Podklad. Scabies norvegica, alebo krustózny svrab, sa považuje za zriedkavú chorobu, a zvyčajne je spôsobená abnormálnou imunitnou odpoveďou hostiteľa na parazita. Diagnóza môže napodobovať rôzne dermatózy a preto býva chybne diagnostikovaná, čo vedie k chybnému manažmentu liečby.
Kazuistika. 85-ročná žena, ktorá trpela na bulózny pemfigoid bola konzultovaná pre podozrenie na alergickú reakciu na používané lieky hydrochlorotiazid alebo lacipil. Počas tohto obdobia bola dávka kortikosteroidu, ktorú používala pre základnú bulóznu diagnózu zvýšená, no kožný nález sa napriek tomu zhoršoval. ELISA na prítomnosť protilátok proti podozrivým liekom z hypersensitivity bola negatívna. Histologické vyšetrenie odhalilo zápalové bunky v hornej časti dermis a parazity. Priame mikroskopické vyšetrenie z materiálu zoškrabaného z ložísk zachytilo početné parazity Sarcoptes scabiei. Pacientka bola liečená lokálnymi keratolytikami s následnou aplikáciou tradičných scabicíd dvakrát tak dlho ako za bežných okolností.
Záver. Scabies norvegica môže byť mylne diagnostikovaný u imunosuprimovaných pacientov, čo vedie k chybnému manažmentu liečby. Diagnózu svrab je potrebné vylúčiť vždy, ak imunosuprimovaný pacient trpí na pruritus.
D. Švecová; N. Chmurova; A. Pallova; P. Babál 1
Authors place of work:
Dpt. of Dermatovenerology, Faculty of Medicine, Comenius University, Bratislava, the Slovak Republic
; Inst. of Pathological anatomy, Faculty of Medicine, Comenius University, Bratislava, the Slovak
Short title. Norwegian scabies in immunosuppressed patient
Conflict of interest. There was no financial or other arrangement with the company whose product is
Published in the journal:
Epidemiol. Mikrobiol. Imunol. 58, 2009, č. 3, s. 121-123
Background. Norwegian or crusted scabies is considered a rare affection and presumably represents an abnormal host immune response to Sarcoptes scabiei. As the condition mimics a range of dermatoses, it can be easily misdiagnosed and mismanaged.
Case report. A 85-year-old woman suffering from bullous pemphigoid was referred for evaluation with presumptive diagnosis of an adverse drug reaction to hydrochlorothiazide or lacipil. Systemic corticosteroid therapy as the mainstay in the control of the bullous skin disorder was increased, but the skin condition worsened. ELISA for the detection of antibodies against the drugs suspected of causing hypersensitivity was negative. Histological examination disclosed inflammatory cells in the upper dermis and parasites. Direct microscopy of the scraped material revealed numerous parasites of the Sarcoptes scabiei type. The patient was treated with topical keratolytics following traditional scabicides for twice as long in comparison with the standard protocol.
Conclusion. Norwegian scabies may be misdiagnosed and mismanaged in immunosuppressed patients. The diagnosis of scabies should always be considered in immunosuppressed patients with pruritus.
Key words: Parasitic infestation – immunosuppressed patient – drug allergy.
It is assumed, that the
Norwegian, or crusted scabies, represents an abnormal host immune response to
the organism and could represent a serious therapeutic problem especially
in immunosuppressed patient. The parasitic disorder could mimic various type of
diagnosis that leads to misdiagnosis and mismanagement [1, 2]. The fulminant
and highly infectious form of ordinary scabies infests epidermis and could lead
to the generalization of the infestation
that is accompanied by erythema with an erythrodermic appearance. Pruritus is
variable and may be slight, intense, or absent. Crusted scabies could represent
a serious diagnostic and therapeutic problem especially in
immunosuppressed patient. We would like to draw further attention to this issue
with rare Norwegian scabies that was misdiagnosed as an adverse drug reaction
in immunosuppressed patient.
85-year-old woman suffering from bullous pemphigoid with four months history of
confluent maculous exanthema on the skin and pruritus was referred for
evaluation. A presumptive diagnosis of an adverse drug reaction was made
at the Dpt.of Internal Medicine, where the patient was hospitalised with
aggravation of her heart ischemic disease. Hydrochlorothiazide, and lacipil
were suspected of drug allergy and changed for another group of drugs. The
patient suffered from bullous pemphigoid from 2005 that was proved by
histopathology and direct immunofluorescence. Her bullous disorder was
controlled by the mainstay dose of prednisone 20 mg/daily and the patient did
not suffer from clinical sign of immune disorder at the time of beginning of
her present complains. The erythematous exanthema gradually covered the large
skin surface accompanied with severe itching despite increased dose of
prednisone to 60 mg/daily at the time of suspected drug allergy. Examination of her skin revealed
disseminated and partial confluent erythematous exanthema on the trunk, back, upper
limbs and on the inner site of her thighs (Fig. 1). Marked hyperkeratosis with
fissures covered both sides of her hands (Fig. 2). Enzyme-linked immunosorbent
assay (ELISA) for measuring levels of antibodies against hydrochlorothiazide
and lacipil proved negative. Histological examination of the punch biopsy
showed inflammatory cells in the upper dermis and disclosed parasites and
faeces in epidermis burrows (Fig. 3). Direct microscopy of material scraped
from hyperkeratotic lesions on hand revealed numerous parasites of the Sarcoptes
An occlusive dressing
with 10% salicylic acid in Vaseline was applied on the hyperkeratotic plaques
and this was following application of precipitated sulphur (10% in Vaseline,
one a day for 6 days) over the entire body. The rash resolved gradually.
She continued with the drugs previously used for concomitant disorders without
Norwegian scabies can
present atypically and mimic a range of other dermatoses. Presented case has been receiving
immunosuppressive therapy for bullous pemphigoid and has been suffering from
the scabies infestation resembling an adverse drug reaction. In an
immunosuppressed host the scabies were reported resembling Darier’s disease
, contact dermatitis , generalized urticaria , dermatitis
herpetiformis , bullous pemphigoid
 and psoriasis . Scabies infestation could have serious consequences –
not only from the epidemiological point of view, but also from the likelihood
of secondary bacterial infection that can give rise to threating complication-
if the diagnosis is missed or delayed. Management of the crusted scabies may
cause serious therapeutic problem. Ivermectin is increasingly used to treat
scabies with hyperinfestation as in the Norwegian scabies. With adequate treatment
there is excellent clinical response .
Ivermectin, as a human drug is not registered in lot of European
countries and therefore its administration is not possible. Additive treatment
includes keratolytic agents that could be added in attempt to reduce crusts and
hyperkeratotic plaques as the condition could be resistant to traditional
scabicides. Our patient was successfully
treated first with keratolytics continuing with a traditional topical
scabicides treatment, but the treatment took two times longer as in
general. Scabies infection can have
serious consequences if the diagnosis is missed or delayed not only from the
epidemiological point of view, but also from the possibility of secondary
bacterial infection that can give rise to threatening complication. In case of
immunosuppressed patient suffering from pruritus the diagnosis of scabies
should be always considered.
redakce došlo 8.12.2008
Svecova, M.D., Ph.D.
Of Dermatovenerology, Faculty of
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Hygiena a epidemiologie