|
| |
| CASE REPORT |
|
| Ahead of print publication |
|
|
Limb salvage using maggot debridement therapy on a diabetic foot ulcer complicated by gas gangrene: First case report in Nigeria
Mustapha Ahmed Yusuf1, Shamsuddeen Muhammad2, Usman Muhammad Bello2, Mohammed Bashir Ibrahim2
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, Aminu Kano Teaching Hospital, Kano, Nigeria
| Date of Submission | 17-Aug-2022 |
| Date of Decision | 22-Oct-2022 |
| Date of Acceptance | 11-Jan-2023 |
| Date of Web Publication | 10-Apr-2023 |
Correspondence Address:
Mohammed Bashir Ibrahim,
Department of Surgery, College of Health Sciences, Bayero University, Aminu Kano Teaching Hospital, Kano
Nigeria
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/njbcs.njbcs_43_22
Maggot debridement therapy (MDT) has resurfaced three decades ago 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 in the critically ill patients. This case study reports on the successful use of MDT to salvage the limb of the index patient who was booked for above knee amputation. The patient is a 53-year-old lady who presented with left foot ulcer of six weeks' duration to our facility. Sterile first instar larvae of L. sericata obtained from an indigenous company (Biosurg wound care Nigeria Limited) were applied using the confinement (free-ranged) method. Staphylococcus epidermidis and Pseudomonas fluorescens were isolated before the application of MDT. However, after the application, the wounds m/c/s yielded no growth. Rapid epithelization and increased vascularity of the tissues were observed in the patient after the application. Maggot debridement therapy was successfully used in the debridement of diabetic foot ulcer complicated by gas gangrene in Nigeria for the first time and the clinical outcome is encouraging.
Keywords: Aminu Kano teaching hospital, biological debridement, gas gangrene, Lucilia sericata, Maggot debridement therapy, Nigeria
How to cite this URL:
Yusuf MA, Muhammad S, Bello UM, Ibrahim MB. Limb salvage using maggot debridement therapy on a diabetic foot ulcer complicated by gas gangrene: First case report in Nigeria. Niger J Basic Clin Sci [Epub ahead of print] [cited 2023 Jun 10]. Available from: https://www.njbcs.net/preprintarticle.asp?id=373996 |
| Introduction | |  |
Maggot debridement therapy (MDT) has resurfaced three decades ago 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 in the critically ill patients.[1] MDT is the intentional application of maggots (first or second instar) of higher dipterans (commonly Lucilia sericata) that are grown and harvested in a sterile manner to effect debridement, disinfection and ultimately promote healing in chronic wounds that do not respond to conventional methods of treatment (wound dressings/surgical debridement/antibiotics) or wounds requiring extended hospital stay like diabetic foot ulcers.[2]
This case reports on the successful use of maggot therapy to salvage the limb of the index patient who was booked for above knee amputation as a result of DFU complicated by gas gangrene. Though, there is paucity of data with regard to the use of MDT in limb salvage in Nigeria. However, for the first time, the Aminu Kano Teaching Hospital has pioneered the use of this therapy to save the limbs of many patients from amputation.
| Case Report | | |
A 53-year-old lady presented with left foot ulcer of six weeks' duration. She was apparently well until six weeks prior to presentation when she developed left leg swelling initially involving the forefoot but later progressed to involve the ankle and the lower leg. The swelling ruptured spontaneously five weeks before presentation discharging purulent effluent and occasionally blood, no history of swelling in other parts of the body. There was associated low-grade intermittent fever relieved by ingestion of antipyretics and generalized body weakness. There is preceding history of numbness and no history of trauma to the limb, no history of cough or contact with chronically coughing adult. Since the onset, patient has been on wound dressing using povidone iodine and antibiotic therapy in a peripheral hospital. Patient was diagnosed of diabetes mellitus 15 years ago and has been on oral hypoglycemic agents since then. She is not known to be hypertensive or sickle cell disease.
Physical examination revealed an ill looking, dehydrated, mildly pale, and afebrile middle age woman.
The wound [Figure 1] revealed an ulcer covering almost the whole of the dorsum of the left foot with darkening of the overlying skin, the skin on the big toe and 2nd toe (D1, D2), the ulcer has a sloppy edge, pale floor and necrotic tissue, firm base with no discharge. | Figure 1: (a) At Presentation Before Maggot Debridement Therapy (b) X-Ray of the Foot with Air Under the Soft Tissue (c) Under Maggot Therapy (d) Wound Healing
Click here to view |
An assessment of diabetic mellitus foot ulcer (DFU) grade IV on Wagner's classification was made and the plan was to carry out all necessary investigations and optimize the patient. However, the patient was placed on parenteral antibiotics (ceftriaxone 1.5 g 12 hrly, metronidazole 500 mg 8 hrly), normal saline 1 litter 8 hrly pending the results. The investigations revealed a RBS - 9.5 mmol/L; CBC- Haemoglobin- 10 g/dL, Platelets count -300 × 103/ul, Total Leukocyte Count - 8.78 × 109/L; U/E/Cr- only K + was deranged (2.6); Doppler Ultrasound Scan- findings were those of moderate arteriosclerotic changes with features of distal digital small arterial steno occlusion; X-ray showed presence of air in the soft tissue; M/C/S- yielded Staphylococcus epidermidis and Pseudomonas fluorescens (S. epidermidis was resistant to Clindamycin, Cloxacillin, Penicillin, and Sulfamethoxazole/Trimethoprim but sensitive to Rifampicin and Fucidic acid while P. fluorescens was resistant to Ceftazidime, Ciprofloxacin, Imipenem but sensitive to Cefepime).
After reviewing the results, an assessment of DFU complicated by gas gangrene was made and the plan was to prepare and counsel the patient for above the knee amputation.
However, before the above knee amputation, patient was noticed to be stable not requiring immediate surgical intervention typical of gas gangrene. This led to the decision of trying MDT for the debridement and limb salvage. Patient was managed by a multidisciplinary team, involving the Orthopedic surgeon, Endocrinologist, Radiologist, Pathologist, and Medical Entomologist.
Application of the maggots
Sterile first instar larvae of L. sericata was obtained from an indigenous company (Biosurg wound care Nigeria Limited). The application was done using the cage dressing method as described previously.[3],[4]
| Discussion | | |
Management of chronic ulcers/wounds still remain a serious challenge to the medical world in spite of the advances made in technology.[5] Approximately, 13% of people living with diabetes mellitus develop one or more ulcers during the course of their disease,[6] and diabetic foot ulcer (DFU) is responsible for more than 60% of lower limb amputation worldwide.[7]
In addition to the DFU, people with diabetes mellitus are at greater risk of many life-threatening infections including gas gangrene. Gas gangrene is most commonly caused by infection with a gram-positive, anaerobic bacillus of the genus Clostridium.[8] Clostridium perfringens is isolated in approximately 90% of patients presenting with gas gangrene followed by other species such as C. septicum, C. novyi and C. fallax.[9] In this patient, the infection was not due to the clostridial organisms and this could probably explain why the patient was stable since gas gangrene is a surgical emergency. Although, it's not surprising to see other non-gas-forming organisms causing infection in a diabetic patient with foot ulcer which is often polymicrobial in origin.
We observed the debridement time to be three days (72 hrs) and the wound was debrided after six cycles (18 days). This finding is contradicting the studies conducted by Mirabzadeh et al.,[3] and Malekian et al.,[4] who reported a longer duration with a median of 38 days. Rapid epithelization and increased vascularity of the tissue was observed in the patient after the maggot therapy. In this patient, Staphylococcus epidermidis and Pseudomonas fluorescens were isolated before the MDT. However, after the MDT, the wounds m/c/s yielded no growth and this this finding is in concordance with previous reports.[10]
| Conclusion | | |
Maggot debridement therapy was successfully used to salvage the foot of a patient with diabetic foot ulcer complicated by gas gangrene who was booked for above knee amputation but had D2-D5 disarticulation. Many DFU can be salvaged using MDT, once the acute infection has been taken care of and the peripheral vessels are patent. These patients should be referred to the appropriate centre where they can get this therapy done immediately.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Sherman RA, Cooper EL. Biotherapy: Medicinal maggots and invertebrate immunology from the clinician's perspective. Advances in Comparative Immunology. Springer; 2018. p. 991-5.  |
| 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. |
| 3. | 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. |
| 4. | 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. |
| 5. | Naik G, Harding KG. Maggot debridement therapy: The current perspectives. Chronic Wound Care Manag Res 2017;4:121-8. |
| 6. | Mariam TG, Alemayehu A, Tesfaye E, Mequannt W, Temesgen K, Yetwale F, et al. Prevalence of diabetic foot ulcer and associated factors among adult diabetic patients who attend the diabetic follow-up clinic at the University of Gondar Referral Hospital, North West Ethiopia, 2016: Institutional-based cross-sectional study. J Diabetes Res 2017;2017:2879249. |
| 7. | Geiss LS, Li Y, Hora I, Albright A, Rolka D, Gregg EW. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult US population. Diabetes Care 2019;42:50-4. |
| 8. | Brucato MP, Patel K, Mgbako O. Diagnosis of gas gangrene: Does a discrepancy exist between the published data and practice. Foot Ankle Surg 2014;53:137-40. |
| 9. | Aggelidakis J, Lasithiotakis K, Topalidou A, Koutroumpas J, Kouvidis G, Katonis P. Limb salvage after gas gangrene: A case report and review of the literature. World J Emerg Surg 2011;6:28. |
| 10. | Agom DA, Agom JD, Anyigor C. Using maggot therapy in treatment of wounds: A review of its effectiveness and patients' experiences. J Med Sci Clin Res 2014;2:2749-60. |
[Figure 1]
|
