DOI: 10.4149/BLL_2015_128

Bratisl Med J 2015; 116 (11)671 – 673

CLINICAL STUDY

Maggot therapy in treatment of a complex hand injury
complicated by mycotic infection
Bohac M1, Cambal M2,4, Zamborsky R5, Takac P3,4, Fedeles J Sr1
Department of Plastic Surgery, University Hospital Bratislava, Faculty of Medicine Comenius University
in Bratislava, Bratislava, Slovakia. bohac.md@gmail.com
ABSTRACT
Complex injuries of the hand remain a therapeutic challenge for surgeons. We present the case of a male whosuffered a devastating injury of the hand caused by a conveyor belt. The patient developed a progressive Absidia corymbifera infection of the affected soft tissues. Initial treatments with serial surgical debridement andtopical and intravenous itraconazole were unsuccessful in eliminating the infection. We decided to use maggot
debridement therapy in a new special design to debride all necrotic, devitalized tissue and preserve only healthy
tissue and functioning structures. This maneuverer followed by negative pressure therapy allowed progressive
healing. In such complex hand injuries, maggot debridement combined with negative pressure therapy could beconsidered to achieve effective and considerable results, although future functional morbidity may occur (Fig. 4,Ref. 18). Text in PDF www.elis.sk.
KEY WORDS: maggot debridement therapy, negative pressure therapy, complex hand injuries, mycotic infection.

Introduction
Complex hand injuries are multi-structural (soft tissue, bones,vessels, tendons, and nerves) injuries with loss of function andsensitivity or loss of the affected body part (1).
Pathogenic microorganisms are frequent complicating factorsof such severe injuries. However, mycotic infection puts patientsat a particularly increased risk. Invasive mycotic diseases are common in immunocompromised patients and individuals with othersignificant comorbidities (5–7). However, several infections of thesoft tissue by Absidia corymbifera (syn. Lichtheimia corymbifera,
Mycocladus corymbifer) have been reported in patients without
immune dysfunction who had experienced traumatic injuries contaminated with soil (2–4). A. corymbifera is the only member of1
Department of Plastic Surgery, University Hospital Bratislava, Facultyof Medicine Comenius University in Bratislava, Bratislava, Slovakia, 21stDepartment of Surgery, University Hospital Bratislava, Faculty of Medicine Comenius University in Bratislava, Bratislava, Slovakia, 3Institute ofZoology, Molecular and Applied Zoology, Slovak Academy of Sciences,Bratislava, Slovakia, 4Scientica, sro, Bratislava, Slovakia, and 5Department of Traumatology, Faculty of Medicine, Slovak Medical University,Bratislava, Slovakia

Address for correspondence: M. Bohac, MD, PhD, Department of Plastic Surgery, University Hospital Bratislava, Medical Faculty of Comenius
University in Bratislava, Ruzinovska 6, SK-826 06 Bratislava, Slovakia.
Phone: +421.903316429,
Acknowledgements: This work was funded by the Operational Program‘Research and Development’ and co-financed by the European Fund for
Regional Development (EFRD) via grant ITMS 26240220030 – “Researchand development of new biotherapeutic methods and their application in
the treatment of some illnesses”.
The VivanoTecR device is manufactured by Hartmann Inc. (DE).

the Zygomycetes phylum recognized to be a human pathogen(14, 15). Treatment efforts for this infection must prevent localand systemic spread because mycotic dissemination is associatedwith high mortality and amputation rates (8–10). Removal of all
necrotic tissue and microbiological diagnosis with target antimicrobial therapy are crucial steps in its early management.
There are a number of existing methods for debridement including mechanical, surgical, autolytic, and enzymatic methods.
Each of these techniques has associated disadvantages, such as
limited efficacy, need for anesthesia, pain, and mechanical damage to the underlying healthy tissue. Maggot debridement therapy(MDT) is a technique that has recently attracted some attention(11). The proven behaviors of MDT are considerable debridement,
granulation support, and antimicrobial effects (12).
Negative pressure therapy (NPT) is useful after thorough debridement to promote wound healing by increasing local bloodflow and open wound closure (13).
To the best of our knowledge, this is the first reported case of
tendon and soft tissue infection by A. corymbifera in a complex
hand injury that was successfully treated with a combination ofitraconazole, MDT and NPT.
Patient
A previously healthy 21-year-old male had a work accident ata conveyor belt, which caused a devastating injury to his upper left
extremity. He was transferred to our department from the district
trauma hospital, where he had undergone fasciotomies and surgicaldebridement two days after the accident. After the patient arrived at
our hospital, the affected extremity was evaluated. Limited vitalityof the soft tissue and extensor tendon over the width of the dorsal

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Bratisl Med J 2015; 116 (11)671 – 673

Fig. 1. The patients’ first photo of the hand before debridement atour department.

Fig. 2. The first application of maggot debridement therapy. In thecentral bag, full (black) maggots can be observed because of the large
amount of necrosis.

Fig. 3. The patients’ hand immediately after two applications of maggot debridement therapy.

Fig. 4. The patients’ hand after groin flap and full-thickness skin graft
coverage.

showed colonization by Staphylococcus haemolyticus. During several debridement procedures, we attempted to remove all necrotic
tissue, but the pathological process slowly progressed. Six daysafter our first intervention, wound cultures revealed colonization
by A. corymbifera. According to the pharmacist recommendation,
we started antimycotic therapy with itraconazole. At this time, anew treatment approach was attempted for precise debridement.
We decided to use MDT in a new special design, using the eggs ofL. sericata, in contrast to the more common use of maggots. The
experimental protocol was approved by the Ethical committee ofthe University Hospital and Faculty of Medicine, Comenius University (Reference number 112/2005). The patient gave informed
consent before the beginning of MDT. Bags with sterile eggsof L. sericata were obtained from Scientica, Ltd. (St. Michael’s
Hospital, Bratislava, Slovakia) and were prepared individually forpatient to match the size of the wound. The biobags were placed
onto the wound. On the top, saline-moistened gauze was placedand secured well with secondary dressing to avoid slippage andensure that surface contact of the biobag is maintained. All outer
dressing must be non-occlusive as the larvae need oxygen to survive. The secondary dressing was changed daily. The bags wereapplied for approximately 72 hours, depending on the patient’stolerance. After two applications of three egg biobags (maggots
were delivered from the eggs) (Fig. 2), we achieved a significant
improvement in the wound condition (Fig. 3). The maggots removed all necrotic tissues, and the mycotic infection was successfully eradicated. However, the wound showed massive colonization
by Proteus mirabilis, which is a typical commensal organism in
the L. sericata maggot’s gut and was sensitive to all common antibiotics. Additionally, early stages of granulation and exposure of
the carpal, metacarpal, phalangeal bones and ends of the extensor
tendons were observed. The wound was not suitable for complex
flap reconstruction in this condition. Ciprofloxacin and NPT (VivanoTecR Hartmann) were used to promote granulation and treat theinfection before definitive wound covering. NPT was activated on
125 mmHg intermittent suction pressure. Dressings were changedin the isolation ward once every 3 to 4 days under strict asepticconditions. After five weeks of NPT, granulation tissue covered
all exposed tendons and only the rest of exposed bones remained.
The swelling decreased, and the wound contracted, leaving a total
defect in size of 300 cm2. According to angiography findings ofthe a. radialis occlusion, we chose to cover the defect with a pedicle groin flap of 12 x 18 cm instead of a free flap. The rest of thesurrounding defect was covered with a split-thickness skin graft.
Three weeks after the last operation had been performed, the flap
was disconnected, and the patient was discharged (Fig. 4). During
six months of follow-up, no infection relapses occurred, and thepatient is currently undergoing rehabilitation and waiting for flap
defatting and extensor tendon reconstruction.
Discussion

distal third of the forearm and dorsum of the hand to nearly theend of the first three fingers was observed (Fig. 1). After the initial
surgical debridement, antibiotic treatment with vancomycin, gentamicin, and metronidazole was started. The first wound cultures
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There is a lack of information in literature to guide the treatment of such complex hand injuries complicated by mycosis.
The few series reporting soft tissue zygomycosis suggest thatBohac M et al. Maggot therapy in treatment of a complex hand injury…
xx

the highest survival rates are obtained using a combination ofextensive debridement and long-term antifungal treatment (16).
The overall mortality of cutaneous A. corymbifera infection was
18.5 %, although in neonates, it can reach more than 50 % (8).
The typical clinical feature of cutaneous zygomycosis is tissue
necrosis with a rapid clinical course. Early diagnosis and target
treatment are essential for a good outcome. Although some invitro studies of Zygomycetes have demonstrated that the Absidia
genus of fungi is sensitive to amphotericin B and relatively low
concentrations of itraconazole and terbinafine, further studies
correlating in vitro and in vivo findings are needed (17). In cases
involving the hand structures, debridement should be adequate inregard to future function, and the advantages of MDT are useful.
The literature and our own results demonstrate that MDT is asafe method with few side effects. MDT is as good as or better
than conventional surgical debridement, is more selective thansurgical debridement, and decreases the time to healing and duration of stay in the ward (18). NPT has also been shown to havegood results in the management of open chronic wounds. Thisis the first reported case of a complex hand injury complicatedby zygomycosis and treated with a combination of antifungal
therapy, MDT and NPT.
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Received February 5, 2015.
Accepted June 26, 2015.

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