Saturday, September 01, 2007

Mistakes

Osler urged us to "Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand......Begin early to make a three-fold category - clear cases, doubtful cases and mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way you gain wisdom with experience."

In this spirit, I present the case of G.K. an 82 yo woman who I have been following for 6 months for a pustulo-vesicular dermatitis of her feet. It had features of dyshidrotic eczema at only minimal control.

On August 31, 2007 the patient was reevaluated. Clinically and dermoscopically there was a suggestion of burrows and a scabies prep was taken. To my great surprise there were 4 - 5 mites and numerous eggs and feces in the mineral oil mount. She has no eruption of arms or torso and her only itching was on her feet.




I took this image from the web, but it shows what I saw -- a number of mites and eggs.

Diagnosis: Localized Norwegian Scabies. This patient is confined to a wheelchair, but is active and alert. Further history revealed that her grown children had scabies three years ago and all were treated (as was this patient) with 5% permethrin cream. Seemingly, they all got better, but then three years later this patient has a localized form of Norwegian scabies. There are only one or two case reports of localized Norwegian scabies, and none in patients like this.

Treatment: The patient, her husband and son who all live together will be treated with Elimite. She will have treatments every other day for two weeks for her feet and complete skin treatments twice, one week apart. She will be seen back in two weeks. A culture was taken for the question of secondary infection (this grew out coagulase sensitive Staph and she was placed on an appropriate antibiotic).

Over the years, I have been humbled by scabies time and again. Scabies localized to the plantar aspects of the feet is just the latest incarnation.

Addendum: Here is an article which addresses localized Nowegian scabies co-authored by the prolix Ted Rosen. Our patient is presumable immunocompetent.
Localised genital Norwegian scabies in an AIDS patient.
Perna AG, Bell K, Rosen T. Sex Transm Infect 2004;80:72-3.
OBJECTIVES: We present a case of an AIDS patient with Norwegian scabies manifest
by a single, crusted plaque localised to the glans penis. METHODS: A 45 year old
man with AIDS presented to our clinic complaining of a red papular pruritic rash
on his abdomen and anterior thighs and a single, thick, crusted, non-pruritic
lesion on the penis. He had been treated with lindane topically prior to the
development of the penile lesion without resolution of the pruritus or red
papular lesions. A mineral oil preparation was obtained from the hyperkeratotic
penile lesion and revealed numerous mite eggs and faeces. RESULTS: The diagnosis
of localised, genital Norwegian scabies was made. The patient was treated with
ivermectin 200 micro g/kg per dose taken as two doses, 14 days apart, with
complete resolution of both pruritus and skin lesions. CONCLUSIONS: This patient
is the first known report of Norwegian scabies localised as a single lesion on
the penis. He was successfully treated with oral ivermectin monotherapy.

2 comments:

  1. Abbas AlshammariSeptember 14, 2007

    Dear VGRD Owners,

    Many thanks for presenting this nice case. I do not find you have done any mistake. Localised scabies is very unusual.The important lesson is to understand the mechanism behind such localisation! Anaesthetic nerves or unaccessible sites to itch because of crippling may be factors.

    ReplyDelete
  2. I am going to have to evaluate my pedal hyperkeratotic eczema cases very carefully after this! I have magnified those soles on my screen and can see a few pustules but no definate burrows. The few cases of Norweigian scabies I have seen have been much less inflammatory. Most instructive.
    Best wishes

    ReplyDelete

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