condition on April 9, The pediatrician immediately performed an intraoral examination, where he observed deficient hygiene and generalized periodontal disease with numerous cavities and halitosis.

The maggots were removed, and the oral cavity was cleaned with sodium bicarbonate mouthwashes daily for eleven days. The infestation was treated with ivermectin at a dose of 0. After these successful surgeries, he was discharged 21 days later to the nephrology department to continued with his renal replacement therapy. The specimens collected were of 1. USA on a microscope slide [ 7 ]. The entomology laboratory at the InDRE used these slides magnified to 4x and 10x and a SZX7 stereoscope and an Olympus BX43 optical microscope to identify the species of the larvae using their morphological characteristics.

A literature review was performed to inform the taxonomical differentiation of these specimens against other members of the Oestroidea superfamily, especially the Calliphoridae, Cuterebridae, and Oestridae families. The characteristics that differentiated Calliphoridae family from other families were the following: body cylindrical and tapering; cephaloskeleton without long window in dorsal cornua and with developed parastomal bar; anterior spinose bands on all thoracic and most abdominal segments fully developed; posterior spiracles never in deep spiracular cavity or on long stalks, around spiracular field seven pairs of papillae; slits of posterior spiracles linear [ 8 ].

The main characteristics used to classify the species of the larvae were its spiracles, peritrema, peritrema opening, tubers, mouth hooks, respiratory tracheas, cephalopharyngeal skeleton, and the number of segments Figure 2. The morphological identification revealed that the larvae obtained from the patient belonged to the Calliphoridae family, and all were in larval stage II of their life cycle [ 9 ].

In order to molecularly support our morphological identification, we employed the COI DNA barcoding approach as detailed in Hebert et al. Paired bidirectional sequence traces were combined to produce a single consensus sequence for each specimen. The larvae of L. Including this publication, five cases of human myiasis have been reported in Mexico of which three correspond to nosocomial myiasis.

Nosocomial myiasis occurs in immobile, weakened, seriously ill, semiconscious, or unconscious patients with multiple risk factors, such as the presence of trauma, surgical or puncture wounds, abscess drainage, assisted breathing and tracheal tubes, or injuries secondary to continuous exposure of mucous membranes [ 6 , 14 ]. Our patient had several known risk factors: he was unconscious and intubated, mechanically ventilated, and had poor oral hygiene, which were the same risk factors reported in patients in the United States and in the two patients previously reported by our research group [ 15 ].

Our case is the third report of nosocomial myiasis in Mexico and the first of a pediatric patient hospitalized in PICU. Our case is similar to myiasis reported in developed countries detected in hospitalized patients in the ICU [ 14 , 20 — 23 ], which is an area of restricted access and with rigorous sanitary control measures designed to avoid nosocomial infections or infestations.

This is different from reports from lesser developed regions namely, Iran, Turkey, India, and the Czech Republic where cases of myiasis generally present in the area of emergency and hospitalization where sanitary control measures are not as strict as in ICUs [ 21 ].

If oral myiasis is diagnosed at the initial stage of the infestation, it can be benign and asymptomatic. Fortunately, in the case we report here, the diagnosis was made in the initial phase of the infestation, the myiasis was appropriately treated, and the patient responded to the treatment adequately, with no lasting complications. However, a delayed diagnosis can cause severe problems, namely, if the diagnosis occurs after the larvae have penetrated into tissue [ 6 ].

Tissue damage is particularly critical for severe or debilitated patients. The usefulness of the analysis of the genetic variation of DNA to obtain reliable information about the larval species has been pointed out. Consequently, the techniques based on the analysis of mitochondrial DNA have numerous advantages over morphological identification when specimens are damaged or lack the necessary characteristics for specific morphological classification, as was the case here [ 26 ].

No matter how benign the end result, nosocomial myiasis has a psychological impact on the patient and family members and seriously damages the reputation and financial capacity of the hospital [ 6 ].

Nosocomial infestations may also imply broader negligence on the part of the hospital authorities and possible failures in the sanitary and structural conditions of the hospital. This negligence could be grounds for legal action, involving significant losses for hospitals if it is sued for negligence [ 27 , 28 ].

In our case, this was the first case of nosocomial myiasis at a specialty hospital. In addition to treating this particular case of myiasis, preventive measures increased number of nurses, and a new protocol were implemented to avoid new cases.

For instance, the protocol in order to control the fly population considered keeping garbage always covered and the use of nets for windows, among others. We report this case as a positive example of early diagnostic, notification, identification, and prevention of future myiasis. We recommend that in general, myiasis prevention should be given greater importance by hospital authorities, especially in hospital units with structural and sanitary deficiencies.

Hospitals must adopt suggested preventive measures to reduce the incidence of nosocomial myiasis, minimize fly populations associated with myiasis in humans, and promote strategies to respond to nosocomial myiasis [ 14 , 30 ]. A prerequisite for the presence of nosocomial myiasis is the lack of awareness among staff who, although they know that flies are not hygienic and carry diseases, do not realize that they can also cause nosocomial myiasis.

Education and general sanitary measures are a cornerstone in the strategy for nosocomial myiasis prevention. Written informed consent from the parents was obtained for publication of their case reports, including any accompanying images.

All authors contributed equally to the research and writing of this report, and all authors have approved the final version of this manuscript.

We also thank Master Elena Atkinson for her valuable support for English language editing. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We will be providing unlimited waivers of publication charges for accepted articles related to COVID Sign up here as a reviewer to help fast-track new submissions. Journal overview.

Academic Editor: Larry M. Received 17 Oct Revised 05 Dec Accepted 02 Jan Published 29 Jan Abstract Prevention of nosocomial myiasis, or hospital-acquired larvae infestation, should be an essential part of all hospital infection control programs. Introduction Nosocomial myiasis is an infestation of larvae during or after hospitalization that was not present or incubating at the time of hospital admission [ 1 , 2 ].

Case Report The patient described in this case is a year-old boy originally from the state of Guanajuato, residing in the state of Queretaro, two neighboring states in central Mexico. Figure 1. Presence of larvae between upper lip and tongue. Figure 2. Lucilia sericata. Second stage larva. References U. Nazni, J. Jeffery, H. Lee et al. View at: Google Scholar S. Mircheraghi, S. Mircheraghi, H. Ramezani Awal Riabi, and A. View at: Google Scholar E.

Ahmadpour, M. Youssefi, M. Nazari, S. Hosseini, A. Rakhshanpour, and M. View at: Google Scholar J. Siegel, E. Rhinehart, M. Jackson, L. Francesconi and O. Borkent and G. Adis, J. Arias, G. Rueda-Delgado, and K. Wattzen, Eds. Amendt, M.

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