Answer

Close endoluminal inspection of the small bowel revealed presence of multiple larvae and adult insects (figure 1A, arrow) with red hallo sign at the site of mucosal attachment, suggestive of a ‘vampire effect’ (figure 1B, arrow). While more common in the developing world, intestinal myiasis in the USA is extremely rare with last documented cases in the medical literature dating back to 1984.1 Our patient was a dog breeder and admitted to an unusual fly infestation during hot summer months requiring frequent calls to pest control services. It is likely that he inadvertently ingested insect eggs and decreased intraluminal acidity with rapid gastric transit seen post-Billroth II surgery resulted in their deposition into the small bowel where completion of the life cycle ultimately lead to the formation of adult flies and development of iron deficiency anaemia. There is no standard treatment for intestinal myiasis. Patient was prescribed intense bowel purgative regimen with 16 L of polyethylene glycol solution followed by a repeat capsule endoscopy which verified resolution of parasitosis. Repeat bloodwork showed no further evidence of iron deficiency anaemia and patient has remained well on follow-up visits.