March 30, 2017
A 46-year-old woman presented to the emergency department with a 10-day history of pain and swelling in her right arm. She had recently returned to the United Kingdom from the Ivory Coast. Examination revealed distinct areas of ulceration with surrounding erythema distal to her right elbow. Cellulitis due to insect bites was diagnosed, and she was treated with antibiotic agents. The following day, the cellulitis appeared worse, and oscillatory movements of larvae were noted (Panel A). After administration of a local anesthetic, four larvae were surgically extracted (Panels B and C). Parasitologic examination confirmed that the larvae were of the species Cordylobia anthropophaga, the tumbu fly. The tumbu fly (also known as the putzi fly or skin maggot) is endemic to the tropics of Africa. Female flies lay eggs in damp clothing or soil, and after transient contact with skin, the larvae burrow into the subcutaneous tissue (typically on the back, buttocks, or posterior aspect of the limbs). Larvae can easily be missed during the initial stages of an infestation. Covering the punctum with paraffin gel can force the larvae to the surface, and in some cases surgical extraction is necessary. After extraction of the larvae, the patient’s arm pain and swelling rapidly resolved.
John J. Park, M.B., Ch.B.
Harvard T.H. Chan School of Public Health, Boston, MA
Jonathan Costello, M.B., B.Ch., B.A.O.
Royal Free London NHS Foundation Trust, London, United Kingdom