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Crusted (Norwegian) scabies1
The Journal of Emergency Medicine, Vol. 22, No. 3, pp. 285–287, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter
PII S0736-4679(01)00485-1
Visual Diagnosis in Emergency Medicine
CRUSTED (NORWEGIAN) SCABIES Louis Tran,
MD,
Eric Siedenberg,
MD,
and Steve Corbett,
MD, FACEP
Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, Reprint Address: Louis Tran, MD, 446 St. Vincent, Irvine, CA 92373
CASE REPORT
imperative as serious consequences can arise if the diagnosis is missed or delayed (4 –5). Secondary bacterial infections, particularly with Staphylococcus aureus or Streptococcus pyogenes, can develop into sepsis or other lifethreatening complications (4). Furthermore, undiagnosed patients can cause a scabies epidemic in nursing homes, residential care facilities, and hospital wards. Skin scrapings of the scabetic papules and, if present, burrows will aid in the diagnosis of crusted scabies and have been recommended as the initial investigative method. The technique can be performed with a scalpel blade without anesthesia. These shave biopsies usually demonstrate the presence of the characteristic S. scabiei mites, its eggs or fecal pellets (Figure 3) (1,6). The abundance of mites in immunosuppressed patients is thought to be because of a deficient immunologic response. In cognitively impaired patients, it is thought to be because of diminished mechanical removal due to mental deficiency or decreased cutaneous sensation (3). Mild cases can be treated topically with permethrin (5%), crotamiton (10%), or lindane (1%). Severe cases of crusted scabies are usually resistant to standard treatment with topical scabicidal therapy. Furthermore, systemic absorption can occur in patients with extensive skin damage, increasing the risk of adverse effects including neurotoxicity, hematologic and hepatic toxicity. Recent studies have shown effective treatment can be achieved with a single oral dose of the antihelminthic agent, Ivermectin (200 mcg/kg) (7). Ivermectin is structurally related to the macrolide antibiotics, and has been used world-
An 81-year-old woman presented to the Emergency Department (ED) with a severe and diffuse dermatitis (Figures 1 and 2), and increasing weight loss and weakness. The patient was also noted by the family to have decreased mental status over the last 4 months. The past medical history included a splenectomy and partial lobectomy. Vital signs were: oral temperature 36.9°C (98.4°F), blood pressure 134/51 mm Hg, pulse 94 beats/min, and respiratory rate 18 breaths/min. Physical examination was unremarkable other than for dry mucous membranes and the hyperkeratotic dermatitis with diffuse maculopapular lesions over the extremities and trunk. The diagnosis was made by the Dermatology consultant on visual inspection and confirmed via skin scrapings (Figure 3).
DISCUSSION Crusted (Norwegian) scabies is a rare variant of scabies caused by an abundant infestation of the mite, Sarcoptes scabiei, and is therefore highly contagious. It is often misdiagnosed as other dermatoses (1). It is characterized by a polymorphic, hyperkeratotic rash that can be maculopapulovesicular, exzematous, or pustular, although the typical burrows of ordinary scabies are usually not obvious. It usually affects patients who are elderly, debilitated, immunosuppressed, or cognitively impaired (1–3). Because of its predisposition to these patients, prompt diagnosis is
Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California
RECEIVED: 9 June 2000; FINAL ACCEPTED: 5 June 2001
SUBMISSION RECEIVED:
18 May 2001; 285
286
L. Tran et al.
Figure 1 and 2. Photograph of patient with hyperkeratotic rash typical of crusted (Norwegian) scabies.
wide for the treatment of several parasitic infestations including onchocerciasis, strongyloidiasis, and filariasis. Eradication of the mites with Ivermectin has been successfully demonstrated in human immunodeficiency virus (HIV) positive patients; however, there have been doubts regarding the safety of Ivermectin in elderly patients (8).
REFERENCES 1. Almond DS, Green CJ, Geurin DM, Evans S. Lesson of the week: Norwegian scabies misdiagnosed as an adverse drug reaction. BMJ, 2000;320:35– 6. 2. Kolar KA, Rapini RP. Crusted (Norwegian) scabies. Am Fam Physician 1991;44:1317–21.
Crusted (Norwegian) Scabies
287
Figure 3. Photograph of the mite, S. scabiei, seen on a skin scraping from this patient.
3. Marliere V, Roul S, Labreze C, Taieb A. Crusted (Norwegian) scabies induced by use of topical corticosteroids and treated successfully with ivermectin. J Pediatr 1999;135: 122– 4. 4. Bonomo RA, Jacobs M, Jacobs G, Graham R, Salata RA. Norwegian scabies and a toxic shock syndrome toxin 1-producing strain of Staphylococcus aureus endocarditis in a patient with trisomy 21. Clin Infec Dis 1998;27:645– 6. 5. Hulbert TV, Larsen RA. Hyperkeratotic (Norwegian) scabies with
gram-negative bacteremia as the initial presentation of AIDS. Clin Infect Dis 1992;14:1164 –5. 6. Elder D, Elenitas R, Johnson B, Jaworsky C. Lever’s Histopathology of the Skin, 8th edn. Philadelphia: Lippincott-Raven Publishers, 1997:559 – 65. 7. Meinking TL, Taplin D, Hermida JL, Pardo R, Kerdel, FA. The treatment of scabies with ivermectin. N Engl J Med 1995;333:26–30. 8. Barkwell R, Shields S. Deaths associated with ivermectin treatment of scabies. Lancet. 1997;349:1144 –5.
PII S0736-4679(01)00485-1
Visual Diagnosis in Emergency Medicine
CRUSTED (NORWEGIAN) SCABIES Louis Tran,
MD,
Eric Siedenberg,
MD,
and Steve Corbett,
MD, FACEP
Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, Reprint Address: Louis Tran, MD, 446 St. Vincent, Irvine, CA 92373
CASE REPORT
imperative as serious consequences can arise if the diagnosis is missed or delayed (4 –5). Secondary bacterial infections, particularly with Staphylococcus aureus or Streptococcus pyogenes, can develop into sepsis or other lifethreatening complications (4). Furthermore, undiagnosed patients can cause a scabies epidemic in nursing homes, residential care facilities, and hospital wards. Skin scrapings of the scabetic papules and, if present, burrows will aid in the diagnosis of crusted scabies and have been recommended as the initial investigative method. The technique can be performed with a scalpel blade without anesthesia. These shave biopsies usually demonstrate the presence of the characteristic S. scabiei mites, its eggs or fecal pellets (Figure 3) (1,6). The abundance of mites in immunosuppressed patients is thought to be because of a deficient immunologic response. In cognitively impaired patients, it is thought to be because of diminished mechanical removal due to mental deficiency or decreased cutaneous sensation (3). Mild cases can be treated topically with permethrin (5%), crotamiton (10%), or lindane (1%). Severe cases of crusted scabies are usually resistant to standard treatment with topical scabicidal therapy. Furthermore, systemic absorption can occur in patients with extensive skin damage, increasing the risk of adverse effects including neurotoxicity, hematologic and hepatic toxicity. Recent studies have shown effective treatment can be achieved with a single oral dose of the antihelminthic agent, Ivermectin (200 mcg/kg) (7). Ivermectin is structurally related to the macrolide antibiotics, and has been used world-
An 81-year-old woman presented to the Emergency Department (ED) with a severe and diffuse dermatitis (Figures 1 and 2), and increasing weight loss and weakness. The patient was also noted by the family to have decreased mental status over the last 4 months. The past medical history included a splenectomy and partial lobectomy. Vital signs were: oral temperature 36.9°C (98.4°F), blood pressure 134/51 mm Hg, pulse 94 beats/min, and respiratory rate 18 breaths/min. Physical examination was unremarkable other than for dry mucous membranes and the hyperkeratotic dermatitis with diffuse maculopapular lesions over the extremities and trunk. The diagnosis was made by the Dermatology consultant on visual inspection and confirmed via skin scrapings (Figure 3).
DISCUSSION Crusted (Norwegian) scabies is a rare variant of scabies caused by an abundant infestation of the mite, Sarcoptes scabiei, and is therefore highly contagious. It is often misdiagnosed as other dermatoses (1). It is characterized by a polymorphic, hyperkeratotic rash that can be maculopapulovesicular, exzematous, or pustular, although the typical burrows of ordinary scabies are usually not obvious. It usually affects patients who are elderly, debilitated, immunosuppressed, or cognitively impaired (1–3). Because of its predisposition to these patients, prompt diagnosis is
Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California
RECEIVED: 9 June 2000; FINAL ACCEPTED: 5 June 2001
SUBMISSION RECEIVED:
18 May 2001; 285
286
L. Tran et al.
Figure 1 and 2. Photograph of patient with hyperkeratotic rash typical of crusted (Norwegian) scabies.
wide for the treatment of several parasitic infestations including onchocerciasis, strongyloidiasis, and filariasis. Eradication of the mites with Ivermectin has been successfully demonstrated in human immunodeficiency virus (HIV) positive patients; however, there have been doubts regarding the safety of Ivermectin in elderly patients (8).
REFERENCES 1. Almond DS, Green CJ, Geurin DM, Evans S. Lesson of the week: Norwegian scabies misdiagnosed as an adverse drug reaction. BMJ, 2000;320:35– 6. 2. Kolar KA, Rapini RP. Crusted (Norwegian) scabies. Am Fam Physician 1991;44:1317–21.
Crusted (Norwegian) Scabies
287
Figure 3. Photograph of the mite, S. scabiei, seen on a skin scraping from this patient.
3. Marliere V, Roul S, Labreze C, Taieb A. Crusted (Norwegian) scabies induced by use of topical corticosteroids and treated successfully with ivermectin. J Pediatr 1999;135: 122– 4. 4. Bonomo RA, Jacobs M, Jacobs G, Graham R, Salata RA. Norwegian scabies and a toxic shock syndrome toxin 1-producing strain of Staphylococcus aureus endocarditis in a patient with trisomy 21. Clin Infec Dis 1998;27:645– 6. 5. Hulbert TV, Larsen RA. Hyperkeratotic (Norwegian) scabies with
gram-negative bacteremia as the initial presentation of AIDS. Clin Infect Dis 1992;14:1164 –5. 6. Elder D, Elenitas R, Johnson B, Jaworsky C. Lever’s Histopathology of the Skin, 8th edn. Philadelphia: Lippincott-Raven Publishers, 1997:559 – 65. 7. Meinking TL, Taplin D, Hermida JL, Pardo R, Kerdel, FA. The treatment of scabies with ivermectin. N Engl J Med 1995;333:26–30. 8. Barkwell R, Shields S. Deaths associated with ivermectin treatment of scabies. Lancet. 1997;349:1144 –5.