2 On the basis of the patient’s clinical symptoms during the earl

2 On the basis of the patient’s clinical symptoms during the early stage of infestation, and taking into account the results obtained from the different diagnostic tests, a presumptive diagnosis of gnathostomiasis was initially reached, followed by one of sparganosis. Since these diseases are very rare in Spain, serological tests were not immediately available, click here but empirical treatments were administered. The morphological features of the fragment of a surgically extracted larva suggested an infestation by Hypoderma spp. The identification of the different species of Hypoderma relies on the examination of larval morphological features,16,17 but the small size of the fragment hindered complete identification.

However, the presence of high anti-H lineatum antibody titers in the patient’s serum (detected by ELISA at different times) was indicative of infestation Cabozantinib supplier by Hypoderma larvae, supporting the previous morphological suspicion of myiasis. The assessment of cross-reactivity with antigens of other members of the Hypodermatinae subfamily, ie, Hypoderma bovis, Hypoderma tarandi, Hypoderma diana, and Przhevalskiana silenus (see Monfray and Boulard18; Boulard et al.19) is useful when performing ELISA prepared with H lineatum antigens, even though they may not be endemic in the patient’s country of origin. Repeated treatment with ivermectin seemed to be effective since the patient quickly became asymptomatic and

the eosinophil count normalized. Ivermectin is effective in the treatment of several myiases, and it is a good alternative when surgical removal is unfeasible.20 This is important since Hypoderma larvae can migrate within the body to involve in the central nervous system21 or, more often, to the eyes, where they cause ophthalmomyiasis.22 In our case, two parasite larvae were surgically removed. Considering that the swellings did not have any breath hole and the larval size, a diagnosis of fly first instars (LI), ready to moult to second Celecoxib instars (LII) was made. Furthermore, after the first and second round of ivermectin treatment, new painful swellings appeared probably due to other undetected parasites,

and it was not until the third ivermectin round that the patient became asymptomatic. Although cases of human myiasis are uncommon in Europe, if symptoms are indicative this disease should be kept in mind by physicians examining immigrants and travelers returning from endemic areas such as Ladakh. While serological analysis is useful in the diagnosis of myiasis-causing Hypoderminae larvae in travelers not previously exposed to larval infestation, molecular identification is important. In this work, the sequencing of a partial mitochondrial cox1 gene sequence confirmed H sinense to be the causal agent. Human cases of infestation by Hypoderma spp. have previously been reported, with H bovis and H lineatum or H tarandi as the agents most frequently identified.

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