Pseudointestinal Myiasis Treated as Helmithic Infection for Four Years

We report a case of pseudointestinal myiasis treated as helminthic infestation for years together with antihelminthic treatment for many times. Careful examination of faecal sample and clinical examination helped to confirm the diagnosis indicating that use of accurate diagnostic tools plays an important role in the confirmation of disease and forms an important part in further planning of appropriate therapy and to avoid unnecessary use of incorrect therapeutic approach.

oping countries where sanitation and hygiene are poor (2)(3)(4).It is the infestation of live human being and vertebrate animals by dipterous larvae.Most of the times, it is misdiagnosed as helminthic infection because of passage of small, white larvae resembling worms and is treated as helminthic infestation to which patient does not respond and keeps on changing the doctors with a label of helminthic infection from one hospital to another hospital.Hence, accurate diagnosis by using appropriate laboratory methods forms an important part in differentiation it from helminthic infection.The confirmation of whether the myiasis is the real cause or is it pseudomyiasis? is also the most important part before starting the appropriate therapy.

Myiasis is an infestation by dipterious fly maggots.
Intestinal myiasis is an accidental myiasis in which eggs or larvae ingested accidentally are not destroyed in the intestine.The larvae mature in the gut and produce symptoms as abdominal pain, vomiting, diarrhea or even ulceration.Severe nervous symptoms because of anxiety may also be seen.Intestinal myiasis caused by various species of larvae has been reported in the past from India (5)(6)(7)(8).However, to the best of our knowledge, till date, no case of pseudo-intestinal myiasis has been reported.
In this report, a case of pseudo-intestinal myiasis, which is diagnosed and treated as helminthic infection for years together, is reported.

CASE
A 25-year old male, agricultural worker, staying in farm-house and defecating in open air, presented with a history of frequent passage of small worms in his stool since four years.The patient had no history of loose stools, pain in the abdomen, weight loss or fever.On the basis of history of passing worms in stools he was given antihelminthic treatment by general practitioner but invain.He kept on changing the doctors for this problem and received antihelminthic treatment for many times.He was advised gastroscopy for this problem by a physician, which showed normal findings, but his problem was not solved.He also opted for Ayurvedic (Indian traditional system) Basti treatment (Medicated oil enema) but his problem continued in spite of this treatment.Finally he approached Dept. of Microbiology for confirmation of diagnosis.Examination of patient at out institute revealed an averagely built and reasonably nourished individual.The patient was not having any problem except for the fear of passing worms in his stool and psychologically much worried about it.There was no pallor, clubbing, icterus, lymphadenopathy or pedal edema.Examination of abdomen and chest showed normal findings.There were no markers of malanutrition.Faecal sample and swab from patient showed no ova/ cyst/larva/adult worm/segments of adult worm.
After eight days, the patient brought his stool sample, which showed presence of small cylindrical larvae about 1 -2 cm long (Figure 1).The patient was asked to bring fresh sample in the hospital itself, which was found negative for parasitic elements.Taking into consideration the defecation habits in open air, he was advised to protect faeces from flies after defecation by using sieve for 15 days and to observe for white worms with and without protection of faeces.Examination revealed presence of worms in unprotected faeces, however no worms were seen in faeces protected with the help of sieve for 15 long days.Thorough counseling of patient was done to correct his psychology.The patient was explained regarding why the worms appear in his stool.Because of incorrect diagnosis since beginning, the patient had to keep on changing the doctors and also had to face psychological problems and financial loss for four long years for no reasons.

DISCUSSION
Intestinal myiasis is an accidental myiasis in which eggs or larvae ingested accidentally are not destroyed in the intestine.It is very rare infestation caused by dipterious fly maggots (1-8) and often misdiagnosed and treated as helminthic infestation.In the present case, the patient was neither suffering from myiasis and nor from helminthic infestation, but in spite of that the patient received loads of antihelminthic drugs for years together because of incorrect clinical and laboratory diagnosis.
Careful examination of faecal sample and clinical examination helped to confirm the diagnosis indicating that use of accurate diagnostic tools plays an important role in the confirmation of disease and forms an important part in further planning of appropriate therapy and to avoid unnecessary use of incorrect therapeutic approach.

Figure 1 .
Figure 1.Small worms like structures in stool specimen of patient