Ekbom Syndrome. Dermatological-psychiatric borderline disease.
Ekbom syndrome, popularly known as delusional parasitosis (1) has been fully clinically described by the Swedish neurologist Karl A. Ekbom, in his publications, in 1938. Until then it was known under different names: dermatophobia, delusions of infestation, and parasitophobic neurodermatitis, although it is not a phobia of parasites (the patient is not afraid of parasites, he is convinced by the invasion of his own body by them). (2) This syndrome should be differentiated from a secondary form of the disease that occurs as a drug reaction or as substrate of other organic diseases. (3) The diagnosis is suspected by the dermatologist who treats the patient for itching sine materia (without any organic substrate identified or any real parasitic cause). During this period, the patient symptoms exacerbates with the therapy and it develops excoriations, self-inflicted, motivated by the need to extract the parasites that he feels crawling under his skin. Confirmation of the diagnosis belongs to the psychiatrist and treatment is strictly psychiatric (4).
Ekbom syndrome presents clinically as: patient describes itching triggered by parasites crawling under the skin. These parasites are called in different ways: insect larvae, worms, beasts, bugs. (5, 6) Although the patient's syndrome is an illusion that is infested by parasites, they are always accompanied by tactile hallucinations, that shows and feels like crawling under the skin, prick or sting or the feeling of itching, forcing patients to resort to various methods to remove parasites, giving self-induced skin changes (abrasions, ulcerations). For these cutaneous changes the patient is addressing to the dermatologist. It also shows visual hallucinations (6) of scales or waste accumulating on clothing that he describes as parasites that infest the skin. At first, the symptoms can be controlled, the patient can have a normal social life. In time, he isolates himself from the rest of the family being afraid not to infect others. In their vision, the parasites infest all the things surrounding them, gaining an obsessive cleaning disorder, disinfection and sometimes destroying all their belongings. (7)
We will present two patients with Ekbom syndrome from the Dermatology Clinic of "St. Spiridon" Emergency Hospital Iasi that were recommended for specialized psychiatric treatment.
CASE HISTORY 1
Patient C. G., 68 years old, from urban area, without any pathological significant medical history, addresses the clinic in April 2013 for a papulo-vesicular rash, intensely pruritic without a typical character for the pruritus, with the onset of approximately two months, after a bus trip besides ethnicity passengers. Initially, the patient received aetiological anti-parasitic treatment (both scabies and pedicures), topical and systemic treatment for pruritus, but the symptoms persisted, although during hospitalization skin lesions were significantly improved (under supervision the patient couldn't self-induce abrasions). Two weeks after discharge, the patient returns to the clinic with persistent symptomatic complaints, increased skin lesions, intense excoriated lesions after scratching. During the medical history inquiry, he describes the itching triggered by beetles that move beneath the skin throughout the body, including the scalp. Also he brings proves of his infestation scales that he harvested from the itchy areas on the body, which he is convinced that are the bugs from under his skin. Multiple investigations have been conducted to rule out organic causes of a pruritus (parasitic, allergic, metabolic, paraneoplastic) and established symptomatic therapy, but without improvement. The patient was recommended psychiatric consultation with suspected Ekbom syndrome, but refused to go. Subsequently, for about an year, he returned repeatedly in our clinic with dermatological symptoms, intensely itchy, related to the bugs under his skin. Recommended treatments were unsuccessful as the patient's skin was showing multiple excoriated injuries, some caused by objects in order to remove parasites and bring them for identification. Eventually, the patient has accepted the psychiatric consultation, which confirmed Ekbom syndrome and was recommended with psychotropic therapy. Subsequently, the patient never returned to the dermatology clinic.
CASE HISTORY 2
The patient M. A., 72 years old, presented in Dermatology Clinic with a disseminated papulo-crusted rash with multiple round and linear erosions after intense scratching covered by haematic scabs, some with depth of ulcers, not fitted for a parasitic skin disease. She claims it started over two years ago when she was stung by an insect that has left eggs under the skin and then started the itching gave by the movement of larvae. In time she followed multiple topical and systemic anti-parasitic treatments with no symptomatic improvement.
The patient recognizes that she uses the nail clipper the remove parasites under the skin. Para-clinical evaluation excluded any cause (endogenous or exogenous) of pruritus, and during hospitalization the patient was directed to psychiatric evaluation, confirming the diagnosis of Ekbom syndrome.
Both patients had a special social status, isolated from the rest of the family just because of the presence of these parasites that, in their view, are potentially contagious, so the quality of life in these cases is much reduced.
Although, at first glance, this syndrome is not very serious, without putting the patient's life in danger, it is disabling for the individual in terms of quality of life. There are patients who are isolated from their family, who give up social activities because of their belief that they have parasites and don't want to infest those around them. The diagnosis is confirmed by a psychiatrist, although is suspected by the dermatologist. Difficulties arise when the patient refuses to accept his affection substrate, thus delaying treatment and cure of clinical disease. The addressability to a psychiatrist of patients with Ekbom syndrome is reduced due to the difficulty of accepting that the skin lesions do not require dermatologic treatment, but psychiatric evaluation and supervision (8). Patients repeatedly addresses to multiple dermatologists for anti parasitic treatment, thus delaying the psychiatric treatment they need. Up to diagnosis and treatment, these patients' quality of life is deeply affected.
Interdisciplinary collaboration is important to allow Ekbom syndrome diagnosis, especially for fair treatment, that is entirely the responsibility of the psychiatrist. (4, 8) Many patients don't believe their illness is psychiatric and they delay the right diagnosis and treatment by repeated addressing to multiple dermatologists, trying various aetiological and symptomatic anti parasitic therapies without results. Meanwhile, their general status degrades; the quality of their lives and families is reduced. Early establishing a presumptive diagnosis by the dermatologist increases the chances that the patient soon reach psychiatrist and benefit from proper treatment.
Alina STINCANU--M. D., Dermatologist at "St. Spiridon" Emergency Hospital Iasi, No. 2 str. Vasile Conta, Iasi, Romania
Dan VATA--M. D., Ph. D., Senior Dermatologist at "St. Spiridon" Emergency Hospital Iasi, No. 2 str. Vasile Conta; Lecturer at "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Dermatology Department, Iasi, Romania; E-mail: firstname.lastname@example.org; tel.: +40.741.084.264
Laura STATESCU--M. D., Ph. D., Dermatologist at "St. Spiridon" Emergency Hospital Iasi, No. 2 str. Vasile Conta; teaching assistant at "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Dermatology Department, Iasi, Romania
Laura GHEUCA SOLOVASTRU--M. D., Ph. D., Senior Dermatologist at "Sf. Spiridon" Emergency Hospital Iasi, No. 2 str. Vasile Conta; Professor at "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Dermatology Department, Iasi, Romania
ACKNOWLEDGEMENTS AND DISCLOSURES
The authors state that they are no declared conflicts of interest regarding this paper.
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(2.) Aw, D. C. W., Thong, J. Y., Chan, H. L. Delusional parasitosis: case series of 8 patients and review of the literature. Ann Acad Med Singapore. 2004;33:89-94
(3.) Bak, R., Tumu, P., Hui, C., et al. A review of delusions of parasitosis, Part 1: Presentation and diagnosis. Cutis. 2008;82:123-30.
(4.) Healy, R., Taylor, R., Dhoat, S., et al. Management of patients with delusional parasitosis in a joint dermatology/liaison psychiatry clinic. Brit J Dermatol. 2009;161:187-218.
(5.) Boggild, A. K., Nicks, B. A., Yen, L., et al. Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. Int J Infect Dis. 2010;14: e317-21.
(6.) Fellner, M. J., Majeed, M. H. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. 2009;27:135-8.
(7.) Hinkle, N. C. Ekbom Syndrome: the challenge of invisible bugs. Ann Rev Entomol. 2010;55:77-94.
(8.) Hinkle, N. C. Ekbom Syndrome: A Delusional Condition of "Bugs in the Skin". Curr Psychiatry Rep.
M. D., Ph. D., Senior Dermatologist
"ST. SPIRIDON" EMERGENCY HOSPITAL IASI
No. 2 str. Vasile Conta, Iasi
Lecturer at "GRIGORE T. POPA" UNIVERSITY OF MEDICINE AND PHARMACY
Dermatology Department, Iasi, Romania
Tel: +40 741 084 264
Submission: September, 23rd, 2015
Admittance: October, 30th, 2015
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|Title Annotation:||Case Reports|
|Author:||Stincanu, Alina; Vata, Dan; Statescu, Laura; Solovastru, Laura Gheuca|
|Publication:||Bulletin of Integrative Psychiatry|
|Date:||Dec 1, 2015|
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