CITW 13: Itch, itch, itch

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 37 year old male with no significant past medical history presents to the ED with a rash. He states that it began one month ago and has been getting worse. Associated symptom is intense pruritus. It is not painful and nothing of note has made it better or worse. He’s never had a rash like this before. He denies any fevers, chills, shortness of breath, chest pain, myalgia/arthralgias, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. He denies any recent exposures (environmental or chemical), medication changes, recent infections, or sick contacts.

Vital Signs: T 98.6, HR 88, RR 14, BP 156/72, SpO2 99% on RA

Pertinent physical exam: Diffuse, papular rash along upper and lower extremities including trunk and back. The neck and face are spared. It is non-blanching, non-weeping, and there are no open sores. It spares the face, lower back, and calves. Patient appears well otherwise. No other pertinent exam findings.

One

TwoWhat’s the diagnosis?

Scabies Infestation

Here are some quick facts:

  • Scabies is a contagious skin infestation caused by the Sarcoptes scabiei female mite who burrows into the upper skin layer where it lives and lays eggs. This results in the patient experiencing intense pruritus and a pimple-like pruritic rash.
  • It is spread by direct skin-to-skin contact with a person infested with scabies, with a typical 4-6 week incubation period with primary exposure, but only 1-3 days for secondary exposures.
  • Scabies is frequently sexually acquired so be sure to look under the hood!
  • Skin findings include a generalized eruption with linear burrows, papules, pustules, and vesicles, typically on the hands (finger webs), feet, lower abdomen, groin, or genitals. Excoriations are common from scratching.
  • Family members and close contacts should be evaluated for similar symptoms, as co-infection is common.
  • Scrapings of the pustules may reveal mites, but the diagnosis is typically clinical.
  • Treat with 5% permethrin cream, applied overnight to all areas of the body. Include the face and scalp in infants and children. Re-apply in one week.
  • For severe infections (heavily infested, immunocompromised) there is typically a crusted form of the rash. For these patients, consider Ivermectin (200 ucg/kg) in two separate oral doses, one week apart.
  • Even with successful treatment and eradication, itching can persist for several weeks. Recommendations for anti-histamines to be taken as needed can often be helpful.
  • All linens and clothes should be washed in hot water, and treatment should extend to all family members. You can also seal “non-washable” items in a plastic bag for up to ten days.

Case Conclusion:

Due to the extensive nature of the infestation, the case was discussed with dermatology who agreed to start him on Permethrin as well as triamcinolone cream.

Sources:

Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 945-946; 1658-1659.

Itchy yet? Did you know that’s a real phenomenon called phantom itch?

Shout out to Dr. Anatoly Kazakin for this case!

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

Faculty Reviewer: Dr. Alyson McGregor

See you next week!

4 thoughts on “CITW 13: Itch, itch, itch

  1. Some of these very severe cases have been misdiagnosed a few times. Just saw one recently, who had already had 2 courses of steroids. So, note that steroids will help with itching a bit, while on them, but will obviously be a cure.
    Also, babies and toddlers tend to get a different distribution given that they play/craw on the floor — don’t dismiss the diagnosis because there is no rash on the hands.

  2. Some of these very severe cases have been misdiagnosed a few times. Just saw one recently, who had already had 2 courses of steroids. So, note that steroids will help with itching a bit, while on them, but will obviously be a cure.
    Also, babies and toddlers tend to get a different distribution given that they play/craw on the floor — don’t dismiss the diagnosis because there is no rash on the hands.

  3. Thank you, Jane! I learned only as an attending that babies can get scabies on their face and scalp. (Unlike adults, where I feel that distribution would make scabies far less likely.) Missed that pearl along the way somehow…

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