of pruritic crawling sensations in similar locations causing self-excoriations occurred in other fam- ily members in other areas of the residence. The physician treated his family with oral ivermectin and topical permethrin and the family’s pet dog with topical permethrin. The family then spent two nights in a hotel while their house was being pro- fessionally fumigated with a pyrethroid pesticide. On return to the household, the pruritic crawling sensations had improved but persisted. There was no further follow-up. Case 3 (Author’s case) A 45-year-old nurse, who lived with two cats in an apartment whose carpets had been treated for carpet beetles, developed pruritic bite-like le- sions with scratchmarks on the anterior abdominal wall and breasts. Microscopic examination of skin scrapings and potassium hydroxide mounts dem- onstrated no evidence of scabies mites or eggs, or other arthropods, or fungi. Repeated examination of the two cats by a veterinarian demonstrated no evidence of ectoparasitic infections. After moving to another apartment in an old home with a base- ment, the patient reported fewer episodes of itching with topical antihistamine therapy until mice were discovered and trapped in the basement andmoths were identified in her bedroom. Following control of the mice and moths by an exterminator, the itch- ing and scratch marks improved again. Lastly, the patient also reported excessively vacuuming of the carpets and was later lost to follow-up.
Figure 1: The typical, self-limited, erythematous and papular rash caused by multiple bites of European itch mites ( Peymotes herfsi ), which are ectoparasites of leaf-rolling fly larvae. The microscopic mites fall from tress or get carried by the wind causing community outbreaks of intensely pruritic rashes in humans exposed outdoors during summer oak tree infestations. Source: Outbreak of pruritic rashes associated with mites - Kansas, 2004. US Centers for Disease Control and Prevention. Month Morb Mort Week Rep 2005; 54: 952-55. No copyright permission required. The photo is courtesy of A. Broce and L. Zurek, Kansas State University. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/ mm5438a3.htm.
Case 4 (Adapted from Donabedian H 2007) 2 A 51-year-old dog breeder whose dogs had been treated for ectoparasites several months earlier reported to an infec- tious disease specialist that she had “worms crawling under her skin” that occasionally exited her skin, jumped into her nose or eyes, and then traveled to her brain causing severe headaches. The physical examination and all laboratory tests were negative, including a serologic test for leptospirosis. Later, the patient produced a sealed plastic bag containing round “worms” rolled in tissue paper. Microscopic examina- tion demonstrated the “worms” to be inanimate, fiber-like matter. When a recommendation was made for psychiatric consultation and possible treatment with antipsychotic medications, the patient accused the physician of being totally uncaring of her suffering and completely ignorant of her condition. The patient dismissed her physician and was lost to further follow-up. DISCUSSION The earliest reports of delusions of infestations were published in the late 19th century and attributed to Thi- bierge, who reported cases of “acarophobia.” 2 In 1938,
jected into the largest nodule, and the patient was instructed to apply a topical steroid cream twice daily to the affected area and to complete a 10-day course of oral cephalexin before returning for follow-up. At follow-up, the patient was tearful and distraught and produced a specimen of a “bug” from her hairline, later identified as a dried pea. The patient was started on oral atypical antipsychotic therapy with olanzapine, 5 mg/day, and demonstrated dramatic improvement and resolution of all symptoms at her one- month follow-up appointment. Case 2 (Author’s case) A physician and his wife experienced episodic crawl- ing sensations on their faces, chests, and backs, especially at night, and developed an increasing number of pruritic, papular lesions in the same locations that became excoriated from scratching. Dermatoscopic examination of the lesions and microscopic examination of skin scrapings from the lesions revealed no evidence of scabies or mite infestations. A pest extermination company examined the premises and found no evidence of animal or arthropod infestation, and a veterinarian found no evidence of ectoparasitic infection on examination of the family’s pet dog. Later, the episodes
J La State Med Soc VOL 166 July/August 2014 155
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