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• W4225254801 abstract "An 8-year-old girl presents to the emergency department (ED) of a large, tertiary care children’s hospital in central Wisconsin during the late summer. Three weeks earlier she was playing at a lake near her home in southeastern Wisconsin and sustained a bug bite to her left lateral neck. She presented to a local clinic, where she was diagnosed as having a local reaction to a bee sting and was treated with hot and cold compresses, diphenhydramine, and cetirizine. During the next 10 days the area continued to swell, and a rash began to form around the site, as well as some bloody discharge. She returned to the local clinic, where she was started on cephalexin for presumed abscess, and a culture of the bloody discharge was obtained. She took only a few doses of the antibiotic due to stomach upset. Three days later, when the skin changes persisted and swelling worsened, her parents brought her to a local ED (Fig 1). Ultrasonography of the area demonstrated what appeared to be a fluid pocket, so incision and drainage was attempted. When lidocaine was injected to numb the area, an insect emerged (Fig 2). It was removed with forceps and disposed of, and the patient was sent home with instructions to continue use of heat and cold packs as needed. The insect was not identified at this time.The patient presents to the tertiary care center 3 days later due to continued swelling of the same area on the left side of her neck. Due to swelling and concern for cellulitis or abscess formation, her primary care physician had prescribed amoxicillin-clavulanate the afternoon before presentation. Her parents were concerned about further stomach upset and did not give her the morning dose. She complains of mild itching and pain at the site of insect removal but has no fever, rash, or other symptoms of illness. She denies recent travel outside the United States. The family has 2 pet dogs at home and no exposure to cats or sick contacts. She is otherwise healthy, with no known allergies and no contributory family history, and daily polyethylene glycol for constipation is her only home medication. Physical examination findings are normal except for an erythematous, swollen area in the left anterolateral neck, approximately 1 × 2 cm, which is well-circumscribed and fluctuant (Fig 3). Two small wounds are visible from the recent incision and drainage. Bedside ultrasonography is performed and demonstrates a 1.6 × 0.6 × 1-cm complex multiloculated cystic focus with minimal hyperemia surrounding, consistent with a developing phlegmon versus postoperative changes from the recent procedure. Pediatric ear, nose, and throat physicians are consulted due to the wound’s proximity to major neck vessels (internal and external jugular veins, carotid artery) and thyroid gland, and dilute fluid is drained from the area. A pediatric infectious disease specialist is also consulted for further evaluation. Review of the photographs confirmed the diagnosis.The differential diagnoses included congenital branchial cleft cyst, cellulitis, abscess, retained foreign body, and recurrence of the original infestation. The original neck swelling was identified with a high level of certainty by the pediatric infectious disease specialist as cutaneous myiasis due to botfly infestation.Pediatric neck masses can generally be categorized as congenital, inflammatory/reactive, or neoplastic in origin. (1) Rarely on the differential diagnosis for a pediatric neck mass is myiasis, or a cutaneous infestation by larvae; the human botfly can cause a cutaneous furuncular myiasis. (2) For people living in North America, it is primarily contracted through travel to Latin America. Case reports have included infestations contracted in Guatemala, (3) Belize, (4) Costa Rica, (5) and Bolivia. (6) However, there are a few existing reports of a human botfly infestation that has been contracted in North America. (7)(8)(9) Most cases of botfly infestation originating in North America are due to Cuterebra species, with 1 reported case of Dermatobia hominis infestation in Winnipeg, Canada. (7) Cuterebra infestations remain rare in North America as well, with fewer than 80 reported in the literature, most of which have been reported from the northeast or pacific northwest. We outline the case of a human botfly infestation contracted in Wisconsin, as well as common characteristics associated with this infestation and treatment interventions.The human botfly, Dermatobia hominis, infests the human body after a female botfly attaches her eggs to a blood-feeding insect such as a mosquito. (2) The blood-feeding insect serves as the intermediate vector, eventually delivering the botfly eggs to hosts. The botfly eggs sense a temperature change once they are deposited on the host's skin, causing them to hatch into larvae and burrow into the host. Those with botfly infestations will often give a history of an insect bite before the development of furuncular myiasis. A local inflammatory reaction almost always develops around the larvae, and patients commonly report pruritus, erythema, swelling, pain, and discharge. Secondary bacterial infections can occur, although they are rare. The botfly maggot produces bacteriostatic secretions during development, which are believed to hinder bacterial growth in the area, although this has not been definitively demonstrated. (10)The larvae maintain a connection to the outside world via a respiratory spiracle. The spiracle can often be seen as a dark speck in the center of the furuncle (Fig 3). The larvae have hooklets that hold them in place in the skin, making removal difficult. (2)(11) If these hooklets remain in the skin during removal of the larvae, which is more common during forced, direct removal via forceps, then the patient can develop a subsequent inflammatory reaction or infection.Ultrasonography can be useful in the management of a Dermatobia hominis infestation. It can identify the presence of larvae before removal, as well as confirm complete removal of the insect after treatment. On ultrasonography, a botfly larva may appear as a hyperechoic mass, with a surrounding hypoechoic halo representing its surrounding cavity. (12) In addition, ultrasonography can identify the extent of a local inflammatory reaction, an associated abscess, and regional vasculature. In this patient, ultrasonography showed no residual larvae, although the fluid collection identified was investigated with incision and drainage.The preferred treatment for botfly infestation involves covering the larvae’s respiratory spiracle with an occlusive dressing. (11) The occlusion is often with a petroleum ointment, fingernail polish, or fat. The botfly is, therefore, forced to emerge from the lesion to respirate. If it fails to emerge, it will asphyxiate and die within approximately 24 hours. In that case, the dead larva is extracted through a sterile surgical technique. In some reports, lidocaine injections have been recommended as a way to remove the fly and avoid surgical incision and exploration. (13) In our case, a lidocaine injection incidentally identified the larvae and provided a therapeutic response.Currently, many human botfly infestations are improperly diagnosed because the condition is rare. Instead, patients are often misdiagnosed as having cellulitis, folliculitis, an abscess, a foreign body, a cyst, or atopic dermatitis. (7) Patients with a botfly infestation will commonly return to their primary care physician or local ED after failed treatment with an antibiotic for presumed cellulitis, as in our patient.The culture from the previous ED visit demonstrated growth of Acinetobacter iwoffii, a normal skin flora bacterium, (14) which may have led to poor wound healing at the infestation site. A 7-day course of doxycycline was started, as recommended by the pediatric infectious disease specialist, and the patient was instructed to follow up in the clinic. Although the cultured organism may have been a contaminant, antibiotic treatment was felt to be appropriate given the increased swelling and lack of wound healing. At the telemedicine follow-up visit, the patient’s condition was improving. Antibiotic treatment was changed to trimethoprim-sulfamethoxazole after susceptibilities from the culture returned, and the patient had no recurrent symptoms." @default.
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• W4225254801 title "Expanding Neck Mass in an 8-year-old Girl" @default.
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• W4225254801 doi "https://doi.org/10.1542/pir.2020-003970" @default.
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