Palliative Management of Advanced Breast Carcinoma Complicated by Myiasis: First Case Report From Bangladesh.

Introduction
Myiasis, derived from the Greek word muia (meaning “fly”), refers to the infestation of human tissues by dipterous larvae.
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Based on the degree of parasitism, myiasis is classified into 3 categories: obligatory (requiring living tissue for development), facultative (developing in necrotic tissue), and accidental or pseudomyiasis (resulting from ingestion of larvae without true tissue invasion).
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Although some flies, for example, flesh flies can deposit live larvae directly in the wound but infestation typically occurs when fly eggs are deposited in sites of skin disruption or natural body orifices. Usually, these flies are attracted by the smell of necrotic tissue and lay their eggs on the open wound. Upon hatching, larvae invade host tissues, leading to pain, secondary infection, tissue destruction, and often profound distress.
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Human myiasis is a neglected parasitic disease that primarily affects individuals in tropical and subtropical regions, particularly those living in socioeconomically disadvantaged conditions. Identified risk factors include poor personal hygiene, poverty, advanced age, chronic illness (such as diabetes mellitus), vascular occlusive disease, mental illness, substance use disorders, frailty, and inadequate access to healthcare.
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The impact of myiasis extends beyond physical suffering. Patients frequently report distressing symptoms such as intense discomfort, malodorous discharge, bleeding, swelling, and ulceration, all of which contribute to significant psychological and social burden. Caregivers, too, often experience substantial emotional strain and stigmatization, particularly in terminally ill individuals where infestations exacerbate existing vulnerabilities.
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A comprehensive review of reported cases between 1997 and 2017 documented 464 instances of human myiasis across 79 countries. Among these, 150 cases (32.2%) were reported from Asia, with South Asia contributing 63 cases, including 9 from South-East Asia.
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However, despite being familiar to the region, published documentation of human myiasis in Bangladesh remains scarce.
To the best of our knowledge, we report the first documented case of cutaneous myiasis in a patient with advanced breast carcinoma in Bangladesh. This case illustrates not only the physical manifestations of this condition but also the pivotal role of palliative care in addressing the complex medical, psychological, and social dimensions of suffering at the end of life.

Case Study
A 52-year-old female presented to the Department of Palliative Medicine at Bangladesh Medical University in April 2025 with a progressively enlarging wound involving the entire right chest wall. On examination, there were 2 large cavitary ulcerated lesions with irregular, indurated edges and areas of necrotic slough. She also had significant facial and neck swelling, predominantly on the right side. The patient reported severe, continuous pain localized to the right chest wall and shoulder joint, which had persisted for the preceding 2 weeks. She also reported active discharge of maggots from the wound over the past 5 days.
Her social background was characterized by significant socioeconomic hardship. She resided in an urban slum, was widowed for over a decade, and was the sole caregiver for her 3 sons, including a 14-year-old with Down syndrome. She previously worked as a home-based tailor but discontinued employment following her cancer diagnosis. Both of her eldest son assumed part-time employment in another city to support the family and the patient continued her treatment through community support and extended family assistance. During her hospital visits, her eldest son was her only caregiver.
The patient had been diagnosed in September, 2023 with invasive ductal carcinoma of the right breast, human epidermal growth factor receptor 2 (HER2) positive. She underwent simple mastectomy with axillary clearance, followed by 6 cycles of adjuvant chemotherapy (CT) with paclitaxel and carboplatin and local radiotherapy. Due to her financial constrain, she could not take Trastuzumab (HER2 receptor antagonist) and completed her chemotherapy and radiotherapy by selling their only property and taking help from others. She was not compliant after her third cycle of CT and discontinued for 3 months. Then she again took another 3 cycles of CT. By the end of 2024, she developed pain of right side of the chest, multiple bony metastases, including right-sided multiple ribs, right shoulder joint, and cutaneous metastasis over the right chest wall. Due to severe pain on her right chest wall, she was referred to our department for pain management on November, 2024. Her pain was managed properly with oral morphine and Paracetamol.
About a month later, she got admitted into our department due to her progressive right upper limb secondary lymphedema and right chest wall cutaneous metastasis, which by then had formed into an ulcerated wound. She and her son had been taught about how to take care of that lymphedematous limb and the wound. They were educated on limb elevation, manual lymphatic drainage, and wound dressing. However, due to absence of caregiver at home, limited mobility due to shoulder and chest wall pain, and lack of personal support, her condition deteriorated significantly. She could hardly do any dressing by herself, sometimes weeks passed to do another dressing as she had to wait for some assistance. Also, her sons could hardly meet both ends, and there was lot of scarcity of dressing materials also. Day by day it was becoming a luxury to continue her treatment of symptoms after arranging a 3-times-a-day meal per day. To add to the misery, then she developed maggots on her wound. Already she was being stigmatized by her extended family members and neighbors due to the foul-smelling wound and now for the presence of maggots. Community members reportedly attributed her condition to “divine punishment” for any of her past bad deeds and expressed reluctance to participate in her funeral rites.
On presentation, the patient was cachectic, propped on her right elbow with evident distress due to pain and other symptoms. She exhibited gross lymphedema of the right upper limb, neck, shoulder, and hemiface, consistent with stage 3 lymphedema. Visual inspection was possible only through her left eye due to periorbital edema.
General physical examination revealed moderate anemia, with a blood pressure of 130/80, a pulse rate of 116 bpm and a temperature of 100°F. There were 2 ulcerated, necrotic cavitary lesions (10 cm × 7 cm and 6 cm × 5 cm) on the right anterior chest wall. Ulcerated metastases extended over the anterior and posterior right chest wall, axilla, and upper medial arm. The wounds were bleeding, foul-smelling, and heavily infested with live larvae. Numerous pale, segmented larvae measuring approximately 1-1.5 cm were observed burrowing deep into necrotic tissue within the primary wound. Additionally, extensive infestation with smaller larvae (~0.5 cm) was observed in the skin creases of the lymphedematous arm and axilla.
Her Eastern Cooperative Oncology Group (ECOG) performance status was 3, Palliative Performance Scale (PPS) score was 30% (measured as she was bed bound, couldn’t do any work, dependent completely to others for total care, intake was reduced, and was drowsy most on her day times), and her Numerical Rating Scale (NRS) of pain score was 10/10. Average Edmonton Symptom Assessment System (ESAS) score was 7/10, indicating a high symptom burden. Hematological findings included anemia (hemoglobin: 7.2 g/dl) and neutrophilic leukocytosis. She was normotensive and non-diabetic. Despite being aware and focused, she was too weak and unable to move because of severe discomfort and swelling in her right upper half of the body, which forced her to sit in a fixed position. Therefore, imaging was not done.
Management began with intravenous morphine, adjusted from oral 30 mg/ day (previously getting) to injectable 15 mg/day as 4 hourly doses for pain control. Initial wound care included copious irrigation with saline mixed with injection metronidazole, which facilitated removal of foul smell and also small larvae. We made a team of 4 by 2 doctors and 2 nurses to do her dressing. Larger maggots were extracted manually with sterile forceps while she was in sitting position and pain was relieved with morphine injection. Inside those gaping wounds a dense swarm of maggots was writhing and their pale, segmented bodies were slicking with discharge and blood. The flesh squelched with every twitch as the larvae were burrowing deeper. Turpentine wash was also applied, and the wounds were dressed with petroleum gauze to suffocate remaining larvae. On the first day, approximately 150 larvae were removed. Pharmacological treatment included oral flucloxacillin 500 mg every 6 hours for 7 days, oral ivermectin 12 mg daily for 3 days, oral albendazole 400 mg twice daily for 3 days, injectable dexamethasone 16 mg daily, and transfusion of 3 units of red cell concentrate.
On the second day, more than 450 larvae were meticulously removed during a dressing session that lasted more than 5 hours. Dressing process was same as the previous day. That day number of small larvae were numerous. Throughout the process, she was at sitting position and was co-operative. She was on morphine and by the end of the day her pain reduced markedly. She also reported symptomatic improvement with pain score reduced to 5/10 and ESAS to 4/10. She was able to lie on her left side for the first time in several weeks! On day 3, 47 additional larvae were extracted, her pain reduced further to 2/10, and She could lie on her left side for the first time in a month! She also expressed substantial emotional relief. To her, those maggots were not only biting insects causing severe pain, also the reason that made her feel dirty, isolated and worthless to the society. Getting relieved from those maggots means a lot to her.
Despite symptomatic improvements, the patient’s condition deteriorated by day five. Venous access became increasingly difficult, and her vital signs declined. Her intake reduced, sometimes drowsy and consciousness was fluctuating. She was put on intravenous fluid. We were managing her in the ward where she died peacefully later on that day. Although she died, her son expressed deep gratitude for the care provided, stating that the interventions allowed him to witness his mother die in dignity, free from the distress and stigma associated with her wounds (Figures 1 and 2).

Discussion
Myiasis is a neglected parasitic infestation, particularly in tropical regions, and remains underreported in many low- and middle-income countries (LMICs) such as Bangladesh. While Musca domestica is the most prevalent fly species in Bangladesh, and Chrysomya bezziana is commonly implicated in myiasis among livestock,
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data on the specific entomological agents responsible for human myiasis in Bangladesh are notably lacking. To date, no systematic studies have been conducted to document the species of dipteran flies involved in human infestations in this region.
Cutaneous myiasis in patients with malignant wounds is relatively uncommon, especially in breast cancer. Although breast carcinoma is not among the most frequently associated malignancies with myiasis, a number of case reports have documented the development of myiasis in fungating breast tumors.3,8 Malignant wounds provide an ideal environment for fly oviposition and larval proliferation due to the presence of necrotic tissue, purulent exudates, blood, and an anaerobic milieu that supports larval development.7-10 In addition to the underlying malignancy, our patient exhibited several risk factors that compounded her vulnerability to infestation: poor socioeconomic status, lack of stable caregiver support, severe lymphedema impairing self-care, and residence in a densely populated, unhygienic urban slum.
Upon admission, the patient was promptly initiated on local wound care and systemic treatment. About 450 larvae were removed on the second day, representing a significant increase from the previous day (~150 larva) and likely reflecting enhanced larval migration induced by petroleum- and turpentine-based occlusive dressing. Manual removal of larvae combined with chemical suffocation proved effective, as evidenced by a 91% reduction in maggot count by day three. The study has shown that symptomatic relief typically follows removal of larvae.
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Systemic antiparasitic therapy included oral ivermectin (12 mg daily), which has been demonstrated to be efficacious at doses of 150 to 200 mcg/kg, with some studies supporting higher doses up to 300 mcg/kg for severe infestations.12,13 In this case, the prescribed dose was consistent with the patient’s estimated body weight (62 kg), supplemented with albendazole which has been used in a study and shown to be effective
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and broad-spectrum antibiotics (flucloxacillin) to manage secondary bacterial infection.
Despite clinical improvement in pain, malodor, and wound-related symptoms, facial and neck edema remained unchanged, likely due to suspected superior vena cava obstruction (SVCO), a common complication in advanced thoracic malignancies.
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She didn’t have any symptoms like cough or engorged vein. Unfortunately, due to her frail condition and financial limitations, no imaging could be performed to confirm SVCO. Similarly, entomological identification of the larvae species was not feasible due to the lack of laboratory referral.
Assessment using the Edmonton Symptom Assessment System (ESAS)—which evaluates 9 core symptoms in cancer patients including pain, fatigue, nausea, depression, and dyspnea—revealed substantial improvements in several domains by the third day of admission. Notably, pain, appetite, well-being, and dyspnea improved markedly, indicating good tolerability and efficacy of the integrated palliative and anti-maggot regimen.
Although inferential statistical analysis was not feasible in this single-patient case report, the observed reductions in pain (10/10-2/10) and ESAS score (7/10-4/10) represent clinically meaningful improvements, exceeding established minimal clinically important differences. These changes were associated with improved comfort and reduced distress, aligning with the core goals of palliative care. Thus, the findings demonstrate clear clinical significance despite the absence of P-values.
However, symptoms such as anxiety, tiredness, and depressed mood remained unchanged, likely reflecting persistent psychosocial distress related to her illness trajectory and socioeconomic context. Importantly, her morphine dose of 15 mg/day remained stable throughout the admission period, suggesting adequate analgesic control.
Although the patient succumbed on the fifth day of admission, her clinical course illustrates the potential for short-term symptomatic relief and dignity-preserving care, even in advanced stages of disease. With a Palliative Performance Scale (PPS) score of 30% on admission and evidence of terminal decline, death was anticipated. Nevertheless, palliative intervention enabled her to experience reduced pain, alleviated her sense of impurity, and partial restoration of function by enhancing mobility in her final days. Her family, particularly her eldest son, expressed gratitude for the opportunity to say goodbye in a less distressing and more humane environment—an outcome often denied to patients in similar circumstances.
This case illustrates how stigmatization and misattribution of illness to “divine punishment” can significantly hinder palliative care by increasing psychosocial distress and limiting social support. Addressing these cultural and social barriers is integral to holistic palliative care. Even limited community education may reduce stigma, promote compassion, and support dignity-focused, patient-centered care at the end of life.