بررسی تاثیر لارودرمانی بر روند بیماری سارکوئید تکسمیان

نوع مقاله : عوامل عفونی - بیماریها

نویسندگان

1 گروه بیماری های داخلی و کلینیکال پاتولوژی، دانشکده دامپزشکی، دانشگاه ارومیه، ارومیه، ایران

2 گروه علوم درمانگاهی، دانشکده دامپزشکی، دانشگاه تبریز، تبریز، ایران

3 گروه حشره شناسی پزشکی و کنترل ناقلین، دانشکده بهداشت، دانشگاه علوم پزشکی تهران، تهران، ایران

چکیده

زمینه مطالعه: پوست بزرگترین ارگان بدن است و در زیبایی و ارزش اقتصادی اسب اهمیت ویژه ای دارد. سارکوئید شایعترین تومور پوستی در اسب می باشد. تاکنون از روش های مختلفی برای درمان سارکوئید استفاده شده ولی هنوز روش درمانی کاملاً موثری برای آن ارائه نشده است. استفاده از لارودرمانی به عنوان یک روش درمانی جایگزین، در پزشکی و دامپزشکی در حال گسترش است و موفقیت های قابل توجهی در درمان ضایعات و بیماری های پوستی مثل زخم های دیابتیک انسان، ضایعات سُم اسب داشته است. گزارش های استفاده از لارودرمانی برای درمان عوارض ضایعات توموری در انسان امیدوارکننده است.
هدف : در مطالعه حاظر هدف اصلی ما بررسی اثرات لارو درمانی بر ضایعات سارکوئید در اسب ها بود.
روش کار: در این مطالعه از میان اسب های مورد بررسی 4 مورد با معاینات بالینی و آزمایشات آسیب شناسی، مبتلا به سارکوئید تشخیص داده شدند و از روش لارودرمانی برای درمان ضایعات سارکوئیدی بهره گرفته شد. برای این مطالعه از لاروهای استریل استفاده شد. برای استقرار لارو ها بر روی ضایعه، از روش لانه گزینی در لانه مصنوعی استفاده شد. تعداد لاروهای به کار برده شده برای هر سانتیمتر مربع حدوداً 10 لارو بود.
نتایج: نتیجه درمان در 2 مورد از اسب ها رضایت بخش بود و حتی در یک مورد ضایعه تا حدود زیادی محدود شد و پیدایش پوست سالم شروع شد. در دو مورد نتیجه مثبتی دیده نشد که احتمالا به علت وسعت ضایعه و ناپایداری لاور ها بر روی آن بود.
نتیجه گیری نهایی: با توجه به نتایج به دست آمده به نظر میرسد لارودرمانی برای درمان ضایعات نکروتیک سارکوئید موثر می باشد ولی لازم است مطالعات بیشتری در این زمینه انجام گیرد.

کلیدواژه‌ها


Introduction

 

The appearance of horse skin is of particular importance because of its impact on its economic value. The incidence of skin tumors in horses is relatively high (Knottenbelt, 2009, 2012), and sarcoid is known as the most common skin tumor in horses. This neoplasm is a fibroblastic tumor that is found in both males and females in different breeds of equine, including donkeys and mules. Sarcoid tumor has a great ability to invade the local tissue though it usually does not have a true nature of metastasis (Funiciello and Roccabianca, 2020). Tumors such as squamous cell carcinoma (SCC), papilloma, and fibroma are very similar in appearance to sarcoid and may be confused with it (Jaglan et al., 2018). The onset of sarcoid tumors is often followed by trauma and physical injury and can manifest itself in the healing wounds of horses (Knottenbelt, 2009). In most parts of the world, equine sarcoids are associated with bovine papillomavirus 1 (BPV 1), except in Canada where it is associated with type 2 viruses (Wobeser et al., 2010; Wobeser, 2017). Vascular changes that occur in sarcoid lesions are most likely due to the presence of BPV in the lesions (Martano et al., 2020). One study has shown that there is a familial-genetic predisposition (up to 21%) in the sarcoid disease (Christen et al., 2014). Genetic studies have shown duplication and deletion in some sarcoid cell chromosomes (Bugno-Poniewierska et al., 2016). A recent study has found some evidence on the influence of miRNA on the pathogenesis and aggressive behavior of equine sarcoid cells (Bogedale et al., 2019).

The epidemiology of equine sarcoid is not well understood due to the lack of demographic data (Wobeser, 2017). The prevalence of equine sarcoidosis in horses has been reported to be between 1-8%. Most sarcoid sites include the head, limbs, neck, and shoulders. Horses in the age range of 0.5 to 31 years are majorly affected with sarcoid lesions, and the disease is most common among Quarter, Thoroughbred, and Arab breeds. Moreover, growing mares are at more risk of equine sarcoidosis compared to others (Wobeser et al., 2010).

the equine skin tumors have been studied in Tehran and East-Azarbaijan provinces of Iran, the most common of which are fibroma (38.4%) and sarcoid (34.8%) in horses (Tolouei Kaleibar et al., 2015). There have also been case reports of sarcoid among Caspian horses, donkeys, and ponies from Iran. In most reports, the lesion was observed in the perineal area (Sakha et al., 2011; Farjani Kish et al., 2014; Saadi et al., 2019).

Clinical sarcoid lesions are divided into six groups in terms of clinical form, including: 1, occult form, 2. wart form, 3. nodular form, 4. fibroblastic form, 5. mixed form, and 6. malignant form (tumor cords in the lymphatic vessels). Milder forms of the tumor, especially if traumatized, can quickly become more invasive (Knottenbelt, 2005). The definitive diagnosis of sarcoid is made by histopathological examination (Knottenbelt, 2009). Although many efforts have been made for many years to find a standard treatment for sarcoid, no effective and reliable method has yet been recorded (Taylor and Haldorson, 2013). Hence, it can be worthwhile to try to find new ways to treat ESD.

Larval therapy is a treatment that uses sterile larvae of fly to treat superficial lesions in humans as well as animals. This method has been used for many years to heal superficial wounds such as war wounds (Fleischmann et al., 2004). In 2003, the US Food and Drug Administration (FDA) approved the method proposed by Dr. Sherman (Sherman, 2003). Today, the most used larvae in larval therapy are Lucilia (Phoenicia) sericata. This fly belongs to the Calliphoridae family and is more popular because it does not have a destructive attachment style to the living tissue (Kenawy and Abdel-Hamid, 2020). Other therapeutic properties have also been mentioned for larval therapy such as antibiotic and anti-biofilm properties, synergy with other antibacterial, antifungal, and anti-inflammatory agents, immune system modulator, angiogenesis stimulator, fibroblast growth regulator, coagulation enhancer, nerve repair, anti-atherosclerosis, and anti-tumor properties (Yan et al., 2018; Sherman et al., 2000; Malekian et al., 2019). The use of larvae in the treatment of infectious and diabetic wounds is much faster and sometimes more effective than conventional treatments. Larval therapy has been started by Dr. Mirabzadeh and his colleagues in Iran for several years and is currently being performed in certain centers in Iran (Mirabzadeh et al., 2017).

Maggot therapy in veterinary medicine is not as well-known as that in human medicine, however many studies have been done. Larval therapy significantly accelerates the rate and extent of recovery in osteomyelitis, secondary infections due to chronic laminitis, navicular bursitis, chronic joint infection, equine canker, collateral cartilage necrosis, panniculitis, ulcers, and abscesses (Bell and Thomas, 2001; Morrison, 2005, 2010; Kočišová et al., 2006; Sherman et al., 2007; Jones and Wall, 2008; Choudhary et al., 2016; Fontenot et al., 2018; Durán et al., 2020).

All in all, there are no reliable studies on the treatment of superficial neoplasms with larval therapy, however hopes have been expressed by various authors (Sherman and Shimoda, 2004; Whitaker et al., 2007). In some reports, larval therapy has been used to treat cancerous lesions (Jones et al., 1998; Lin et al., 2015).

Given that these larvae feed on skin lesions and are known as small surgeons of nature, it seemed that there could be the possibility of a positive effect of this type of treatment as a primary or adjunct treatment to sarcoid. Therefore, the present study was designed and performed to investigate the effect of larval therapy on equine sarcoid disease (ESD).

Materials and Methods

Preparation of Larvae

The larvae used in this study were L. sericata. The larvae were prepared in sterile packages of 200 pieces in special packages from the Larval Therapy Center of Tehran University of Medical Sciences. Air transport was used to transport the larvae to reduce the time it took for the larvae to reach the patient's bed. During the transport of larvae, the package should be kept at 4°C.

Animals

To find horses with ESD, periodic 6-month examinations were performed for skin lesions in the East-Azarbaijan province of Iran. By clinical examination, follow-up of the appearance of lesions, and performing histopathological tests, four horses were diagnosed with equine sarcoidosis which were selected for this study.

Application of Maggots

Larval therapy was performed for each horse at different times, after attracting the attention of horse owners. The lesion was first flushed with normal saline to remove wound exudates and to delineate the tumor border. There are two ways to place the larvae on the wound: the open method and the basket-enclosed method. Depending on the condition and characteristics of the wound, one of these two methods can be used for maggot therapy (Zubir et al., 2020). In this study, direct implantation of larvae at the lesion site (open method) was used.

About 30 minutes before the beginning of maggot-therapy, the larvae were released out of the refrigerator to adapt to the environment. To limit the larval mission to the desired location, a nest-like environment was made for the larvae using tampons and Locoplast adhesive. The nest was formed for small lesions by cutting the middle of several tampons and for large lesions by stacking tampons together. After making the artificial nest wall, the larvae were washed with some physiological normal saline from a special container and passed through a sterile grid to be placed on the nest.

The larvae were gently taken with surgical forceps and placed on the lesion. Next, a piece of sterile mesh was glued to the tampons using the Leucoplast glue. Using a two-meter bandage, a light bandage was applied to the entire nest to absorb both secretions and as a fall that allowed oxygen to the larvae to be used (Figure 1). It should be noted that closing the larval therapy site should not be too tight or too loose since if it is too tight it will put too much pressure on the larvae and will kill them. And if the bandage is too loose, it will cause instability of the artificial nest of larvae and the nest will break with the slightest movement of the animal.

 

After 2-4 days from the beginning of larval therapy, depending on the secretions absorbed by the bandage and the condition of the animal to go along with the larval therapy, the bandage was opened and after washing, the lesion was examined. Based on the results and conditions of the animal, it was decided whether re-larval therapy was necessary or the process should be stopped. If the expected improvement was not achieved in one round of larval therapy, it was repeated with the same actions as for the first time. In this study, clinical observation of the lesion was used to evaluate the effects of larval therapy.

 

Figure 1. Maggot therapy in one of the horses with sarcoid lesions. A: Primary lesion. B: Wash the lesion. C: Rub the zinc oxide cream around of lesion. D: Put a tampon around the lesion. E: Tighten the tampon to the limb. F: Put the larvae on the lesion. G: Grid attaching on the structure. H: Apply a light dressing on the structure of the artificial nest

Results

 

Out of 136 horses examined in 12 equestrian farms, 5 horses were suspected of having sarcoid lesions, in four of which ESD was confirmed by histopathological examination (Figure 2). All ESDs confirmed in the present study were in fibroblastic form. The percentage of ESD diagnosed in the horses in this study was about 3%.

Larval therapy was completed for two ESD cases. Horse number 1 was a 5-year-old stallion of Kurd breed and was white. This horse was kept in the Shabestar area and the conditions of the stables were not good. The lesion was located in the distal part of the right hindlimb. Three days after larval therapy, the dressing was removed and it was observed that

 

Figure 2. One of the histopathology pictures of ESD horses. The proliferation of dermal fibroblast cells and proliferation of collagen fibers are observed in curvilinear and eddy bands. Epithelial components are rarely seen in this image.

the larvae had grown only slightly larger and had died in their secretions. Two more larval therapies were performed for this horse, which resulted in a great improvement after the third round (Figure 3).

 

 

                                     Figure 3. Horse number one before and after maggot therapy

 

 

Horse number 2 was an 8-year-old crossbred chestnut horse that was kept in Gogan city. The location of the lesion was the end of the horse's right forelimb. When the mares were transported, a wound was created at the site for traction, which later became sarcoid. The dressing was removed three days after larval therapy. Even in this case, the larvae had died after a small increase in the secretions. The secretions, in this case, were more than that in the previous case and the lesion itself was completely cleared of necrotic and dead tissues. After larval therapy, signs of healthy skin growth were observed around the lesion. After removing the dressing, larval therapy was performed for the second time, in which no significant changes were observed compared to the first round (Figure 4).

 

 

                                         Figure 4. Horse number two before and after maggot therapy

 

 

In the other two horses with equine sarcoid, there were also lesions in the limbs. In these two horses, due to the greater extent of lesions than the previous two cases, the expected results were not obtained.

Discussion

A field study of 136 horses suspected of having skin lesions in the East-Azarbaijan province of Iran revealed that about 3% of the horses examined for skin lesions had sarcoid lesions. The prevalence of sarcoid in the world has been reported 1-8% in a previous study (Wobeser et al., 2010). In one study, the proportion of equine sarcoid cases from equine tumor lesions was about 34.8% (Tolouei Kaleibar et al., 2015).

The results of larval therapy on equine sarcoid lesions showed that L. sericata larvae could help limit ESD complications by superficial debarment of tumor lesions. Necrotic tissues were well cleared and, in some cases, there was a noticeable change in the size and nature of the lesion. The growth of healthy tissue around the lesion appeared to have been increased.

Different treatments and various surgical procedures including conventional surgical resection, laser, and CO2 surgery, cryotherapy, thermotherapy, radiation therapy, chemotherapy, immunotherapy and local immunomodulation, and antiviral drugs have had relative success in ESD treatment (Taylor and Haldorson, 2013). Expensive and not available methods such as radiation therapy have shown good results in research, however they can be used in a limited number of tumors. Moreover, cryosurgery often requires general anesthesia (Knottenbelt, 2009). However, there is no definitive cure for equine sarcoid (Taylor and Haldorson, 2013).

One of the problems with research on equine sarcoid tumors is that horses are large and expensive animals, therefore research studies on large populations of horses are very rare. Hence, a lot of studies are retrospective (Wobeser, 2017). Some experiments are performed in a laboratory environment (in-vitro) on samples taken from the lesions (Weber et al., 2020).

There are limited studies on the effect of larval therapy on neoplastic lesions. In previous reports, however, good results were not obtained for larval therapy of two equine skin tumors (melanoma and SCC), while a proliferative lesion in horses was completely healed with larval therapy (Lepage et al., 2012).

There are few limited reports on the use of larval therapy for human tumors. In one case, larval therapy was performed for an SCC wound in a human chest. In this case, the odor and appearance of the wound improved after two rounds of larval therapy, but due to pain in the area, larvae therapy was not repeated (Jones et al., 1998). In one report, the use of L. sericata for the treatment of a type of tumor called Kaposi's Sarcoma reduced odor and infection, improved blood flow, and prevented amputation. The author considers the use of maggot-therapy beneficial for malignant wounds and recommends that more studies be done in this regard (Lin et al., 2015). In some cases of cutaneous neoplasms such as SCC, associated with myiasis, the tumor has grown slowly. Fly larvae may have positive effects in controlling the growth of tumor lesions (Hawayek and Mutasim, 2006; Wollina, 2010; Biswas and McNerney, 2016). Our findings are in line with previous human medical findings on some of the cancers.

In one study, the anti-tumor and anti-leukemic properties of fatty acids isolated from larval extract were demonstrated. w-6 PUFA was the most abundant fatty acid in larval extract (Jun-Qing, 2008). In another study, larval extract was shown to inhibit hepatoma H22 through the activated mitogenic protein kinase p38 (p38MAPK) pathway in mice (Zhang et al., 2017). Two recent studies carried out on the extracts from the larvae of another Calliphoridae fly (Chrysomya megacephala) confirmed the antitumor property of larvae.

According to some scientists, studies on horse skin can be considered a model for human skin lesions (Harman et al., 2019). Therefore, our findings can be the basis for the use of maggot-therapy in the treatment of human skin cancers.

One of the challenges in this study was to place the larvae in restless horses. Manipulation of the dressing by the animal, which was performed even after larval therapy, required constant care of the horse. The slight irritation and itching caused by the larvae can also increase the horse's tendency to manipulate the dressing. In previous reports as well, some horses were discomfort during the maggot-therapy (Sherman et al., 2000; Choudhary et al., 2016). In large lesions, as in the case of horse number 4, the dressing was not tightened well and the instability of the artificial nest affected the performance of the larvae on the lesion. In modern larval therapy, the risk of transmitting infectious agents from the larvae to the patient is very unlikely (Ahmadnejad and Kaboudari, 2020). Another concern about larval therapy is how to deal with flies that produce maggots and the larvae used in wounds, which must be compatible with human and environmental standards (Stadler, 2020).

According to the results obtained in the present study, larval therapy seems to be a good modality to remove necrotic tissue of fibroblastic sarcoid lesions. This therapy can also be facilitated by stimulating the regeneration of healthy skin around the sarcoid lesion. However, it is suggested that further studies be performed on the use of larval therapy for treating various forms of sarcoids and even other neoplastic lesions in horses.

Acknowledgments

We thank the horse owners for allowing this treatment to be performed on horses.

Conflict of Interest

The authors declared no conflict of interest.

 

 

 

 

References

 
 
Ahmadnejad, M., & Kaboudari, A. (2020). Maggot therapy-related zoonotic diseases and modern larval therapy solutions to ensure safety. Journal of Zoonotic Diseases, 4(4), 1-8.
Bell, N. J., & Thomas, S. (2001). Use of sterile maggots to treat panniculitis in an aged donkey. Veterinary Record, 149(25), 768-770. [DOI:10.1136/vr.149.25.768] [PMID]
Biswas, S., & McNerney, P. (2016). Myiasis on a Giant Squamous Cell Carcinoma of the Scalp: A Case Report and Review of Relevant Literature. World Journal of Oncology, 7(2-3), 34-39. [DOI:10.14740/wjon966w] [PMID] [PMCID]
Bogedale, K., Jagannathan, V., Gerber, V., & Unger, L. (2019). Differentially expressed microRNAs, including a large microRNA cluster on chromosome 24, are associated with equine sarcoid and squamous cell carcinoma. Veterinary and Comparative Oncology, 17(2), 155-164. [DOI:10.1111/vco.12458] [PMID]
Bugno-Poniewierska, M., Staroń, B., Potocki, L., Gurgul, A., & Wnuk, M. (2016). Identification of Unbalanced Aberrations in the Genome of Equine Sarcoid Cells Using CGH Technique. Annals of Animal Science, 16(1), 79-85. [DOI:10.1515/aoas-2015-0068]
Choudhary, V., Choudhary, M., Pandey, S., Chauhan, V. D., & Hasnani, J. J. (2016). Maggot debridement therapy as primary tool to treat chronic wound of animals. Veterinary World, 9(4), 403-409. [DOI:10.14202/vetworld.2016.403-409] [PMID] [PMCID]
Christen, G., Gerber, V., Dolf, G., Burger, D., & Koch, C. (2014). Inheritance of equine sarcoid disease in Franches-Montagnes horses. Veterinary Journal, 199(1), 68-71. [DOI:10.1016/j.tvjl.2013.09.053] [PMID]
Duran, D., Galapero, J., Frontera, E., Bravo-Barriga, D., Blanco, J., & Gomez, L. (2020). Histological and Immunohistochemical Study of Wounds in Sheep Skin in Maggot Therapy by Using Protophormia terraenovae (Diptera: Calliphoridae) Larvae. The Journal of Medical Entomology, 57(2), 369-376.  [DOI:10.1093/jme/tjz185] [PMID]
Farjani Kish, G., Dehghani Nazhvani, S., Namazi, F., & Jalali, Y. (2014). Penile sarcoid in horse: clinicopathological characteristics with brief literature review. Comparative Clinical Pathology, 23(2), 459-462. [DOI:10.1007/s00580-013-1841-2]
Fontenot, R. L., Crabtree, N. E., Hollier, H. D., Mochal-King, C. A., & Eddy, A. L. (2018). Management of a Traumatic Penetrating Abdominal Wound and Associated Complications in a Horse. Journal of Equine Veterinary Science, 71, 112-119.            [DOI:10.1016/j.jevs.2018.10.010]
Funiciello, B., & Roccabianca, P. (2020). Equine Sarcoid. In Equine Science. Intech Open. [DOI:10.5772/intechopen.91013]
Harman, R. M., Theoret, C. L., & Van de Walle, G. R. (2021). The Horse as a Model for the Study of Cutaneous Wound Healing. Adv Wound Care (New Rochelle), 10(7), 381-399. [DOI:10.1089/wound.2018.0883] [PMID]
Hawayek, L. H., & Mutasim, D. F. (2006). Myiasis in a giant squamous cell carcinoma. The Journal of the American Academy of Dermatology, 54(4), 740-741. [DOI:10.1016/j.jaad.2005.07.012] [PMID]
Hua, Y., Wu, J., & Qian, J. (2008). Inhibitory effect of fatty acids from specifically-cultivated Chrysomya megacephala (Fabricius)(Diptera: Calliphoridae) larvae on tumor cells and HIV-1 integrase in vitro and their ingredient analysis. Acta Entomologica Sinica, 51, 137-142. Available at: http://www.insect.org.cn/CN/Y2008/V51/I2/137
Jaglan, V., Singh, P., Punia, M. et al. (2018). Pathological studies and therapeutic management of equine cutaneous neoplasms suspected of sarcoids. Pharmaceutical Innovation Journal, 7, 96-100. Available at: www.thepharmajournal.com [Accessed October 10, 2020]. [DOI:10.20546/ijcmas.2018.710.047]
Jones, G. and Wall, R. (2008). Maggot-therapy in veterinary medicine. Research in Veterinary Science, 85, 394-398. [DOI:10.1016/j.rvsc.2007.12.006] [PMID]
Jones, M., Andrews, A. and Stephen, T. (1998). A case history describing the use of sterile larvae (maggots) in a malignant wound. worldwide wounds 1, 16-21
Kaleibar, M. T., Eshghi, D., & Helan, J. A. (2015). A survey on the status of equine skin tumors and associated epidemiological factors in Iran. Comparative Clinical Pathology24(6), 1407-1415. [DOI:10.1007/s00580-015-2089-9]
Kenawy, M. A., & Abdel-Hamid, Y. M. (2020). Maggot Therapy “Use of Fly Larvae for Treatment of Wounds”-A Review, Egyptian Academic Journal of Biological Sciences, E. Medical Entomology & Parasitology 12, 1-10.
Knottenbelt, D. C. (2005). A suggested clinical classification for the equine sarcoid. Clinical Techniques in Equine Practice. [DOI:10.1053/j.ctep.2005.10.008]
Knottenbelt, D. C. (2009). Pascoe's principles and practice of equine Dermatology E-Book. Elsevier H. Elsevier Health Sciences: Elsevier Health Sciences. Available at:    https://www.elsevier.com/books/pascoes-principles-and-practice-of-equine-dermatology/knottenbelt/978-0-7020-2881-6 [Accessed October 10, 2020].
Knottenbelt, D. C. (2012). The approach to the equine dermatology case in practice. Veterinary Clinics of North America: Equine Practice, 28, 131-153. [DOI:10.1016/j.cveq.2012.01.004] [PMID]
Kočišová, A., Pistl, J., Link, R., Čonková, E., & Goldova, M. (2006). Maggot debridement therapy in the treatment of footrot and foot scald in sheep. Acta Veterinaria Brno75(2), 277-281.                [DOI:10.2754/avb200675020277]
Lepage, O. M., Doumbia, A., Perron‐Lepage, M. F., & Gangl, M. (2012). The use of maggot debridement therapy in 41 equids. Equine Veterinary Journal44, 120-125. [DOI:10.1111/j.2042-3306.2012.00609.x] [PMID]
Lin, Y., Amin, M., Donnelly, A. F., & Amar, S. (2015). Maggot debridement therapy of a leg wound from Kaposi's sarcoma: A Case report. Journal of Global Oncology1(2), 92.
Maggot Therapy. (2004). (W. Fleischmann, M. Grassberger, & R. Sherman, Eds.). Georg Thieme Verlag. [DOI:10.1055/b-002-54063]
Malekian, A., Djavid, G. E., Akbarzadeh, K., Soltandallal, M., Rassi, Y., Rafinejad, J., ... & Totonchi, M. (2019). Efficacy of maggot therapy on Staphylococcus aureus and Pseudomonas aeruginosa in diabetic foot ulcers: a randomized controlled trial. Journal of Wound Ostomy & Continence Nursing46(1), 25-29. [DOI:10.1097/WON.0000000000000496] [PMID]
Martano, M., Altamura, G., Power, K., Restucci, B., Carella, F., Borzacchiello, G., & Maiolino, P. (2020). Evaluation of hypoxia-inducible factor-1 alpha (HIF-1α) in equine sarcoid: an immunohistochemical and biochemical study. Pathogens9(1), 58.          [DOI:10.3390/pathogens9010058] [PMID] [PMCID]
Mirabzadeh, A., Ladani, M. J., Imani, B., Rosen, S. A. B., & Sherman, R. A. (2017). Maggot therapy for wound care in Iran: a case series of the first 28 patients. Journal of Wound Care26(3), 137-143.            [DOI:10.12968/jowc.2017.26.3.137] [PMID]
Mohd Zubir, M. Z., Holloway, S., & Mohd Noor, N. (2020). Maggot therapy in wound healing: a systematic review. International Journal of Environmental Research and Public Health17(17), 6103. [DOI:10.3390/ijerph17176103] [PMID] [PMCID]
Morrison, S. (2010). Maggot debridement therapy for laminitis. The Veterinary Clinics of North America. Equine practice26(2), 447-450.         [DOI:10.1016/j.cveq.2010.06.002] [PMID]
Morrison, S. E. (2005). How to use sterile maggot debridement therapy for foot infections of the horse. In Proceedings of the 51st Annual Convention of the American Association of Equine Practitioners, Seattle, Washington, USA, 3-7 December, 2005 (pp. 461-464). American Association of Equine Practitioners (AAEP).
Saadi, A., Azizi, S., Farshid, A. A., & Yousefi, A. (2019). Surgical management of penile sarcoid in a stallion. Journal of Equine Science30(4), 99-104. [DOI:10.1294/jes.30.] [PMID] [PMCID]
Sakha, M., Ozmaie, S., Sohrabi-Haghdoost, I., Mortazavi, P., Jahandideh, A., & Ameri, M. (2011). Perineal sarcoid in a Caspian miniature horse. Comparative Clinical Pathology20(5), 547-549.  [DOI:10.1007/s00580-011-1201-z]
Sherman, R. A. (2003). Blow fly larvae. FDA. Available at: https://www.fda.gov/media/74541/download [Accessed October 11, 2020].
Sherman, R. A., & Shimoda, K. J. (2004). Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clinical Infectious Diseases39(7), 1067-1070. [DOI:10.1086/423806] [PMID]
Sherman, R. A., Hall, M. J. R., & Thomas, S. (2000). Medicinal maggots: an ancient remedy for some contemporary afflictions. Annual Review of Entomology45(1), 55-81.     [DOI:10.1146/annurev.ento.45.1.55] [PMID]
Sherman, R. A., Morrison, S., & Ng, D. (2007). Maggot debridement therapy for serious horse wounds–a survey of practitioners. The Veterinary Journal174(1), 86-91. [DOI:10.1016/j.tvjl.2006.05.012] [PMID]
Stadler, F. (2020). The maggot therapy supply chain: a review of the literature and practice. Medical and Veterinary Entomology34(1), 1-9.               [DOI:10.1111/mve.12397] [PMID]
Taylor, S., & Haldorson, G. (2013). A review of equine sarcoid. Equine Veterinary Education25(4), 210-216. [DOI:10.1111/j.2042-3292.2012.00411.x]
Weber, L. A., Meißner, J., Delarocque, J., Kalbitz, J., Feige, K., Kietzmann, M., ... & Cavalleri, J. M. (2020). Betulinic acid shows anticancer activity against equine melanoma cells and permeates isolated equine skin in vitro. BMC Veterinary Research16(1), 1-9.   [DOI:10.1186/s12917-020-2262-5] [PMID] [PMCID]
Whitaker, I. S., Twine, C., Whitaker, M. J., Welck, M., Brown, C. S., & Shandall, A. (2007). Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgraduate Medical Journal83(980), 409-413. [DOI:10.1136/pgmj.2006.055905] [PMID] [PMCID]
Wobeser, B. K. (2017). Making the diagnosis: Equine sarcoid. [DOI:10.1177/0300985816664793]
 
Wobeser, B. K., Davies, J. L., Hill, J. E., Jackson, M. L., Kidney, B. A., Mayer, M. N., ... & Allen, A. L. (2010). Epidemiology of equine sarcoids in horses in western Canada. The Canadian Veterinary Journal51(10), 1103.
Wollina, U. (2010). Massive scalp myiasis with bleeding in a patient with multiple malignancies. International Wound Journal7(4), 297-299.DOI:10.1111/j.1742-481X.2010.00691.x] [PMID] [PMCID]
Yan, L., Chu, J., Li, M., Wang, X., Zong, J., Zhang, X., ... & Wang, S. (2018). Pharmacological properties of the medical maggot: a novel therapy overview. Evidence-Based Complementary and Alternative Medicine2018. [DOI:10.1155/2018/4934890] [PMID] [PMCID]
Zhang, W. J., Jiang, W. Z., & Lan, X. L. (2017). Exploration of the anti-tumor effects and mechanisms of Chrysomya megacephala extracts in H22 hepatoma-bearing mice. Guangxi Medical Journal39(2), 215-219.