Clinical Practice and Cases in Emergency Medicine

Introduction: Subungual myiasis is an infection under the fingernail or toenail caused by an infestation of fly larvae. It is rarely reported internationally, with only one previously reported case in the United States.

Case Report: An 80-year-old female with a history of polyneuropathy, peripheral artery disease, peripheral venous insufficiency, and chronic bilateral lower extremity edema presented to the emergency department (ED) after staff at her skilled nursing facility noted what appeared to be several whitish-colored maggots moving under the nail of the patient’s left great toe. Thorough examination was consistent with subungual myiasis with associated onycholysis without evidence of associated cellulitis or soft tissue infection. Manual extraction of six larvae was performed, and the patient’s foot was soaked in chlorhexidine. She was discharged back to her facility with a plan for daily chlorhexidine soaks and prompt follow-up with a podiatrist. To date she has not presented to the ED since with the same issue.

Conclusion: Due to its extraordinarily rare incidence, there is little consensus regarding the treatment of subungual myiasis beyond the manual extraction of larvae. Oral ivermectin has been reported as an additional treatment option for myiasis, but research is limited. Antibiotics are generally only recommended when there is evidence of associated bacterial infection. This case should raise awareness for emergency physicians regarding the recognition and management of subungual myiasis.