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Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 139-142

Orbital myiasis presenting in a patient with fungating squamous cell carcinoma: Is there a role for ivermectin?

1 Department of Ophthalmology, Municipal Eye Hospital, Mumbai, Maharashtra, India
2 Department of Ophthalmology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Sasha A Mansukhani
Akshi Eye Centre, 169 A, Mayur Niwas, 2nd Floor, Dr. Ambedkar Road, Dadar T.T. Circle, Dadar East, Mumbai - 400 014, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3897.216430

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An 84-year-old female presented with multiple maggots crawling out of a large fungating left orbital mass. Computed tomography scan showed a heterogeneously enhancing mass arising from the left orbit surrounding the eyeball, displacing it laterally. Two days treatment with use of turpentine, betadine, hydrogen peroxide, and local removal was unsuccessful as the maggots would escape into depths of the orbit and crevices of the mass. A trial of 12 mg dose of ivermectin daily was given. After the first dose of the drug, the maggots were easier to remove manually. The orbit was maggot-free by the 2nd day. Ivermectin is of benefit in cases where conventional removal fails due to inaccessible worms. In view of its low cost and low side-effects profile, it can be explored as a first-line treatment along with manual removal.

Keywords: Ivermectin, maggots, orbital myiasis

How to cite this article:
Mansukhani SA, Nicholson AD, Agrawal AH, Hussain FS. Orbital myiasis presenting in a patient with fungating squamous cell carcinoma: Is there a role for ivermectin?. J Clin Ophthalmol Res 2017;5:139-42

How to cite this URL:
Mansukhani SA, Nicholson AD, Agrawal AH, Hussain FS. Orbital myiasis presenting in a patient with fungating squamous cell carcinoma: Is there a role for ivermectin?. J Clin Ophthalmol Res [serial online] 2017 [cited 2022 Jul 4];5:139-42. Available from: https://www.jcor.in/text.asp?2017/5/3/139/216430

Orbital myiasis is rare, accounting for less than about 5% of all cases of myiasis.[1] Orbital myiasis has been conventionally managed with the application of betadine, turpentine, and paraffin combined with manual removal.[2],[3] Ivermectin is a broad-spectrum antiparasitic drug, and it has been tried with success in a few cases of orbital myiasis.[4],[5],[6],[7],[8] We describe limitations of conventional removal and the utility of ivermectin in treating orbital myiasis in this context.

  Case Report Top

An 84-year-old female presented with multiple worms crawling out of a large left-sided orbital mass. At the time of presentation, she was delirious, with intense itching and in extreme agony. The relatives reported that the mass had been growing slowly over the past 2½ years, and was completely covering the left eye for 1 year. Over the past 2 weeks, she had become increasingly delirious, with pain and discomfort in the mass, associated with worms crawling out of the mass.

On examination, she was disoriented, unkempt, afebrile, and hypertensive. Gross examination revealed a 10 cm × 8 cm × 6 cm size fungating mass over the left orbital region, with inferior extension till mid-cheek. The surface was irregular, blackish, and necrotic; and was covered with copious greenish, purulent foul smelling discharge. On displacement of the mass downward, the upper eyelid could partially be visualized. However, the globe and the lower lid could not be visualized, due to multiple maggots crawling out of the orbit and the size of the mass. The maggots varied in size from pinhead size to 1.5 cm long. Surrounding skin was erythematous and warm. There were no signs of infestation on the scalp, or elsewhere on the body. She had enlarged and firm preauricular and upper cervical lymph nodes. There was a mature cataract in the right eye, the examination was otherwise normal [Figure 1] – Large fungating mass over left orbital region with multiple maggots].
Figure 1: Orbital myiasis before ivermectin

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A provisional diagnosis of primary orbital tumor such as squamous cell carcinoma, complicated by superimposed orbital myiasis and cellulitis was made. Immediate treatment included an urgent stabilization of fluid and electrolyte balance. Her laboratory investigations revealed total leukocyte count of 21,000/c mm. A sample of the discharge from the lesion was sent for microbiological evaluation. Gram-stain revealed a Gram-negative organism and she was started empirically on intravenous injection piperacillin-tazobactam (brand name Piptaz) 4.5 g every 6 h and amikacin (generic drug amikacin sulfate) 15 mg/kg/day every 8 h. Later antibiotic susceptibility testing revealed  Pseudomonas aeruginosa Scientific Name Search ecies sensitive to ciprofloxacin, piperacillin-tazobactam, and amikacin. Injection Amikacin was tapered and stopped, while injection piperacillin-tazobactam was continued at the same dose for 10 days for soft tissue infection coverage.

A contrast-enhanced computed tomography (CT) scan of the head revealed a heterogeneously enhancing fungating mass arising from the left orbit surrounding the eyeball displacing it forward and laterally. There was orbital fat stranding without bony erosion or intracranial extension [Figure 2] – CT scan of the orbit showing the extent of the lesion].
Figure 2: Orbital myiasis computed tomography scan

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With a primary aim to relieve immediate pain due to maggot infestation, cleaning was done several times a day with turpentine, Betadine and hydrogen peroxide and manual removal of pus and crusts, and the maggots accessible from the surface. Sterile forceps and gauze were utilized for the same, and the mass was flushed with normal saline. However, after 2 days of regular cleaning, removal of the maggots was not possible due to the escape of the worms into the depths of the orbit and the crevices of the mass. The patient was unfit for any surgical procedure such as mass debulking or exenteration. Therefore, we decided to give a trial of ivermectin, and a 12 mg dose (200 μg/kg) was administered orally once daily for 2 days. The evening following the first dose of the drug, more maggot emerged to the surface of the mass. They were easier to remove manually and did not resist capture or attempt to crawl away into the orbit. On the 2nd day of ivermectin use, the eye was rendered maggot-free [Figure 3] – Orbit free of maggots]. The patient exhibited no side effects to ivermectin. Another concern was a Mazzotti like a reaction to numerous dying parasites. She was monitored for any signs of fever, rash and angioedema, and exhibited none.
Figure 3: Orbital myiasis postivermectin

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An incisional biopsy sample was sent for histopathological examination revealed it to be squamous cell carcinoma. Once the patient stabilized, she underwent a subtotal orbital exenteration with primary closure of the wound. Margins were clear of tumor cells.

  Discussion Top

Ivermectin is an antihelminthic drug synthesized from avermectin compounds. Avermectins were discovered in Japanese soil samples and were produced by the microorganism Streptomyces avermitilis.[9] Ivermectin has been described as a wonder drug because it has changed medical practice human and veterinary alike. Initially approved for cattle parasitic infections, its role in Onchocerciasis has become essential.[9]

Ivermectin acts by binding to glutamate-gated chloride channels in the muscle and nerve cells of the parasite. This causes a chloride ion influx, and hyperpolarization resulting in paralysis of the parasite.[10],[11] The other pharmacodynamic effect of the drug is that it is an agonist of gamma-aminobutyric acid (GABA) at the GABA channels found in the peripheral nervous system of parasites. GABA is an inhibitory neurotransmitter. The safety of the drug in humans is because the glutamate-gated chloride channels ( first site of action) are not expressed in human neuronal and muscle membranes and the GABA channels (second site of action) are only found in the central nervous system of humans. Ivermectin is not able to penetrate the blood-brain barrier (BBB) in humans, due to the large size of the molecule and efflux of the drug by P-glycoprotein found on the BBB.[10] While the use of ivermectin for filariasis and onchocerciasis has been well established, the utility for ectoparasites and myiasis has only been recently explored.[12],[13] Review of literature revealed very few case reports of the use of ivermectin in orbital myiasis. De Tarso et al. reported a case in 2004, describing massive orbital myiasis in which ivermectin eliminated the larvae, before enucleation.[4] Costa et al. in 2005 successfully used ivermectin in a patient with advanced ethmoidal cancer with naso-orbital myiasis, to clear the maggots before orbital exenteration.[5] Osorio et al. reported in 2006 the successful use of ivermectin in two cases of orbital myiasis with skin cancers.[6] Thomas et al. reported a case of nasal myiasis with an orbital spread which was treated with ivermectin and local application of Turpentine.[7] Puthran et al. in 2012 described myiasis of an empty socket where the authors avoided exploratory surgery by giving ivermectin.[8] We chose to give ivermectin in the oral form, as used by Osorio et al. in patients with tumors.[6] The use of topical ivermectin drops, prepared by dissolving the tablet in water, was reported by Puthran et al. in a case with an empty socket.[8] The dose of ivermectin was chosen to be 200 μg/kg based on the dose recommended for filariasis, scabies, strongyloides, and ascaris.[10] Other case reports of orbital myiasis have also used the same dose.[5],[8]

Ivermectin is metabolized by the liver, and almost completely excreted in the feces.[14] The drug is contraindicated in pregnancy, as teratogenic effects were seen in studies on mice. Furthermore, there is no safety and efficacy data for use in children <15 kg in weight.[14] Another contraindication is known allergy to the drug.

The side effects of ivermectin are rare due to its parasite-specific mechanism of action as explained above. The listed side effects are dizziness (2.8%), pruritis (2.8%), diarrhea and nausea (1.8%), abdominal pain and fatigue (0.9%).[14] Postmarketing experience has reported Steven-Johnson syndrome, orthostatic hypotension, and elevation of liver enzymes.[14] Mazzotti like an allergic reaction to the dying parasites has been noted with use in onchocerciasis, but to a lesser extent than with other microfilaricidal drugs.[10] There have been reports of encephalopathy in patients with onchocerciasis and concurrent heavy loa-loa infestation.[10]

We did not find any side effects to ivermectin in our treatment of orbital myiasis, similar to the experience of other authors using it for the same indication.[5],[8]

We found ivermectin to be of benefit in this patient. It is an affordable drug and a safe drug, with minimal side effects.[15] Thus, ivermectin has demonstrated its usefulness in selected cases which do not respond to the conventional method of removal. It can be explored as a first line treatment in view of its low cost and high safety profile.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Caça I, Unlü K, Cakmak SS, Bilek K, Sakalar YB, Unlü G. Orbital myiasis: Case report. Jpn J Ophthalmol 2003;47:412-4.  Back to cited text no. 1
Agarwal DC, Singh B. Orbital myiasis – A case report. Indian J Ophthalmol 1990;38:187-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Mathur SP, Makhija JM. Invasion of the orbit by maggots. Br J Ophthalmol 1967;51:406-7.  Back to cited text no. 3
De Tarso P, Pierre-Filho P, Minguini N, Pierre LM, Pierre AM. Use of ivermectin in the treatment of orbital myiasis caused by Cochliomyia hominivorax. Scand J Infect Dis 2004;36:503-5.  Back to cited text no. 4
Costa DC, Pierre-Filho Pde T, Medina FM, Mota RG, Carrera CR. Use of oral ivermectin in a patient with destructive rhino-orbital myiasis. Eye (Lond) 2005;19:1018-20.  Back to cited text no. 5
Osorio J, Moncada L, Molano A, Valderrama S, Gualtero S, Franco-Paredes C. Role of ivermectin in the treatment of severe orbital myiasis due to Cochliomyia hominivorax. Clin Infect Dis 2006;43:e57-9.  Back to cited text no. 6
Thomas S, Nair P, Hegde K, Kulkarni A. Nasal myiasis with orbital and palatal complications. BMJ Case Rep 2010;2010:Bcr0820103219.  Back to cited text no. 7
Puthran N, Hegde V, Anupama B, Andrew S. Ivermectin treatment for massive orbital myiasis in an empty socket with concomitant scalp pediculosis. Indian J Ophthalmol 2012;60:225-7.  Back to cited text no. 8
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Crump A, Omura S. Ivermectin, wonder drug from Japan: The human use perspective. Proc Jpn Acad Ser B Phys Biol Sci 2011;87:13-28.  Back to cited text no. 9
Kircik LH, Del Rosso JQ, Layton AM, Schauber J. Over 25 years of clinical experience with ivermectin: An overview of safety for an increasing number of indications. J Drugs Dermatol 2016;15:325-32.  Back to cited text no. 10
Ottesen EA, Campbell WC. Ivermectin in human medicine. J Antimicrob Chemother 1994;34:195-203.  Back to cited text no. 11
Moreno M C. Ectoparasitosis of clinical importance in Chile. Rev Chilena Infectol 2011;28:435-9.  Back to cited text no. 12
Abdo EN, Sette-Dias AC, Comunian CR, Dutra CE, Aguiar EG. Oral myiasis: A case report. Med Oral Patol Oral Cir Bucal 2006;11:E130-1.  Back to cited text no. 13
U.S. Food and Drug Administration. FDA Approved Drug Products, Stromectol Label Information; 2009. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/050742s022lbl.pdf. [Last accessed on 2016 Jun 10].  Back to cited text no. 14
Guzzo CA, Furtek CI, Porras AG, Chen C, Tipping R, Clineschmidt CM, et al. Safety, tolerability, and pharmacokinetics of escalating high doses of ivermectin in healthy adult subjects. J Clin Pharmacol 2002;42:1122-33.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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