International Journal of Surgery Case Reports 86 (2021) 106334

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Saving diabetic foot ulcers from amputation by surgical debridement and

maggot therapy: A case report
Kazem Hajimohammadi a, 1, Naser Parizad b, 2, Amireh Hassanpour c, 2, Rasoul Goli d, *
a
Imam Khomeini Teaching Hospital, Urmia University of Medical Sciences, Urmia, Iran
b
Patient Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
c
Department of Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran
d
Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: A diabetic foot ulcer (DFU) is one of the major diabetes complications that may lead
Diabetic foot to limb amputation. Amputation can have profound physical and psychological effects on an individual's life.
Larva Nowadays, the prevention of limb amputation and treatment of DFUs are known as the major health challenges.
Debridement
Case presentation: The present case report is of a 72-year-old woman with a 20-year history of type 2 diabetes who
Amputation
Case report
has had asymmetrical and superficial DFUs with sizes of 6 × 5 cm and 3 × 3 cm on the heel and the sole of the
right foot, respectively. The ulcers were infected by S. aureus and E. coli. The patient had been hospitalized
several times for receiving treatment, and not only the ulcers had not been healed, but also they had considerably
extended so that the risk of foot amputation had been greatly increased. The patient was transferred to our
wound care service. After conducting one session of surgical debridement, the patient underwent ten sessions of
maggot therapy (one session every two days) using sterile Lucilia sericata. After about six months, the patient's
DFUs were completely healed.
Clinical discussion: DFU can affect a patient's quality of life and lead to infection, sepsis, amputation, and even
patient death. Therefore, using effective treatment approaches is very important for the management of DFUs.
Conclusion: The combined use of surgical debridement and maggot therapy is a safe and effective method for
improving diabetic foot ulcers and preventing amputation.

1. Introduction increased from 1.5 to 3.5 cases per 1000 patients with diabetes [3].
Lower limb amputation can lead to disability, increased length of hos­
One of the most serious and costly complications of diabetes is the pital stay, and premature death [5].
refractory and non-healing diabetic foot ulcer (DFU) [1]. DFU can lead There are many conventional and modern methods for managing
to infection, gangrene, necrosis, and skin defects in all layers from the DFUs and preventing amputation, including antibiotic therapy, necrotic
distal to proximal areas of the body [2]. DFU can be caused by a tissue debridement, wound dressing, Negative Pressure Wound Therapy
defective healing process resulting from intrinsic (neuropathy, vascular (NPWT), Hyperbaric Oxygen Therapy (HBOT), stem cell-based therapy,
disorders, and other systemic effects of diabetes) and extrinsic factors growth factor therapy, and Maggot Debridement Therapy (MDT) [6,7].
(wound infection, callus formation, and high-pressure injection) [3]. The single use of different methods may not be considerably efficient
Approximately 20% of patients with diabetes refer to the medical cen­ and cause pain and mechanical damage to healthy underlying tissues
ters with the chief complaint of DFU [2]. It is estimated that about [3]. In this regard, MDT is an effective method for treating DFUs and
15–34% of patients with diabetes suffer from DFU, 20% of moderate to preventing foot amputation in patients with diabetes [8].
severe forms of which may eventually lead to foot amputation [1,4]. MDT, also known as larval therapy, refers to the medical use of fly
Over the last decade, the yearly rate of DFU-related amputation has larvae (under sterile conditions) to treat refractory DFUs [9]. The main

* Corresponding author at: Nursing and Midwifery Faculty, Campus Nazlu, 11 KM Road Seru, Urmia, West Azerbaijan 575611-5111, Iran.
E-mail addresses: [email protected], [email protected] (R. Goli).
1
Imam Khomeini University Hospital-Ershad Ave-Modarres Blvd, Urmia, West Azerbaijan, Iran.
2
Nursing and Midwifery Faculty, Campus Nazlu, 11 KM Road Seru, Urmia, West Azerbaijan, Iran, Postal Code: 575611-5111.

https://doi.org/10.1016/j.ijscr.2021.106334
Received 11 July 2021; Received in revised form 19 August 2021; Accepted 21 August 2021
Available online 25 August 2021
2210-2612/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
K. Hajimohammadi et al. International Journal of Surgery Case Reports 86 (2021) 106334

mechanism of MDT is to reduce the bacterial burden of the infection site Table 1
through the digestion of bacteria, production of antibacterial secretions, Patient's laboratory data on admission.
and destruction of biofilms [10]. The effectiveness of Lucilia sericata Urine analysis (UA) Cell blood count (CBC) Biochemistry
larvae has been proven as an influential factor in MDT, disinfection, and
Color: yellow WBC: 22500 uL BUN: 14.8 mg/dl
improvement of DFU healing processes [3]. Following the successful use Appearance: semi-clear RBC: 4240000 uL Creatinine: 0.9 mg/dl
of MDT in various countries, especially the United States and Europe, the PH: 5 HGB: 10.2 g/dl Urea: 40.9 mg/dl
United States Food and Drug Administration (FDA) has approved the Specific gravity: 1013 HCT: 32.9% Calcium: 8.70 mg/dl
medical use of Lucilia sericata larvae [11]. Protein: negative MCV: 77.6 fL Phosphorous: 4.9 mg/dl
Sugar: negative MCH: 24.1 pg Sodium: 130 mEq/dl
Refractory DFUs do not readily respond to standard pharmacological Blood: negative MCHC: 31 g/dl Potassium: 3.9 mEq/dl
therapies, and the prevention of DFU-related amputation is of para­ Urobilinogen: negative PLT: 548000 uL Blood sugar: 644 mg/dl
mount importance since limb amputation can have a significant impact Ketone: negative Neutrophils 92.2% LDL: 288 mg/dl
on an individual's life [5,10]. This case report is of a female patient with Cast: not seen Lymphocytes 6.5% HDL: 37 mg/dl
Bacteria: few ESR 1 h 120 mm/h Cholesterol: 195 mg/dl
DFUs who was a candidate for amputation, although she recovered
WBC: 3–5 Serology Triglycerides: 130 mg/dl
using surgical debridement and MDT. RBC: 0–1 CRP: positive(+3) HemoglobinA1C: 7.5%

2. Case presentation
Table 2
The patient was a 72-year-old woman from the Armenian minority
The results of the patient's wound culture.
living in Urmia city who had a 20-year history of type 2 diabetes, which
Wound culture Results
led to the formation of DFUs on the heel and sole of her right foot four
years ago. The patient was from a family with low socioeconomic status Culture Staphylococcus aureus
and only had primary education. She has also been sewing in a workshop Sensitive Imipenem - Meropenem - Ceftriaxone
Resistant Trimethoprim-Sulfamethoxazole
for 25 years. She had uncontrolled diabetes and also reported a history
Intermediate Clindamycin - Ciprofloxacin
of hypertension on physical examinations. To control her blood sugar WBC 3–5
level, she had undergone a pharmacological treatment with metformin RBC 2–3
500 mg tablet three times a day (TDS). In addition, Losartan 40 mg Bacteria Moderate
tablet had been prescribed for her hypertension twice a day (BID). The
patient had a family history of diabetes and hypertension. She denied
antibiotics, including Meropenem 1 g TDS, Clindamycin 600 mg BID,
any history of drug or alcohol abuse, although she smoked a pack of
and Vancomycin 1 g BID. Furthermore, the patient's blood sugar level
cigarettes a day. No pathological findings were indicated on neurolog­
was checked using a glucometer every 6 h, and the insulin administra­
ical examinations. Despite that the patient had been hospitalized several
tion protocol was performed using regular insulin. In addition, the levels
times for receiving DFU treatment, she had not recovered. This case
of blood glucose were also controlled using Neutral Protamine Hagedorn
report was reported according to the SCARE 2020 Guidelines to ensure
(NPH) insulin (subcutaneous injection of 16 units in the morning and 8
the quality of reporting. [12].
units in the evening).
The patient had referred to Imam Reza Hospital in Urmia, Iran on 24
The osteomyelitis was examined in the patient's right leg by Color
July 2020 with a chief complaint of persistent fever and vomiting. The
Doppler Imaging (CDI) and Magnetic Resonance Imaging (MRI). The
patient was admitted with a diagnosis of sepsis caused by a DFU infec­
findings of CDI showed no signs of Deep Vein Thrombosis (DVT) in the
tion. Upon arrival to the emergency department, the patient's vital signs
right lower limb. However, imaging examination of the right lower limb
were as following: 39.2 ◦ C, Respiration Rate: 18 bpm, Pulse Rate: 112
showed numerous small and calcified atheroma that had led to multiple
bpm, Blood Pressure: 150/95 mmHg. The patient had asymmetrical and
arterial stenoses. The findings of the MRI were as follows:
superficial DFUs with sizes of 6 × 5 cm and 3 × 3 cm on the heel and the
sole of the right foot, respectively (Fig. 1). Moreover, some of the pa­ “Soft tissue swelling was se en at the dorsal and plantar aspect of the foot.
tient's laboratory data on admission are presented in Table 1. There is an abnormal sign (bone marrow edema) associated with adjacent
The culture antibiogram obtained from DFUs showed drug resistance soft tissue swelling in the cuboid, talus, navicular, calcaneus, and pha­
to S. aureus and E. coli (Table 2). The patient received intravenous (IV) langes of 2nd finger.”

Fig. 1. Patient's DFUs before the beginning of MDT.

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K. Hajimohammadi et al. International Journal of Surgery Case Reports 86 (2021) 106334

Unfortunately, the patient did not recover from DFU using conven­ author) who was trained and certified in this field. Furthermore, after
tional methods, although she received treatments including antibiotic the completion of MDT sessions, the patient's DFUs were re-stimulated
therapy and normal saline dressing (TDS). The patient was asked for using mechanical debridement and normal saline, so that all the dead
orthopedic consultation, based upon which she became a candidate for tissues were removed again and the granulation tissues appeared
right foot amputation. The patient withheld consent to the amputation (Fig. 3). The patient's DFUs had partially healed on 16 October 2020
and was then referred to our wound care service. Moreover, the patient (Fig. 4) and closed three months after the intervention. After treatments
was bedridden at this stage. were done with MDT in 3 weeks, the silver-containing dressing was
Concerning the presence of necrotic and infectious tissue, surgical applied to the wound by a trained nurse for five months to make gran­
debridement of DFUs was initially performed by a surgeon on 18 August ulation tissue grow faster and promote the healing process. The patient
2020. Infected living and non-living tissues were isolated from the was discharged from our wound care service with a good general health
wound bed. This action causes the release of Platelet-Derived Growth condition (Fig. 5). Before discharging the patient, she was instructed to
Factors (PDGFs), which can improve wound healing and provide a avoid placing excessive pressure on the tissue and be on a crutch or
suitable environment for it. PDGF begins inflammatory reaction by wheelchair until the completion of recovery. Offloading is important for
stimulating chemotaxis and mitogenicity abilities of macrophages, DFU healing. Moreover, the patient was educated about the complica­
neutrophils, fibroblasts, and smooth muscle cells to the site of the wound tions of the procedures after the intervention and their warning signs,
[13]. Then the larvae of L. sericata were prepared under sterile condi­ and how to manage them. No adverse effects were presented during or
tion, and the patient underwent MDT. These larvae consume dead tissue after therapeutic intervention. The patient's DFUs healed completely
and bacteria at the wound site and secrete antimicrobial enzymes that after about six months (Fig. 6) and the patient declared that “I am scared
improve wound healing. MDT was performed in four stages of wound of losing my leg, but I have completely recovered with the proper
preparation, applying larvae to the wound, hydrocolloid dressing, and therapeutic procedure.”
removing larvae after 48 h (Fig. 2). Wound preparation was done by
placing the surgical drape on the patient's wound and irrigating it with 3. Discussion
physiological saline. At each phase of the intervention, the patient was
inquired a query about tolerating the maggot therapy and continuing the Severe DFU can affect a patient's quality of life and lead to infection,
intervention every twenty minutes. If the response was “yes,” the sepsis, amputation, and even patient death. Therefore, using effective
intervention was continued, but if the response was “no,” the inter­ treatment approaches is very important for the management of DFUs
vention was stopped. Overall, ten sessions of MDT were conducted (one [2]. Nowadays, regarding the emergence of antibiotic-resistant bacteria,
session every 48 h). The procedures were performed by a nurse (first many physicians have turned their attention to the use of maggot
therapy [14]. The FDA approved the use of this method for medical
purposes in 2004 [11]. MDT is also applied to treat health conditions,
including other types of diabetic ulcers, bedsores, burns, carbuncles,
abscesses, and boils where other treatment methods are not advanta­
geous [9]. MDT is a very simple and relatively cost-effective treatment
approach so that, unlike antibiotic therapy, it causes no dangerous side
effects. However, some patients may encounter itchy skin, such that
something crawls on the skin. Regarding the stimulation of the nervous
system resulting from larvae distension, some patients may experience
different levels of pain, which can be relieved by removing the larvae at
the right time or using medication. Anxiety is another complication
caused by MDT. Therefore, it is very important to psychologically pre­
pare the patient before the procedure begins [15]. MDT can be easily
performed by trained healthcare professionals, even without the need
for hospitalization.
The present case report was of a female patient who had a 20-year
history of uncontrolled type 2 diabetes, which had led to the forma­
tion of DFUs. The patient had a poor general health condition, and her
DFUs were not treated using routine hospital treatment methods (IV
antibiotic therapy and normal saline dressing) so that she was at a
considerable risk of foot amputation.
Given that the patient was from strata with low socioeconomic status
and had no underlying disease other than hypertension and that there
was no evidence of osteomyelitis, she was found to be very susceptible to
the implementation of MDT. In this study, necrotic tissues were first
removed surgically using a new approach, and a suitable environment
was then provided for wound healing. After conducting surgical
debridement, ten sessions of MDT were performed (one session every 48
h) using sterile L. sericata. The patient's DFUs miraculously healed after
about six months, and the patient was also discharged from our wound
care service with a good general health condition.
In line with our study results, Parizad et al. showed that the com­
bined use of MDT, surgical debridement, silver dressing, and NPWT is
very effective in treating refractory DFUs [16]. In a clinical trial, Mal­
ekian et al. concluded that MDT using sterile maggots of L. sericata is a
safe and effective method for treating the DFUs infected with Staphylo­
coccus aureus and Pseudomonas aeruginosa [10], which is consistent with
Fig. 2. The application of MDT for repairing the patient's DFUs. our results. Siavash et al. and Dehghan et al. also revealed that MDT, as a

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K. Hajimohammadi et al. International Journal of Surgery Case Reports 86 (2021) 106334

Fig. 3. The patient's DFUs after the completion of MDT sessions.

new treatment approach, is effective in treating atypical DFUs that are

refractory to conventional therapies [17,3]. In line with the results of
our study, Mirabzadeh et al. showed the MDT as an acceptable and easy-
to-use method for the treatment of complicated and extensive DFUs
[18]. Most studies in this area have demonstrated the effectiveness of
MDT in improving DFUs. However, the findings of this case report boldly
indicated that MDT could be also utilized in patients who have
complicated and non-healing DFU and are candidates for foot
amputation.

4. Conclusion

Foot amputation causes irreparable damage to the patient's perfor­

mance and quality of life. Therefore, new and effective treatment
methods are required to prevent foot amputation. This case report study
was shown that the combined use of surgical debridement and MDT is a
safe and effective approach to improve the healing of DFUs and prevent
foot amputation. Consequently, wound care teams are recommended to
use this method to accelerate the healing process and prevent foot
amputation.
Fig. 4. The patient's DFUs one month after the intervention.

Sources of funding

None.

Fig. 5. The patient's DFUs three months after the intervention.

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K. Hajimohammadi et al. International Journal of Surgery Case Reports 86 (2021) 106334

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

None.

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