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Patient 2. A 4-year-old boy was examined in late August 2004 by a pediatrician because his mother was concerned about what she thought was an insect bite on his left cheek. She had been able to express drainage from the lesion. The physician prescribed application of bacitracin ointment to the lesion. Three days later, the child’s parents noticed that the lesion was pulsating and used tweezers to remove a larva from the lesion. At a follow-up visit, the physician noted a dime-sized area of erythema and induration on the child’s left cheek, with a small amount of central crusting. The family was instructed to continue applying bacitracin ointment. The larva was examined by an entomologist, who identified a Cuterebra larval instar.
Patient 3.
An 8-year-old girl visited her pediatrician in mid-August 2004 because she had two raised erythematous lesions on her right cheek with areas of excoriation consistent with insect bites. Hydrocortisone cream was recommended. The day before her follow-up visit 11 days later, her mother noticed a moving white spot in the center of one lesion; the other lesion had nearly resolved. The child’s father squeezed the lesion, and a white larva was extruded. At the follow-up visit, the child had a 15-mm indurated area on her right lower cheek with a central opening. No fluctuance or drainage was apparent. The child was prescribed a course of amoxicillinclavulanate. The larva was identified by an entomologist as a Cuterebra larval instar (Figure 1
).
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At the visit with the dermatologist, the physician noted motion beneath the skin surface at the site of the lesion. Myiasis was suspected, and the dermatologist excised the larva. The patient continued on cephalexin and was instructed to apply bacitracin to the lesion. At a follow-up appointment 2 weeks later, the area around the lesion was pruritic and swollen, but improved.
These patients share features of previously described myiasis acquired in North America: human cases often present in the late summer and fall months, and the locations of lesions among these four patients reflect the most common areas affected: face, scalp, neck, shoulders, and chest.5 All had furuncular, or subcutaneous, myiasis, one of the most common forms of human myiasis.6 All patients visited medical providers at least twice, and all were placed on either topical or oral antibiotics. Of these four patients, three had lesions from which larvae emerged spontaneously or were extracted by family members and did not require excision of the lesion. Although Cuterebra myiasis is typically self-limited, the majority of affected persons choose to have the larva removed if it does not emerge spontaneously. This can be done either by simple excision or by occlusion of the hole through which the larva breathes, typically by using petroleum jelly. By suffocating the larva, it will emerge from the skin.6,7 After the larva is removed from the lesion, the inflammation resolves spontaneously. Usually no antibiotics are needed, although secondary bacterial infections can occur.2,7
In botfly-endemic areas of North America, clinicians should consider cutaneous myiasis among patients presenting with lesions that have a characteristic central opening in the skin and perceived or visible movement or among patients with furunculosis or cellulitis that does not respond to antibiotic treatment.
Received August 9, 2006. Accepted for publication November 2, 2006.
* Address correspondence to Elizabeth A. Talbot, Dartmouth-Hitchcock Medical Center, Section of Infectious Disease and International Health, One Medical Center Drive, Lebanon, NH 03756. E-mail: Elizabeth.A.Talbot{at}hitchcock.org 
Authors’ addresses: Rachel Plotinsky, Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA, and New Hampshire Department of Health and Human Services, Bureau of Disease Control and Laboratory Sciences, Concord, NH. Present address: Dartmouth-Hitchcock Medical Center, Section of Infectious Disease and International Health, One Medical Center Drive, Lebanon, NH 03756, Telephone: +1 (603) 650-5000, Fax: +1 (603) 650-6110, E-mail: Rachel.N.Plotinsky{at}hitchcock.org, plotinsky{at}hotmail.com. Elizabeth A. Talbot, New Hampshire Department of Health and Human Services, Bureau of Disease Control and Laboratory Sciences, Concord, NH, and Dartmouth College, Hanover, NH. Present address: Dartmouth-Hitchock Medical Center, Section of Infectious Disease and International Health, One Medical Center Drive, Lebanon, NH 03756. Harry Davis, Franklin Pierce College, Rindge, NH.
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