Myiasis: Nursing Intervention

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  • -Myiasis
    Sounds like (my-eye-uh-sis)
    is the infestation of maggots in or on the body; maggots are larvae from flies (Robbins & Khachemoune, 2010).
    -Myia
    is the Greek word meaning fly (Merriam-Webster’s collegiate dictionary, 1995, p. 769).
    -Nosocomial myiasis
    is the occurrence of maggot infestation of a person within the hospital setting (Tucker & Goulard, 2008).
    -Myiasis can be caused by different types of Dipteria—a two-winged insect (Merriam-Webster’s collegiate dictionary, 1995, p. 327).
    -Myiasis can be classified according to type or clinical presentation.
  • -Myiasis is usually caused by flies from the Oestridae family. This is subdivided into 3 subfamilies:
    Oestridae (sounds like es-trid-ee). Greek origin meaning “gadfly or frenzy”
    Calliphoridae (sounds like cal-lif-or-id-ee). Greek origin meaning “to bear beauty”
    Sarcophagidae (sounds like sar-cof-aj-id-ee) Latin from Greek origin meaning to “to eat flesh”
    (Robbins & Khachemoune, 2010).
    Specie Examples
    -Dermatobia hominis—bot fly– is from the Oestridae family.
    -Cochliomya hominivorax—blow fly—is from the Calliphoridae family.
    -Wohlfahrtia vigil—flesh fly—is from the Sarcophaidae family.
  • It is facultative, meaning it usually does not usually cause myiasis. But, if presented with an area (such as an open wound bed). The female fly will lay eggs in the area (“Facultative myiasis-producing flies”, 2011).
    Extra-credit question: what does “musca” mean?
    Latin word for fly (http://www.memidex.com/musca )
  • Cutaneous myiasis is subdivided into 3 types by clinical manifestation:
    Furuncular:
    Larvae presents as a boil lesion.
    Migratory:
    also known as creeping. Larvae moves under skin layers.
    Wound:
    also known as traumatic. Larvae presents in wound bed.
  • -Dermatobia hominis, human bot fly, is an example of a fly specie which cause furuncular myiasis.
    -It is a common cause of furuncular myiasis.
    -Obligate parasite.
    -Commonly from subtropic such as Mexico and South America.
    -Often affects dogs, cats or cattle (Trombetta, et al., 2009).
    -Female fly lay eggs on surfaces & vectors such as mosquitos (Robbins & Khachemoune, 2010).
    -Invasive; it burrows under the skin to cause a boil.
    -Eggs hatch on skin & remains in the subdermal layers (deep) of the skin for 5-10 weeks (Robbins & Khachemoune, 2010).
    -Usually does not usually affect humans (Gingrich, Spickler, & Davis, 2004).
    -Will affect specific sites of the individual (i.e. nose, wound, foot) (Gingrich, Spickler, & Davis, 2004).
  • Gasterophilus spp., horse bot fly, is an example of a fly specie which causes migratory myiasis.
    It is a most common parasite to horses.
    Obligate parasite.
    Female lay eggs on the hairs of horses.
    Larvae hatch on skin and tunnel into the epidermis (superficial) layer of skin. A distinct serpentine pattern is visible under the skin.
    Human infestation is by way of contact with an infected horse (Robbins & Khachemoune, 2010).
  • -Cochliomyia hominivorax, blow fly, is an example of a fly specie which causes wound (traumatic) myiasis.
    -Obligate parasite.
    -Distributed in warm areas of the Americas (S. America, Mexico and Argentina) (Trombetta et al., 2009).
    -Infestation frequently associated with dogs, cats and cattle (Trombetta et al., 2009); rare in humans (Robbins & Khachemoune, 2010). -Eradication program in 1960s via male sterile flies (Gingrich, Spickler, & Davis, 2004)
    -Female fly lay hundreds of eggs to cause multiple infestation (Robbins & Khachemoune, 2010).
    -Will infect ANY warm-blooded animal (Gingrich, Spickler, & Davis, 2004)
    -Eggs hatch in “8-12 hours” after deposit on wound (Gingrich, Spickler, & Davis, 2004)
    -Multiple larvae will be present(Gingrich, Spickler, & Davis, 2004)
    -Wound will increase in size and depth as the larva feed (Gingrich, Spickler, & Davis, 2004)
    -Larva will be visible within 3 days (Gingrich, Spickler, & Davis, 2004)
    -Distinct odor (Gingrich, Spickler, & Davis, 2004)
    -Death can result if not treated (Gingrich, Spickler, & Davis, 2004)
  • Dermatobia hominis “favors the skin of scalp, face, and extremities” (Robbins & Khachemoune, 2010, p. 49). After hatching from the egg, the larvae invades the body by the skin of the host (Robbins & Khachemoune, 2010)
  • With the exception of Sarcophagidae. Flies lay eggs on an area.
    Eggs are deposited on host.
    Eggs hatch usually within 24 hours.
    Larvae emerge from eggs.
    Larvae grows in stages called instar, it will change in shape and specific sub-anatomical structures such as spiracle will appear and increase in number with each separate instar stage.
    Mature larvae leave host to become pupa.
    Within pupa, metamorphosis into reproductive fly (Sherman, Roselle, Bills, Danko, & Eldridge, 2005).
  • Localized redness, pain, swelling.
    Localized intense itching (pruritus).
    Sensation of movement under skin.
    Serous or serosanguinous discharge at site
    Malodor if affected area is wound bed.
    *Thread like structure removed (Sharma, Pai, & Pai, 2008).
    *Definitive diagnosis of myiasis is by nurse practitioner or physician if identification of larva removed from area.
  • Accidental myiasis. The patient ate contaminated food and ingested fly eggs. Eggs survived within the intestines and developed into larvae which was excreted out of the body (Das et al., 2010).
  • Patient
    Unable to perform proper self-care.
    Bed-ridden; poor hygiene of skin and orifices.
    Decreased blood flow to extremities (e.g. Peripheral vascular disease).
    Open wounds not covered.
    Wounds beds with necrotic tissue in wound bed.
    Soiled wound dressings/linens/clothing not promptly changed.
    Immune-compromised.
    Cognitively impaired.
    Environment
    Warm climate (e.g. tropical or summer weather season).
    Food containers left uncovered in room
    Overflowing garbage bins in room (Sherman et al., 2005).
  • Notify the patient after definitive diagnosis.
    Calm the patient; offer comfort, support and empathy. Myiasis is a socially-sensitive diagnosis.
    Notify the nurse supervisor or nurse manager.
    Locate the medical center policy and protocol to control myiasis
    Gather materials to prepare for larval removal:
    Basin, 4X4 pads, specimen cups, Isopropyl (70%) alcohol,
    Pre-made mixture of 1 part hydrogen peroxide to 3 parts sterile water or sterile saline, marker/pen.
    Determine patient’s immune status.
    Using standard precautions, express [remove] larvae (NP or MD)
    If entire larvae visible, use 4X4 pads to brush the larvae out. DO NOT SMOOSH or SMASH. Put intact larvae aside.
  • If entire larvae not visible [in skin], apply petroleum jelly to the
    affected area on skin. This will occlude the breathing of the larvae thus causing it to move. When visible, use 4X4 pads to brush larvae
    out. DO NOT SMOOSH or SMASH. Put intact larvae aside.
    6.Using standard precautions, place all larvae into specimen cup. Add
    70% isopropyl alcohol into cup; enough to completely submerge
    larvae. Seal cup. Label: write patient’s name, date, time, name of
    clinician who collected specimen and type of solution (70% isopropyl
    alcohol). Send this to lab IMMEDIATELY (within 24 hours).
    7.Wipe the infected area using sterile saline or hydrogen peroxide or
    Dakin’s solution [0.125% sodium hypochlorite].
    8.Soak infected area using hydrogen peroxide and water mixture (step
    4a). Soak for 20 minutes.
  • Dispose of soiled or used dressings in proper receptacle. If possible,
    apply new dressings to affected site.
    10.Document what was done. Look for new orders (e.g. blood
    collection, antibiotic, immunization). Often, a broad-spectrum
    antibiotic such as Ivermectin is prescribed (Department of Veteran Affairs,
    Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999).
  • Additional Information:
    The Center for Food Security & Public Health, Iowa State University
    http://cfsph.iastate.edu/DiseaseInfo/disease.php?name=screwworm-myiasis&lang=en
  • Thank you for viewing Myiasis: Nursing Intervention presentation. Below is a link to Zoomerang© survey evaluation. Please take 10 minutes to answer questions. This survey can be completed at any time. If you would like to contact me. Please see contact information on final slide.
    http://www.zoomerang.com/Survey/WEB22E58645U4D
  • Myiasis: Nursing Intervention

    1. 1. Myiasis: Nursing InterventionMyiasis: Nursing Intervention By: Bridgette C. Williams, BSN, RNBy: Bridgette C. Williams, BSN, RN SUNY Institute of TechnologySUNY Institute of Technology
    2. 2. Lesson Plan: Myiasis • Topic: Myiasis (maggot infestation for nurse clinicians and educators) • Prerequisites: Undergraduate nursing degree • Objective: Differentiate types of myiasis in context of the nursing process • Rationale: Myiasis is an occurrence in the health care setting • Part I: Classification—types of myiasis infestation • Part II: Fly Life Cycle—development from egg to fly • Part III: Signs & Symptoms—signs of maggot infestation • Part IV: Nursing Interventions—protocol for maggot removal • Part V: Conclusion December 2011 B. Williams, BSN, RN, MAMS 2
    3. 3. Presentation Objectives • At the end of this presentation learners will be able to: – Define myiasis. – Identify one myiasis classification. – Describe at least 2 signs of infestation. – Explain at least 2 stages of the fly reproductive life cycle. – Differentiate at least 2 risk factors. – Apply at least 2 nursing interventions to care plan for myiasis. December 2011 B. Williams, BSN, RN, MAMS 3
    4. 4. PART IPART I ClassificationClassification
    5. 5. Definition • Myiasis (sounds like my-eye-uh-sis) – is the infestation of maggots in or on the body • Nosocomial myiasis – is the occurrence of maggot infestation in the hospital setting • Myiasis can be classified according to type or clinical presentation • (Robbins & Khachemoune, 2010; Tucker & Goulard, 2008; Merriam-Webster’s collegiate dictionary, 1995). December 2011 B. Williams, BSN, RN, MAMS 5
    6. 6. Myiasis Classification Classification by type •Obligate: fly eggs on any host surface •Facultative: fly eggs on opportunistic areas •Accidental: fly larvae feed on host not of usual source Classification by clinical presentation •Cutaneous •Orifices •Intestinal •Wound •(Trombetta, Oliva, Galache, Bava, & Troncoso, 2009; Werminghaus, Hoffman, Mehlhorn, & Bas, 2008; Robbins & Khachemoune, 2010; .Das, Madan, & Gautam, 2010) December 2011 B. Williams, BSN, RN, MAMS 6
    7. 7. Fly Families • Oestridae family. This is subdivided into 3 subfamilies: – Oestridae (sounds like es-trid-ee) – Calliphoridae (sounds like cal-lif-or-id-ee) – Sarcophagidae (sounds like sar-cof-aj-id-ee) Specie Examples • Dermatobia hominis—bot fly–Oestridae family • Cochliomyia hominivorax—blow fly—Calliphoridae family • Wohlfahrtia vigil—flesh fly—Sarcophagidae family • (Robbins & Khachemoune, 2010). December 2011 B. Williams, BSN, RN, MAMS 7
    8. 8. Quiz Question 1 • True of False: The common house fly (Musca domestica) does not cause myiasis. December 2011 B. Williams, BSN, RN, MAMS 8
    9. 9. Quiz Question 1 Answer • Answer: False. The common house fly can cause myiasis. It is facultative • (“Facultative myiasis-producing flies”, 2011). December 2011 B. Williams, BSN, RN, MAMS 9 ImageSource: http://www.naturephoto-cz.eu/musca-domestica-picture-14134.html Musca domestica
    10. 10. Cutaneous Myiasis • Cutaneous myiasis is subdivided into 3 types by clinical manifestation: – Furuncular: Larvae presents as a boil lesion – Migratory: also known as creeping. Larvae moves under skin layers – Wound: also known as traumatic. Larvae presents in wound bed • (Robbins & Khachemoune, 2010). December 2011 B. Williams, BSN, RN, MAMS 10
    11. 11. Furuncular Myiasis Epidemiology • Dermatobia hominis, human bot fly • Obligate parasite • Found in Mexico and South America • Often affects dogs, cats or cattle • Eggs on surfaces & vectors • Site specific • Invasive; it burrows under the skin to cause a boil • (Trombetta, et al., 2009; Robbins & Khachemoune, 2010; Gingrich, Spickler, & Davis, 2004). December 2011 B. Williams, BSN, RN, MAMS 11 Image Source: http://www.greatapeproject.org/en-US/curiosidade.info/Show/ 1942,have-you-ever-eaten-a-buge Dermatobia hominis
    12. 12. Migratory Myiasis Epidemiology • Gasterophilus spp., horse bot fly • Most common parasite to horses • Obligate parasite • Eggs on the hairs of horses • Distinct serpentine pattern visible under skin • Infestation is by contact with an infected horse • (Robbins & Khachemoune, 2010). December 2011 B. Williams, BSN, RN, MAMS 12 Image Source: http://www.slow-life.co.uk/2010/02/03/the-evil-bee/ Gasterophilus spp.
    13. 13. Wound Myiasis Epidemiology • Cochliomyia hominivorax, blow fly • Obligate parasite • Distributed in warm areas of the Americas • Infestation frequently associated with animals • Female fly lays hundreds of eggs • Larvae of this specie will feed on living tissue (usually larvae feed on dead tissue) • Distinct odor in wound • Death can result if not treated • (Trombetta et al., 2009; Robbins & Khachemoune, 2010; Gingrich, Spickler, & Davis, 2004) December 2011 B. Williams, BSN, RN, MAMS 13 Image Source: http://www.icb.usp.br/~marcelcp/Cochliomyia.htm Cochliomyia hominivorax
    14. 14. Quiz Question 2 • True or False: Myiasis is only associated with open areas. December 2011 B. Williams, BSN, RN, MAMS 14
    15. 15. Quiz Question 2 Answer • False. Myiasis can occur on intact skin. • (Robbins & Khachemoune, 2010) December 2011 B. Williams, BSN, RN, MAMS 15 Image Source: http://www.icb.usp.br/~marcelcp/Dermatobia.htm Dermatobia hominis
    16. 16. PART IIPART II Life CycleLife Cycle
    17. 17. Life Cycle • Fly lay eggs on an area 1. Eggs are deposited on host 2. Eggs hatch usually within 24 hours 3. Larvae emerge from eggs. • instar (usually up to 3) • spiracle 1. Mature larvae leave host to pupa. 2. Within pupa, metamorphosis into reproductive fly • (Sherman, Roselle, Bills, Danko, & Eldridge, 2005). December 2011 B. Williams, BSN, RN, MAMS 17 Image Adapted From: Sherman, R.A., Roselle, G., Bills, C., Danko, L.H., & Eldridge, N. (2005). Healthcare-associated myiasis: Prevention and intervention. Infection Control And Hospital Epidemiology, 26(10), 828-832. Image Adapted From: Nazni, et al. (2011). Nosocomial nasal myiasis in an intensive care unit. Malaysian Journal of Pathology, 33(1), 53-56. Life cycle Spiracle
    18. 18. PART IIIPART III Signs & SymptomsSigns & Symptoms
    19. 19. Signs & Symptoms of Infestation • Redness, pain, swelling • Intense itching (pruritus) • Sensation of movement under skin • Serous or serosanguinous discharge at site • Malodor if affected area is wound bed • *Thread like structure removed • (Sharma, Pai, & Pai, 2008). • *Definitive diagnosis of myiasis is by nurse practitioner or physician if identification of larva removed from area. December 2011 B. Williams, BSN, RN, MAMS 19 Image Source: http://www.langetextbooks.com/_levinson/gallery.php?id=m-n
    20. 20. Quiz Question 3 • Describe 2 signs of infestation. December 2011 B. Williams, BSN, RN, MAMS 20
    21. 21. Quiz Question 3 Answer • Redness (locale) • Pain (locale) • Itching (locale) • Swelling (locale) • Sensation of movement under skin • Discharge at site • Malodor (if in wound bed) December 2011 B. Williams, BSN, RN, MAMS 21
    22. 22. Case Study 1 • A 75-year old woman with venous hypertension and diabetes presented to the emergency room for an ulcer on the right leg. Necrotic tissue and tunneling were present in the wound bed. “Worms” were observed by the nurse assistant. What is the possible clinical presentation? December 2011 B. Williams, BSN, RN, MAMS 22
    23. 23. Case Study 1 Answer • Answer: Wound myiasis • (Victoria, Trujillo, & Barreto, 1999). December 2011 B. Williams, BSN, RN, MAMS 23
    24. 24. Case Study • A 25 year old man from a rural setting presented to an outpatient clinic complaining of passing worms in the stool for the past month. He had no complaints of blood in the stool. Blood pressure was within range. Stool sample collected and lab technician reported 4 active “worms” were microscopically identified. What is the possible clinical presentation? December 2011 B. Williams, BSN, RN, MAMS 24
    25. 25. Case Study 2 Answer • Accidental myiasis • (Das et al., 2010). December 2011 B. Williams, BSN, RN, MAMS 25
    26. 26. PART IVPART IV Nursing InterventionsNursing Interventions
    27. 27. Risk Factors 1. Patient – Limited mobile/immobile; poor hygiene of skin and orifices – Open wounds not covered – Immune-compromised – Cognitively impaired 1. Environment – Warm climate (e.g. tropical or summer weather season) – Food containers left uncovered in room – Overflowing garbage bins in room • (Sherman et al., 2005). December 2011 B. Williams, BSN, RN, MAMS 27
    28. 28. Nursing Intervention for Myiasis 1. Notify the patient 2. Calm the patient and/or staff 3. Notify the nurse supervisor or nurse manager 4. Locate the medical center policy and protocol to control myiasis 5a. Using standard precautions, remove larvae (NP or MD) • Brush the larvae out. DO NOT SMOOSH or SMASH. Put intact larvae aside. 5b. If entire larvae not visible [in skin], apply petroleum jelly •(Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999). December 2011 B. Williams, BSN, RN, MAMS 28
    29. 29. Nursing Interventions...continued 6. Larvae (all) in specimen cup. Add 70% isopropyl alcohol in cup. • Seal cup. Label: write patient’s name, date, time, name of clinician who collected specimen and type of solution. • Send to lab IMMEDIATELY (within 24 hours). 7. Wipe infected area; use sterile saline or hydrogen peroxide or Dakin’s solution [0.125% sodium hypochlorite]. 8. Soak infected area using hydrogen peroxide and water mixture (1:3) Soak for approx. 20 minutes. • (Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999). December 2011 B. Williams, BSN, RN, MAMS 29
    30. 30. Nursing Interventions...continued 9. Dispose of used dressings in proper receptacle. Apply new dressings 10. Document what was done. • Often, broad-spectrum antibiotic (i.e. Ivermectin) is prescribed •(Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999). December 2011 B. Williams, BSN, RN, MAMS 30
    31. 31. Critical Reasoning Exercise • An 83 year old patient with diabetic foot ulcer is diagnosed with Alzheimer’s and PVD is in your care. You are the charge nurse of the 70 bed nursing home facility and the only RN on shift. The doctor is on call. The nurse assistant frantically calls for your assistance. The nurse assistant tells you she was attempting to adjust the sheets in the in the bed and observed the dressing fell off and “white worms” were seen crawling in the wound bed. As the charge nurse, apply 2 nursing interventions for possible myiasis infestation. December 2011 B. Williams, BSN, RN, MAMS 31
    32. 32. Critical Reasoning Exercise Ans. • Standard precautions and check on the patient to ensure safety. • Assess vital signs, pain, wound bed. Offer pain med. • Notify the nurse manager/supervisor. Notify the doctor on call. • Access myiasis policy/protocol/procedure. • Perform myiasis removal. Be sure to preserve the larva in 70% Isopropyl alcohol labeled and sealed in a specimen cup. Clean the wound bed as stated in protocol. • Contact lab; notify technician of pending arrival. Send specimen to lab immediately. • Document what was done. • Look for new orders. December 2011 B. Williams, BSN, RN, MAMS 32
    33. 33. Myiasis Prevention • Cover all wounds • Change wound dressings as ordered and when visibly soiled • Keep open orifices clean, especially if patient has an artificial airway • Establish a turning or repositioning schedule for limited mobile patients • Thorough skin assessment at least 1 time per week • Do not leave open food containers in room • Keep garbage receptacles covered with a lid • (Sherman et al., 2005) December 2011 B. Williams, BSN, RN, MAMS 33
    34. 34. PART VPART V ConclusionConclusion
    35. 35. Conclusion • Nosocomial myiasis is maggot infestation which occurs in a hospital. • Common signs/symptoms include redness, pain, itching. • Risk factors include open wound beds with or without necrotic tissue, bed-ridden patient and unkempt environment. • Nosocomial myiasis is preventable. Additional Information: The Center for Food Security & Public Health, Iowa State University: http://cfsph.iastate.edu/DiseaseInfo/disease.php?name=screwworm-myiasis&lang=en December 2011 B. Williams, BSN, RN, MAMS 35
    36. 36. Reflection • Constructing science information in the format of a slide presentation is challenging. Many details must be abbreviated on slides. • First experience constructing presentation with quiz questions, case studies. • First experience including a synthesis critical reasoning example. • First experience using online survey Zoomerang©. • First presentation using Elluminate Live! V.10©. December 2011 B. Williams, BSN, RN, MAMS 36
    37. 37. Evaluation • Thank you for viewing Myiasis: Nursing Intervention presentation. Below is a link to Zoomerang© survey evaluation. Please take 10 minutes to answer questions. This survey can be completed at any time. If you would like to contact me. Please see contact information on final slide. • http://www.zoomerang.com/Survey/WEB22E58645U4D December 2011 B. Williams, BSN, RN, MAMS 37
    38. 38. References • Das, A., Pandey, A., Madan, M., Asthana, A.K., & Gautam, A. (2010). Accidental intestinal myiasis caused by genus Sarcophaga. Indian Journal of Medical Microbiology, 28(2), 176-178. • Department of Veteran Affairs, A Maryland Health Care System: The Infection Control/Hospital Epidemiology Program (111/MD). (2008). Policy Memorandum (512-11/COS IC-015). Baltimore, MD: Author. • Facultative myiasis-producing flies. (2011). The Merck Veterinary Manual. Retrieved from: http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/71719.htm • Gingrich, E., Spickler, A.R., & Davis, R. (2004). Screwworm myiasis [PowerPoint presentation]. The Center for Food Security & Public Health Iowa State University. Retrieved from: http://cfsph.iastate.edu/DiseaseInfo/disease.php?name=screwworm-myiasis&lang=en • Myiasis. (1995). In Merriam-Webster’s collegiate dictionary (10th ed.). • Robbins, K., & Khachemoune, A. (2010). Cutaneous myiasis: A review of the common types of myiasis. International Journal of Dermatology, 49, 1092-1098. • Sharma, P., Pai, H.S., & Pai, G.S. (2008). Furuncular myiasis mimicking pyoderma [Letters to Editor]. Indian Journal of Dermatology, Venerology and Leprology, 74(6), 679-681. December 2011 B. Williams, BSN, RN, MAMS 38
    39. 39. References • Sherman, R.A., Roselle, G., Bills, C., Danko, L.H., Eldridge, N. (2005). Healthcare-associated myiasis: prevention and intervention. Infectious Control and Hospital Epidemiology, 26(10), 828-832. • Trombetta, L., Oliva, A., Galache, V., Bava, J., Troncoso, A. (2009). Cutaneous myiasis due to Cochliomyia hominovorax in a drug user. Journal of Infection in Developing Countries, 3(11), 873-876. • Tucker, S. –M., & Goulard, S. (2008). More than just a fly on the wall: A case of nosocomial myiasis in the intensive care unit. Canadian Association of Critical Care Nurses, 31. • Victoria, J., Trujillo, R., & Barreto, M. (1999). Myiasis: A successful treatment with topical Ivermectin. International Journal of Dermatology, 38, 142-144. • Wa, N., Jeffery, J., Lee, H.L., Lailatul, A.M., Chew, W., Heo, C.C., Sadiyah, I., Khairul, M, -A., Heah, S.K., Mohd, H.H. (2011). Nosocomial nasal myiasis in an intensive care unit. Malaysian Journal of Pathology, 33(1), 53-56. • Werminghaus, P., Hoffman, T.K., Lehlhorn, H., Bas, M. (2008). Aural myiasis in a patient with Alzheimer’s disease. European Archives of Otorhinolaryngology, 265(7), 851-853. doi: 10.1007/s00405-007- 0535-2 December 2011 B. Williams, BSN, RN, MAMS 39
    40. 40. ENDEND Bridgette C. Williams, BSN, RN, MAMSBridgette C. Williams, BSN, RN, MAMS williab5@sunyit.eduwilliab5@sunyit.edu

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