Notes on Practice: Hemophilia and Maggots: From Hospital Admission to Healed Wound

Background

   Hemophilia A is a congenital bleeding disorder where factor VIII, a protein necessary for normal coagulation, is present in decreased amounts or is completely absent in the blood stream. Of patients with this disorder, 21% to 33% will develop an inhibitor or antibody against factor VIII,¹ preventing the use of conventional treatment (replacement of the factor VIII protein).

Historically, people with high titer inhibitors are treated with bypassing agents. These infusion products bypass the requirement for factor VIII or IX in the coagulation chain.¹ However, bypassing agents are not as reliable in achieving hemostasis as factor VIII and their effect cannot be adequately monitored with specific laboratory tests,² especially in a surgical setting. Therefore, non-invasive procedures should be considered whenever possible and surgical intervention should be used only as a last resort. Traditional methods of medical treatment may not be possible and alternative treatments must be sought.

   One such alternative is maggot debridement therapy (MDT) - the medical use of live maggots (Phaenicia sericata, green blowfly larvae) for cleaning nonhealing wounds. From as early as the 1500s, physicians noted that soldiers with worm-infested wounds tended to heal better than those with non-infested wounds. William Baer, an orthopedic surgeon at Johns Hopkins University, Baltimore, Md., was the first physician in the US to actively promote maggot therapy; his results were published posthumously by his colleagues in 1932. The use of maggots lost favor after WWII with the introduction of antibiotic therapy and the improvement of surgical techniques and was used only occasionally during the 1970s and 1980s when antibiotics, surgery, and other modalities of modern medicine failed.³

   Sherman et al⁴ performed prospective controlled studies to examine the utility of MDT in the treatment of soft tissue wounds. They found that medicinal maggots have three actions: They debride wounds by dissolving necrotic tissue, they disinfect the wound by killing bacteria, and they stimulate wound healing with proteolytic enzymes and secretions of such substances as calcium carbonate, allantoin, and urea.⁴ As such, this modality was shown to be a viable treatment option for many patients with necrotic or nonhealing wounds. The controlled studies demonstrated that MDT debrided wounds faster than other nonsurgical modalities, including hydrocolloid pads, topical disinfectants (one-fourth strength Dakin's solution, acetic acid), and bacitracin saline wet-to-dry gauze packs. Subsequent case reports support these findings.

History

   Thirty-nine-year-old Mr. J was admitted to the hospital in September 2002 with a necrotic ulcer of his right foot, complicated by a history of severe factor VIII deficit hemophilia with a high titer inhibitor and hepatitis C, contracted several years before as a result of using blood products to control his hemophilia-related bleeding. Because he was involved in a motor vehicle accident when he was 20 that caused a non-union of his left femur, he uses a wheelchair full time for mobility. Mr. J described his current pain at a level 8 to 10. On admission, wound cultures showed no bacterial growth to explain his symptoms. Magnetic resonance imaging ruled out osteomyelitis.

Diagnosis

   The probable cause of Mr. J's foot ulcer was a bite from an aggressive house spider (Tegenaria agrestis).⁵ The site was initially painful and gradually became necrotic. This process occurred over approximately 2 months, with increasing pain and necrosis the week before admission. On admission, the wound appeared to be a full-thickness skin loss involving the entire medial aspect of the midfoot, around the sole to the lateral aspect of his foot (see Figures 1 and 2). After consulting a general surgeon and an orthopedic surgeon, both of whom recommended surgical debridement, the patient insisted that clinicians contact his hematologist and hemophilia nurse specialist. He was not a candidate for surgery because of his high titer inhibitors that required treatment with bypassing agents.

Treatment

   Mr. J was given morphine and acetaminophen (500 mg) and oxycodone hydrochloride (5 mg) and the pain was reduced to level to 3 to 4. Mr. J's hematocrit on admission was 37.6 and dropped to 27.3 by day 7 of treatment. Initially, whirlpool therapy was ordered, followed by normal saline dressings to be changed every shift, but Mr. J refused whirlpool therapy because of his pain and because frequent dressing changes increased bleeding from the wound (also, by this time he also had a hemarthrosis of his left shoulder). Bleeding from his foot, secondary to his hemophilia, was controlled with Surgicel (Johnson & Johnson Wound Care, Somerville, NJ) and compression dressings. At this point, he received an infusion of recombinant factor VIIa, a bypassing agent. Debridement was necessary due to the severity of the wound, but his condition ruled out surgery. Maggot therapy was determined to be a viable alternative by the wound care nurse in consultation with the primary care physician. The maggots arrived from the supplier 24 hours after they were ordered. The larvae are purchased disinfected - ie, eggs are chemically disinfected with Lysol, sodium hypochlorite, or another agent - and then placed in sterile containers, so the newly hatched maggots remain disinfected.

   To prepare the wound for the maggots, a hydrocolloid dressing was applied around the wound edges. Five to eight disinfected maggots per square centimeter of wound surface were placed in the wound bed. Moist saline gauze then was applied. A cage-like dressing using nylon, chiffon, or similar mesh is recommended to keep the maggots contained⁴ but in this case Medipore tape (3M Health Care, St. Paul, Minn.) was used because it is porous and remains in place better than some other products. The dressing was moistened with normal saline every 4 hours to keep the maggots moist. The satiated maggots were replaced every 48 to 72 hours. After three changes (6 days), the maggots started migrating out of the wound. Debridement was completed in an additional 7 days using an enzymatic debridement product (Panafil, Healthpoint, Fort Worth, Tex.) (see Figures 3 and 4).

   Before discharge from the hospital, Mr. J's dressing type was changed to SilvaSorb (Medline, Mundelein, Ill.) with the thought that ionic silver would help control the bioburden and extend wear time, which would mean fewer outpatient visits. This product also maintains a balanced moisture level and is nonadherent.

   To closely monitor Mr. J's progress, dressing changes were ordered three times per week by his physician. The scabs and exudates that collected around the wound edges were soaked with normal saline and carefully and slowly debrided as they loosened. By the beginning of December, the wound was closed (see Figures 5 and 6) and the patient was discharged from the outpatient clinic.

   The cost of the maggots to the facility was $125.00, compared to a minimum cost for outpatient surgery of $1,680.00 (not including laboratory monitoring and factor replacement that would have been required by a surgical procedure). In this case, MDT was an inexpensive, effective, non-surgical alternative for debriding the patient with hemophilia and a high titer inhibitor.

1. Goodnight SH, Hathaway WE. Disorders of Hemostasis and Thrombosis: A Clinical Guide, 2nd ed. New York, NY: McGraw-Hill;2001:127-137,192

2. Beutler E, Lichtman MA, Coller BS, Kipps TJ, Seligsohn U. Williams Hematology, 6th ed. New York, NY: McGraw-Hill;2001:1650.

3. Maggot debridement therapy. Available at:www.ucihs.uci.edu/com/pathology. Accessed March 1, 2004.

4. Sherman RA. Maggot debridement in modern medicine. Infect Med. 1998;15(9):651-656.

5. Symptoms, diagnosis and treatment of the bite of aggressive house spider (compared to brown recluse spider bite. Available at: www.Montana.edu/wwwpb/home/spider2.html.