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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 2  |  Page : 164-166

Successful application of Maggot Debridement Therapy (MDT) on a Fournier's gangrene: First case report in Nigeria


1 Department of Medical Microbiology and Parasitology, College of Health Sciences, Bayero University; Department of Clinical Microbiology, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Surgery, College of Health Sciences, Bayero University, Kano-Nigeria/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Surgery, Abubakar Imam Urology Centre, Kano, Nigeria
4 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
5 Department of Medical Microbiology and Parasitology, College of Health Sciences, Bayero University, Kano, Nigeria

Date of Submission09-Aug-2022
Date of Decision26-Aug-2022
Date of Acceptance19-Sep-2022
Date of Web Publication23-Nov-2022

Correspondence Address:
Kabir Musa Adamu
Department of Surgery, Bayero University/Aminu, Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_42_22

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  Abstract 


Fournier's gangrene is a rapidly progressing soft tissue infection and a urological emergency affecting the external genitalia or the perineum. Maggot debridement therapy (MDT) has resurfaced as a result of the steep rise in the emergence of antibiotic-resistant strains of pathogenic bacteria and the need for an effective non-surgical method for wound debridement. This case study reports on a 66-year-old known diabetic who presented to our facility with complaints of scrotal swelling and multiple foul-smelling ulcers around the genital area. There was associated history of pain and fever for twelve-day duration. Sterile first instar larvae of L. sericata were applied using the free-ranged method. Significant decrease in the peri-wound oedema, rapid epithelization and increased vascularity were observed in the patient after the therapy. Maggot debridement therapy was successfully used in the debridement of Fournier's gangrene in Nigeria for the first time, and the clinical outcome is encouraging.

Keywords: Fournier's gangrene, free rage method, Lucilia sericata, maggot debridement therapy, necrotizing fasciitis


How to cite this article:
Yusuf MA, Ibrahim BM, Abubakar A, Aji SA, Abubakar F, Abubakar MK, Sheshe AA, Muhammad S, Ibrahim M, Bello U, Abbas MA, Muhammad A, Adamu KM. Successful application of Maggot Debridement Therapy (MDT) on a Fournier's gangrene: First case report in Nigeria. Niger J Basic Clin Sci 2022;19:164-6

How to cite this URL:
Yusuf MA, Ibrahim BM, Abubakar A, Aji SA, Abubakar F, Abubakar MK, Sheshe AA, Muhammad S, Ibrahim M, Bello U, Abbas MA, Muhammad A, Adamu KM. Successful application of Maggot Debridement Therapy (MDT) on a Fournier's gangrene: First case report in Nigeria. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Dec 3];19:164-6. Available from: https://www.njbcs.net/text.asp?2022/19/2/164/361893




  Introduction Top


Fournier's gangrene is a rapidly progressing soft tissue infection and a surgical/urological emergency affecting the external genitalia or perineum requiring prompt diagnosis and treatment.[1] The infection is mostly polymicrobial in origin affecting different age groups with increased risk in people with medical comorbidities.

Maggot debridement therapy (MDT) is the deliberate application of maggots of the Lucilia sericata species in a sterile manner to effect debridement and disinfection and promote healing in wounds that do not respond to treatment.[2] It is a very suitable and cost-effective option for the developing countries especially in patients who do not have the resources or are unfit to undergo a surgical procedure.[3],[4]

Despite the approval of MDT as a medical device 18 years ago by both the United States (US); Food and Drug Administration (FDA) and the United Kingdom; National Health Service (NHS), there is still a gap in the knowledge and technical know how of how to rear and maintain the species for medical use among heath care workers. Thus, very few centers in Africa including Nigeria are using this method. This case study adds to the previous studies conducted by the author on the effectiveness of Maggot therapy in promoting wound healing in Nigeria.


  Case Report Top


A 66-year-old man known diabetic presented to our facility with complaints of multiple foul-smelling ulcers around the genital area, swelling of the scrotum and the penis. There was associated history of pain and fever for twelve days. He was apparently well until twelve days prior to presentation when he noticed a lesion on the skin initially involving only the frontal part of the genital area but later progressed to involve the groin, lower scrotal sac, and medial part of both thighs [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d. No preceding history of trauma, burns, or sting of an insects. No history of similar lesion or swelling in other parts of the body. Since the onset, patient had visited other healthcare facilities where he had surgical debridement on two occasions and was placed on antibiotics and wound dressing using Eusol. However, patients' condition initially improved but later started deteriorating for which he was brought to our hospital.
Figure 1: (a) Patient at presentation before MDT. (b) Wound under MDT. (c) Complete granulated wound awaiting skin graft. (d) Completely healed wound

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Physical examination revealed an elderly man, dehydrated and pale looking with temperature of 38°C, pulse rate of 120/min, and blood pressure of 110/60 mmHg. The wound [Figure 1]a revealed a grossly edematous scrotum and penis with multiple ulcers.

Blood samples were taken for investigations and the patient was resuscitated using parenteral antibiotics (ceftriaxone 1.5g twice in a day, metronidazole 500mg three times in a day), normal saline 1 liter three times in a day pending the results. The investigations revealed an RBS – 11.5 mmol/L; CBC- hemoglobin – 9.5 g/dL, platelets count – 450 × 103/ul, total leukocyte count – 14 × 109/L; U/E/Cr – raised creatinine (150); M/C/S – yielded Staphylococcus aureus and Escherichia coli sensitive to ceftriaxone and meropenem. The results were noted, the patient was optimized appropriately, and maggot debridement therapy was commenced.

Application of the Maggots

First instar larvae of L. sericata was obtained indigenously and used for the MDT. The application was done using the free-ranged (confinement) method as described previously,[5],[6] with some modifications due to the sensitivity of the genital area.


  Discussion Top


In this case report, we described for the first time in Nigeria how MDT was used to debride and facilitate healing of Fournier's gangrene in a 66-year-old known diabetic patient.

The efficacy of MDT for infection control has been demonstrated repeatedly in a variety of clinical and medical settings around the world.[5],[6],[7] Maggot therapy not only effectively debrides the necrotic tissue of patients with fasciitis, but also disinfects the wound, minimizes tissue loss, and promotes the growth of granulation tissues.[7]

In this patient, complete debridement was achieved after eight cycles (eight days). Fonseca-Muñoz and colleagues (2020) reported two cases of Fournier's gangrene debrided by maggots. Although, the first case differs from our finding (had three cycles) while the second case agrees with our finding (had eight cycles). Even though, each cycle of MDT can stay in place between 24 hrs and 72 hrs. However, in the index patient, because of the sensitivity of the genital area, each cycle lasted for 24 hrs as compared to the 48–72 hrs by the above study. The advantage of this modified method is that the larvae were removed at 2nd instar stage before the patient started feeling pain or discomfort while the disadvantage is that the patient may have more cycles since the duration is reduced. It has been reported that, the sensation felt by patients during MDT is usually due to the increased size and crawling of the maggots over the wound bed.[8] Although, the index patient was adequately counselled before the therapy and there was a provision for anxiolytic/analgesics in case of any discomfort. In addition to this, the patients also had the option of discontinuing the treatment at any time.

We isolated S. aureus and E. coli from the wound at presentation before MDT was administered, this is similar to what other researchers reported earlier on the microbiology of Fournier's gangrene.[1],[7] However, the repeated wound culture yielded no growth after the MDT leading to a decrease in the antimicrobial use. This finding agrees with previous studies conducted about MDT's ability to debride, disinfect, and stimulate growth factors.[5],[6],[7] Furthermore, we observed a decrease in the peri-wound oedema, rapid epithelization, and increased vascularity of the tissue which lead to one hundred percent graft take. Similarly, it helped to decrease the long duration the patient would have spent in the hospital. These findings are similar to what many researchers reported about the ability of MDT to reduce extended hospital stay and overall cost of managing wounds.[9],[10]


  Conclusion Top


Maggot debridement therapy was successfully used in the debridement of Fournier's gangrene in an elderly man in Nigeria for the first time, and the clinical outcome is encouraging.

Declaration of patient consent

The patient consented that his clinical information can be used in a journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest declared by the authors.



 
  References Top

1.
Hagedorn JC, Wessells H. A contemporary update on Fournier's gangrene. Nat Rev Urol 2017;14:205-14.  Back to cited text no. 1
    
2.
Choudhary V, Choudhary M, Pandey S, Chauhan VD, Hasnani J. Maggot debridement therapy as primary tool to treat chronic wound of animals. Vet World 2016;9:403-9.  Back to cited text no. 2
    
3.
Tanyuksel M, Araz E, Dundar K, Uzun G, Gumus T, Alten B, et al. Maggot debridement therapy in the treatment of chronic wounds in a military hospital setup in Turkey. Dermatology 2005;210:115-8.  Back to cited text no. 3
    
4.
Gottrup F, Apelqvist J, Bjarnsholt T, Cooper R, Moore Z, Peters E, et al. EWMA document: antimicrobials and non-healing wounds: evidence, controversies and suggestions. J Wound Care 2013;22(Suppl 5):S1-89.  Back to cited text no. 4
    
5.
Mirabzadeh A, Ladani M, Imani B, Rosen S, Sherman R. Maggot therapy for wound care in Iran: a case series of the first 28 patients. J Wound Care 2017;26:137-43.  Back to cited text no. 5
    
6.
Malekian A, Djavid GE, Akbarzadeh K, Soltandallal M, Rassi Y, Rafinejad J, et al. Efficacy of maggot therapy on staphylococcus aureus and pseudomonas aeruginosa in diabetic foot ulcers: A randomized controlled trial. J Wound Ostomy Continence Nurs 2019;46:25-9.  Back to cited text no. 6
    
7.
Fonseca-Muñoz A, Sarmiento-Jiménez HE, Pérez-Pacheco R, Thyssen PJ, Sherman RA. Clinical study of Maggot therapy for Fournier's gangrene. Int Wound J 2020;17:1642-9.  Back to cited text no. 7
    
8.
Jukema G, Menon A, Bernards A, Steenvoorde P, Rastegar AT, Van Dissel J. Amputation sparing treatment by nature:“surgical” maggots revisited. Clin Infect Dis 2002;35:1566-71.  Back to cited text no. 8
    
9.
Naik G, Harding KG. Maggot debridement therapy: The current perspectives. Chronic Wound Care Manage Res 2017;4:121-8.  Back to cited text no. 9
    
10.
Sherman RA, Cooper EL. Biotherapy: Medicinal Maggots and Invertebrate Immunology from the Clinician's Perspective. Advances in Comparative Immunology: Springer; 2018. p. 991-5.  Back to cited text no. 10
    


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