Chikungunya , Dengue , and Malaria Co - Infection after Travel to Nigeria , India

pain/edema (3.3%), and vascular or nervous injury (1.7%) (3). In the past decade, pin-site myiasis has been described as a new complication; 6 cases have been reported (1 in the United States, 2 in Venezuela, and 3 in Greece) (2,4–6). All case-patients had predisposing risk factors for parasitic infestation, such as diabetes mellitus, immobilization, alcohol and drug use, or decreased immune status. Our patient had the same risk factor (previous surgical interventions) as that reported for a patient in Venezuela (2). Also, the anatomic region (leg) involved and the larvae species (C. hominivorax) identified for our patient were observed in other reported cases (2,5,6). C. hominivorax screwworm fly is the main species involved in wound myiasis in the New World (1). Wound myiasis is initiated when female flies oviposit on or near a wound (<300 larvae/wound). Upon hatching, larvae, which have small spines on each body segment that resemble the threads of a screw, penetrate head first into the tissues, burrow deeper perpendicular to the skin surface (resembling a screw), and cause extensive destruction of tissue and a bloody discharge (1). C. hominivorax larvae differ from larvae of other fly species because they feed only on living flesh (7). The anatomic site around a lesion becomes swollen, and local tissue destruction can cause pain and secondary bacterial infection (1). Our patient was co-infected with P. aeruginosa, which was similar to a patient with pin-site myiasis reported by Paris et al. (5). Removal of the metallic fixators (a necessary procedure in 50% of reported cases) (1) was not required for our patient. Surgical cleansing, extraction of all larvae, and antimicrobial drug therapy resulted in resolution of the infection. After a screwworm eradication program was developed by the Animal and Plant Health Inspection Service of the US Department of Agriculture, screwworm was eradicated in the United States in 1966, in Mexico in 1991, in Belize and Guatemala in 1994, in El Salvador in 1995, in Honduras in 1996, in Nicaragua in 1999, in Costa Rica in 2000, and in Panama in 2006 (7). Current distribution of C. hominivorax screwworm flies is limited to South America and some Caribbean Islands (1). However, physicians should be aware of the possible reemergence of myiasis as a complication of surgery and use of metal fixators.