Introduction: Myiasis refers to the infestation of human or vertebrae tissue with dipterous (two-winged) larvae (maggots). Infestations involving the lower respiratory tract are exceedingly rare. Only four other cases of pulmonary myiasis have been documented in the medical literature within the United States (not due to a tracheostomy or secondary to some other iatrogenic cause). We describe a patient that presented to the emergency department after having expectorated a live Cuterebra larva during a coughing fit. 

Case Presentation: A 51-year-old white female presented to the emergency department after expectorating a live Cuterebra larva during a coughing fit. She reported recent travel to Florida and recalled an insect flying into her mouth while on an evening walk. One week later, she developed a non-productive cough. She was subsequently treated for bronchitis with antibiotics unsuccessfully. On presentation, she was afebrile and appeared without distress. However, she brought a larva with her in a bag that she claimed had been coughed up. The live specimen was subsequently sent to pathology where it was measured at 15 mm in length. A CBC showed leukocytosis (11.6 x 109/liter) and eosinophilia (34%). The specimen was subsequently recognized by the Entomology department at the University of Georgia to be a larva from the genus Cuterebra. The patient underwent bronchoscopy revealing a protuberant mass in the left posterolateral portion of the trachea. Forceps were used to remove a tissue sample from within the cavitation. A tracheal biopsy revealed chronic tracheitis with eosinophilia and retained larval fragments. After specimen removal, the area was debrided and irrigated with saline. The patient had a complete resolution of symptoms within three weeks. 

Final Diagnosis: Tracheopulmonary Myiasis

Management/Outcome/Follow up: Treatment initially involves mechanical removal of the maggots followed by anti-parasitic drugs such as ivermectin and anti-inflammatory drugs such as prednisone. Prevention of secondary bacterial infection may be necessary. Repeated bronchoscopy with saline wash helps remove remaining larvae without damaging bronchial epithelium. While tracheopulmonary myiasis in humans is rare, it must be considered in the differential diagnosis among patients presenting with unexplained respiratory distress and hypoxia with a recent travel history to tropical regions.