(P16) Crawling Sensation on the Scalp in a 60 Years Old Man

Chief Complaint : A 60-year-old man complained of something crawling on his head

History of Present Illness : A 60-year-old man with history of gout and chronic kidney disease, came to the emergency department with complaints of something crawling on his head and 3 worms were found on his pillow [figure 1A]. He underwent left craniectomy with abscess removal for left fronto-temporoparietal lobe epidural abscess 5 years ago. 4 months after craniectomy, he underwent cranioplasty utilizing three-dimensional titanium mesh for the skull defect. On clinical examination, he was conscious, afebrile with normal vital signs. Inspection of the head revealed titanium mesh exposure[figure 1B] with maggots crawling. Brain computed tomography showed encephalomalacia in the left temporoparietal lobe [figure 2] . Intraoperatively, titanium mesh was detached. Several maggots on the dura were removed and the epidural abscess was cleaned gently. The scalp defect was reconstructed by a plastic surgeon. Broad spectrum intravenous antibiotic was administered for 8 weeks. He became maggots free and discharged without neurologic sequelae.

Pertinent Physical Exam: On clinical examination, he was conscious, afebrile with normal vital signs. There were no apparent neurologic deficits. Inspection of the head revealed titanium mesh exposure with maggots crawling through the implant holes. There was no purulent discharge or cerebrospinal fluid leakage from the wound.

Pertinent Laboratory Data: Blood test revealed leukocytosis with neutrophil predominance.

Case Discussion: Maggots infestation of the brain is very rare in developed countries. There have been only 17 published cases since 1937 and the mortality rate is 35%.[3] All of the death cases were before 1980’s. Neglected skin tumors and poor wound care were the most common causes of cerebral myiasis.[3] The infestation location tended to be in the frontal region statistically. Myiasis can be clinically classified as primary or secondary.[4] In primary myiasis, larvae penetrate the skin and complete its life cycle inside the host. In secondary myiasis, female flies lay their eggs around the wounds and larvae feed on necrotic flesh. The exact species of larvae is not identified in our case. To our knowledge, this is the first cerebral myiasis case in Taiwan. Also, it is the first cerebral myiasis case associated with an artificial implant and cranioplasty flap. Treatment includes debridement of the necrotic tissue, reconstruction of the defect and broad spectrum antibiotics. Surprisingly, in most of the cases of brain myiasis including this case, there were no fatal meningitis or further central nervous system infection of the patient suggesting that maggots infestation of the wound may prevent secondary bacterial infection.[2,5]
In conclusion, cerebral myiasis is an exceedingly rare neurosurgical event in developed countries. Meningitis is uncommon in patients with cerebral myiasis despite extensive dura invasion. Management of cerebral myiasis may involve multidisciplinary team including emergency physicians, neurosurgeons, infectious disease specialists and plastic surgeons. The outcome is usually good.

References and Acknowledgements (Optional): 1.Noutsis C, Millikan LE: Myiasis. Dermatol Clin 12:729–736, 1994.
2.Cheshier SH, Bababeygy SR, Higgins D, Parsonnet J, Huhn SL. Cerebral myiasis associated with angiosarcoma of the scalp: Case report. Neurosurgery 2007;61:E167
3.Curzi C, Bartoletti V, Canova G, Giordan E. A severe case of brain myiasis: Treatment rationale and review of literature. Asian J Neurosurg 2021;16:582-6.
4.Aggarwal A, Maskara P. Maggots in the brain: Sequelae of ignored scalp wound. World Neurosurg 2018;109:115‑6.
5.Giri SA, Kotecha N, Giri D, Diyora B, Nayak N, Sharma A. Cerebral myiasis associated with artificial cranioplasty flap: A case report. World Neurosurg 2016;87:661.e13‑6.