As Plain as The Rash On His Feet
Tuesday, July 29, 2008
Even before he entered the examining room to meet his new patient, dermatologist Howard Luber was confident he knew what was wrong with the man.
The diagnosis was so obvious, Luber recalled, that his nurse suggested it after taking Robert Clark's history and looking at the angry, encrusted rash that blanketed nearly every inch of the 64-year-old's body except his face.
Luber's certainty was all the more surprising because of who the patient was and what he'd endured: A physician who specialized in infectious diseases, Clark had seen numerous doctors, including three dermatologists, immunologists, internists and infectious disease experts, all of whom had been stumped by the cause of his ferocious, uncontrollable itching. He had undergone two skin biopsies and taken countless drugs, but he would still awaken with fingernails bloody from scratching his skin raw. Doctors who had treated him for more than a year couldn't decide whether his problem was severe eczema, a rare cancer, an unusual fungal infection, an autoimmune disorder or an unspecified allergy.
"It's pretty hard to believe," said Luber, who called Clark's malady "bread and butter dermatology. I don't have a good explanation" for why his problem went undiagnosed for so long. Maybe, he suggested, doctors were focused on more severe disorders and the skin's worsening appearance camouflaged the underlying problem. "If you're not thinking of it, you could miss it."
Clark, a former researcher at the National Institutes of Health who lives in the Phoenix area, has a different perspective: He didn't attempt to second-guess his doctors. "I just acted like a patient, and that's what got me in trouble," he said. "I never at any point until the end of this illness suspected they didn't know what they were doing. Dr. Luber saved my life."
Clark's problem, which he called "devastating" and "life-changing," began in 2004, when he developed an itchy rash on his left side. His internist wasn't sure what was wrong but prescribed the usual treatment for such maladies: an antihistamine, cortisone cream, various ointments for dry skin and oatmeal baths. When the rash got worse, he sent Clark to dermatologist number one, who performed a skin biopsy and then prescribed Elidel, a topical medicine used to treat eczema.
That didn't work, nor did the other antihistamines the dermatologist prescribed. By the time Clark got to dermatologist number two he was having trouble concentrating. Some nights he donned thick ski gloves or thin white cotton ones to try to prevent his furious scratching; he often awoke with lacerated skin or to find drops of blood on his sheets.
Several months later a new symptom arose: a painful fuzzy rash on Clark's feet that was diagnosed as a rare fungal infection. Doctors also noticed that his eosinophil count, a measurement of a type of white blood cell, was extremely high, suggesting either a rare skin cancer or an allergy. But to what? No one could say.
The rash now covered much of his body, and dermatologist number three, along with two infectious disease specialists, an immunologist and an endocrinologist, wasn't sure what was wrong. One doctor suggested chemotherapy. Another thought the problem might be a drug reaction. A third prescribed a high dose of prednisone, a steroid Clark took for six months. It blunted the itching but led to severe pain in his hips, which was diagnosed as avascular necrosis, permanent bone damage linked to long-term use of corticosteroids.
Clark said he was so disabled by the pain and itching that he had stopped practicing; he is now retired. In an effort to give him some relief, the immunologist prescribed narcotic pain medication and insisted that Clark see dermatologist number four: Luber. Clark balked, but the immunologist insisted, so he went, after canceling an initial appointment.
Clark recalled that Luber "was in the room less than a minute when he said, 'You will be feeling better in a few days.' " The dermatologist gently scraped Clark's inflamed, leathery skin and then had him look at the slide under the microscope.
The problem was immediately obvious: The skin sample was teeming with a common parasite called scabies, a tiny mite passed from direct contact with an infected person. The eight-legged mite thrives in overcrowded conditions or among people with substandard hygiene, but it can affect anyone, according to the American Academy of Dermatology.
Outbreaks have plagued humans for more than 2,500 years and can occur in institutions such as homeless shelters, nursing homes and sometimes hospitals. Diagnosis may be delayed because scabies mimics other skin conditions and mites are difficult to see with the naked eye.
Its most characteristic symptom is itching at night so ferocious it can keep sufferers from getting any sleep. The mite burrows into the skin, laying eggs and producing toxins, causing an allergy that triggers the itching. Mites are attracted to warmth and human scent, and can live up to 24 hours on bedding.
Clark had the most severe form of scabies, called Norwegian or crusted scabies. In these cases, thousands of mites hide under skin, which becomes thickened, retarding penetration of topical medicines.
Treatment with topical medicines and, in severe cases, an anti-parasitic drug called ivermectin -- Clark took both -- is standard, and the residence of an infected person must be thoroughly cleaned and clothing washed in the hottest water possible. All members of a household must be treated, because the incubation period can be as long as eight weeks.
Luber, who diagnoses about six cases annually, recalled that Clark was "very surprised. I remember him saying that no one had mentioned scabies," which would not show up on a biopsy.
Clark said that his wife turned out to have a milder case, as did the couple's housekeeper. And as Luber predicted, Clark started to feel better within a day, although it took weeks before the itching subsided. He said he doesn't know where he contracted the disease but suspects it might have been from a patient.
When Clark told some of the physicians who examined him what had happened, he said they were not sympathetic.
"Several told me I was an infectious disease specialist and I should have figured it out," he recalled. "That was very unfair and made me angry. I was a basket case who couldn't put two and two together."