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A 21 year old heterosexual man, living in the urban area of São Goncalo, presented to the sexually transmitted diseases (STD) clinic at the Universidade Federal Fluminense in Niterói, Brazil, complaining of a painful penile lesion. The lesion had started 1 month previously as an itchy and painful small nodule on the glans penis. After a few days, the patient reported that a blood stained serous exudate began to discharge from an opening that had appeared within the lesion. He sought medical assistance at the local health centre as soon as the lesion appeared and was initially treated for presumptive primary syphilis. The patient recalled that, shortly before the appearance of his penile lesion, he had noticed more flies at home than usual. It was his practice to sleep occasionally in the nude and take only quick showers before going to work. He did not have a regular sexual partner and used condoms irregularly with casual female partners.
Examination of his genitalia demonstrated a clearly demarcated hyperaemic area of 1x2 cm adjacent to the urethra (fig 1). The lesion contained a 3 mm diameter orifice from which serohaemorrhagic material could be expressed with compression of the glans penis. Through the orifice, it was possible to observe a larva moving around inside the lesional cavity. It was not possible to determine whether there was one larva or more as manipulation of the glans penis was very painful for the patient. There was no associated lymphadenopathy.
Glans penis showing the posterior aspect of the larva within the lesional orifice.
An attempt was made to prevent the larva from breathing by obstructing the orifice with 10% xylocaine gel which also provided local anaesthesia. Despite waiting for 1 hour, the larva failed to migrate out of the lesion and so an attempt to encourage it to leave the lesion was made by compression of the glans penis. This procedure was very painful for the patient and so he was given a local 0.5 ml subcutaneous injection of 1% lidocaine. To make the procedure easier sterile surgical scissors were used to carefully open the orifice by a further 2 mm. Thereafter, a continuous manual pressure on the gland penis resulted in the expulsion of one larva from the lesional...