Extensive debridement and 6+ weeks of antibiotics were effective in treating cerebral myiasis, leading to survival despite severe intracranial infection and tissue loss.
Extensive surgical debridement combined with prolonged broad-spectrum antibiotics and antiparasitics can lead to survival in rare, typically fatal cases of cerebral myiasis.
Myiasis refers to infestation of human tissues by fly larvae (Diptera). Cerebral myiasis (CM) is extremely rare. Only eight confirmed cases have been described in the world literature to date. It is fatal, especially when a large area of the brain is affected, and represents diagnostic and therapeutic challenges due to its rarity. We present a case of CM in a patient after neurosurgery. Male patient (42 years), white, single, experiencing homelessness, with epilepsy, alcohol use disorder and crack/cocaine use. On 12/11/2023, after a seizure, he underwent drainage of post-traumatic subdural hematoma. After discharge, he did not attend scheduled outpatient follow-up. On 04/26/2025 he was referred from an urgent care unit to the emergency department with scalp myiasis (220 larvae removed). CT showed right frontoparietal craniotomy, burr holes and bone discontinuity, with multiple small hypoattenuating images associated with gas foci, suggesting the presence of larvae in brain parenchyma. In the operating room, extensive dehiscence of the surgical wound with intracranial myiasis, bone defect and extensive osteomyelitis was observed, with foul-smelling brownish purulent discharge and exposure of areas of necrotic dura mater. Excision of necrotic tissue, removal of larvae from the brain surface and subdural purulent material were performed and sent for culture and histopathology. Cultures grew Staphylococcus aureus and Staphylococcus epidermidis. Histopathology reported: “material compatible with myiasis and material from drainage of right frontal abscess with chronic xanthomatous inflammatory process with acute suppurative flare and fibrin deposition in connective tissue”. A second surgery was performed on 05/05/2025 for debridement and another on 05/28/2025 for drainage of brain abscess. He received ivermectin, meropenem and vancomycin for 10 weeks, surviving with motor and cognitive sequelae. An important risk factor includes neglected wounds. Brain infestation by fly larvae triggers an inflammatory response, leading to tissue damage and potentially fatal complications. Mortality is high, with 6 of 7 reported cases dying from the disease. Larval infestation may have a protective effect against bacterial infections and allow greater tolerance to delays in treatment. Extensive debridement down to healthy brain tissue followed by 6 or more weeks of broad-spectrum antibiotics is effective in managing this condition and can lead to survival.
Gonsalez et al. (2026) studied this question. Extensive debridement and 6+ weeks of antibiotics were effective in treating cerebral myiasis, leading to survival despite severe intracranial infection and tissue loss.