A 40-year-old woman from a poor socioeconomic background, residing in a rural area of southern Iran (Kerman), was admitted on 22 October 2021 with a bloody discharge, severe pain, and swelling of the genital area. The pain and swelling had been started six days before admission. She had sought medical help for an ulcer and bloody discharge at Jiroft Hospital and was hospitalized for three days. She received antibiotics and was then referred to our tertiary University center because her condition did not improve. She had no gynecological disease. Her menstrual cycle was regular, and she used folded cloths instead of sanitary pads during her menstruation. Moreover, she washed the clothes with water and hung them on the clothesline to dry before reuse. Her medical history revealed no evidence of any underlying disease (immunosuppression, chronic illness, such as diabetes or tuberculosis, and steroid therapy) or mental disorder. She had no history of trauma or insect bite. Her physical examination was normal, although she had been blind since childhood.
The patient had no abdominal pain, gastrointestinal or urinary symptoms, fever, or chills. She did have a history of COVID-19 infection in June 2021, from which she recovered spontaneously without being hospitalized. At admission, her vital signs were as follows: pulse rate 86 bpm; temperature 37.2 C; BP 110/70 mmHg; and O2 97%. We found no evidence of lymphadenopathy. Auscultation of her heart and lungs revealed normal conditions. The examination of her abdomen disclosed no tenderness or rebound tenderness.
Before examination of her external genitalia, she reminded us that she was a virgin, and had not had sexual intercourse throughout her life. Serology, blood, and urine tests were requested.
The examination of the external genitalia revealed a tender mass measuring 6 cm x 4 cm in the vulvar area and an ulcer measuring 1 cm x 1 cm next to the clitoris (Figure 1). In the clitoral region, the patient had a bloody discharge.
The patient's total and differential leukocyte counts were within normal limits, and her hemoglobin level was 14.2 g/dL. The results of a complete urine examination revealed normal values. Serological tests for the human immunodeficiency virus and syphilis (rapid plasma reagin card test) were negative. Counseling in regard to infectious disease and surgery counseling was requested. The patient was then transferred to the operating room (OR) with the assumed diagnosis of necrotizing fasciitis. A longitudinal incision was performed on the mass under sterile conditions. Necrotic fluid was drained, and approximately 30 visible maggots were removed with non-toothed forceps. Necrotic tissue, which was largely superficial and subcutaneous, was debrided completely. The fascia and muscles were not involved. After washing with normal saline, the patient was transferred to the ward without wound suturing. Debridement of the necrotic vulvar mass along with daily washing was performed for 7 days. Some maggots were seen until the third day and removed. This was followed by surgical lavage. Intravenous clindamycin (900 mg three times a day) and ceftriaxone (1 g twice daily) were started to prevent secondary bacterial infection. The wound was sutured on the seventh day (Figure 2). Antibiotic therapy was continued for four days, and the patient was discharged with normal lab tests on the eleventh day after admission. The wound culture-confirmed larvae of the blowfly. At the time of discharge, the patient was advised to keep the vagina and vulva clean.