Georgia epidemiology report, Vol. 20, no. 12 (Dec. 2004)

December 2004

volume 20 number 12

Delusory Parasitosis: Bugged by "Bugs" Influenza Update

Delusory parasitosis is a real condition first described in the medical literature more than a century ago. Originally called "delusion of parasitosis", it was described as an emotional disorder in which the patient has an unwarranted belief that live organisms, such as mites or insects, are present on or in his body. It can be caused by many other medical ailments - heavy metal poisoning, exposure to toxins, diseases such as AIDS, anemia, carcinoma, diabetes, hyperthyroidism, lupus, lymphoma, and multiple sclerosis. Nutritional deficiencies, allergies, drug reactions, alcohol or drug withdrawal, menopause, niacin overdose, rheumatoid arthritis, stress and even vitamin overdoses are known to trigger the symptoms. People with delusory parasitosis are otherwise reasonable, are not usually phobic about insects, and come from a variety of socioeconomic and occupational backgrounds. They will report feeling something biting, stinging, or crawling inside their skin and will dig into the skin trying to find and dislodge whatever's causing it. Telling them that insects and parasites do not behave in this manner will have no effect on their beliefs. They will use harsh cleaning compounds, even pesticides and gasoline, on their skin to get rid of the "bugs" or "worms" crawling under their skin and infesting them. They may also bathe excessively. In nearly every case, there is a real reason for the sensations. However, rarely is the reason the one given, making this condition difficult to diagnose and even more difficult to deal with.
Common symptoms reported by sufferers of delusory parasitosis include: The feeling of bugs, worms, fibers, or mites biting,
crawling, or burrowing into, under, or out of the skin. Being able to feel and see these "bugs" or "worms"
even if no one else can. If someone else can see them, it is rarely a physician. Thinking their home or furniture is infested. The conviction that no one seems to believe the "bugs" or "fibers" exist except themselves, or maybe a friend, who is "also infested".

Reporting to have seen many doctors, who either refuse to listen, refuse to see them, or refer them to someone else.
Trying lots of different remedies, none of which worked at all or for long.
Offering to show or send you the "bugs" or "fibers". Being convinced that the problem is spreading to
family, family pets, and friends. Seeing whatever is causing their problem reported on
the internet.
Diagnosing Delusory Parasitosis The differential diagnosis of itchy bites in humans is
complicated by the fact that some of the causes are relatively rare. The major alternatives to be considered are scabies, fleas, body lice, mosquitoes, sand flies, horse flies, spiders, centipedes, bed bugs, ticks, midges, bird mites, and harvest mites. Diagnosis requires information on the circumstances in which the bites occurred, and the nature and distribution of lesions. In difficult cases, an entomologist should be consulted.
Other factors may be responsible for bites of "unknown origin." There are literally hundreds of non-insect agents capable of causing itching and skin irritation. Household products most often implicated are phosphate detergents, soaps, cosmetics, ammonia-based cleaning agents, hair products, medications, printing inks, and certain types of clothing.
Environmental factors, both physical and chemical, can cause symptoms similar to bug bites. Tiny fragments of paper, fabric or insulation can pierce the skin, forming a "bite." They can also cause crawling sensations, which usually results in scratching and possibly a rash. Usually fragments affect body parts that are not covered by clothing such as hands, arms, neck and head. Static electricity can increase the attraction of tiny fragments to exposed skin, exacerbating the problem. Low humidity and electronic equipment can contribute to static electric-

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ity. Dry air alone can cause irritation, producing a condition known as "winter itch" that is often mistaken for insect or mite activity.
Indoor air pollution can cause dizziness, headaches, and eye, nose and throat irritation, conditions often blamed on an "insect bite." Some sources of air pollution are ammonia-based cleaning agents, formaldehyde emitted from wall and floor coverings, tobacco smoke, and solvents and resins contained in paints, glues and adhesives. Reactions to air-borne chemicals most often occur in buildings with inadequate ventilation. One must also consider stress, drug and alcohol abuse, and dry skin
Thorough testing, including a complete physical checkup, should lead to an accurate diagnosis and treatment for most sensations of infestation caused by metabolic disorders or other medical problems listed above. A referral to a dermatologist, allergy specialist, or infectious disease specialist may be considered to rule out a physical cause of the problem.
If necessary, medical specimens can be submitted by the physician to entomologists, parasitologists, or other biologists for verification or identification. These experts, who may be found at a university extension service or in public health departments, not only can identify or rule out various kinds of parasites that may be causing the condition, but they can also provide additional biological information that may greatly assist in arriving at a satisfactory diagnosis and treatment.
The literature on dealing with delusory parasitosis recommends reminding people that if professionals can't pinpoint an offending organism, it is very unlikely that all of them are wrong, and other avenues should be pursued. Stating it this way rarely works. Neither will suggesting that they might want to visit the mental health clinic. Sufferers are often reluctant to consult a psychiatrist, and if the suggestion to do so is not made carefully, the patient may seek help from another physician.

Take a good history to help rule out environmental causes.
Rule out other organic causes such as allergies and contact dermatitis.
Determine whether there is a history of drug abuse. Consider psychotherapy. Management of patients with
delusory parasitosis is best handled through the cooperation of dermatalogists, psychiatrists, and entomologists or parasitologists. Psychiatrists are needed to confirm the diagnosis of delusory parasitosis and to diagnosis any underlying psychiatric disorders. In addition, psychiatrists are able to conduct psychotherapy and provide a longtern commitment during the treatment phase. The drug most often mentioned in the literature as being effective for treating delusory parasitosis is the antipsychotic agent pimozide, which can provide significant relief of both itch and delusions.
People with delusory parasitosis often go from doctor to doctor seeking relief and confirmation of their suffering. Because patients are wary that a psychiatrist may challenge their delusions, they are likely to resist recommendations to seek psychiatric help. A physician might persuade such patients to see a psychiatrist by suggesting that a mental health professional could help them manage the emotional hardships created by their affliction.
This article was written by Rosmarie Kelly, Ph.D., M.P.H.
References:
http://delusion.ucdavis.edu/ http://edis.ifas.ufl.edu/BODY_MG343 http://www.medscape.com/viewarticle/417324 http://www.ipm.ucdavis.edu/PMG/PESTNOTES/
pn7443.html http://www.entomology.ucr.edu/ebeling/ebel14.html http://www.ahealthyme.com/topic/parasitosis
Hillert, A, et al. 2004. Delusional Parasitosis. Dermatol Psychosom 5:3335
Hinkle, Nancy C. 2000. Delusory Parasitosis. American Entomologist 46 (1): 17-25.

Treatment of Delusory Parasitosis Run appropriate diagnostic tests to rule out other
medical conditions. Rule out true infestation.

Potter, Michael F. 1997. Invisible Itches: Insect and NonInsect Causes. University of Kentucky Cooperative Extension Service. ENT-58.
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I n f l u e n z a Update

The Centers for Disease Control and Prevention (CDC) recently informed us that the injectable influenza vaccine, Fluvirin, manufactured by Chiron Corporation, will not be available for distribution in the United States (U.S.) for the 2004-2005 influenza season. Chiron Corporation was to supply about half of the 100 million doses of influenza vaccine expected to be available. For this season, the U.S. will have available approximately 58 million doses of another injectable influenza vaccine, Fluzone, manufactured by Aventis Pasteur, and approximately 3 million doses of a live, attenuated influenza vaccine (LAIV/Flumist), manufactured by MedImmune.
Upon notice of the inactivated influenza vaccine shortage, the Advisory Committee on Immunization Practices (ACIP) and CDC issued interim recommendations on priority groups for vaccination this influenza season. The priority groups are:
children ages 6 months to 23 months; people 65 years of age and older; adults and children 264 years of age and older with chronic
lung or heart disorders including heart disease and asthma; chronic metabolic diseases (including diabetes); kidney diseases; blood disorders (such as sickle cell anemia); or weakened immune systems, including persons with HIV/AIDS; women who will be pregnant during the influenza season; residents of nursing homes and other chronic-care facilities; children and teenagers, 6 months to 18 years of age, who take aspirin daily; health-care workers who provide direct, hands-on care to patients; and household members and out-of-home caregivers of infants under the age of 6 months. Individuals not in these priority groups are asked to forego influenza vaccination this season.
For health-care providers administering vaccine, please vaccinate only persons who fall into a priority group and ask that otherwise healthy individuals forego vaccination this season. Other steps the public can take to prevent influenza include frequent hand-washing, covering coughs and sneezes, avoiding contact with eyes, nose, and mouth, and staying away from

school and work while ill. Respiratory etiquette materials are available for download at http://health.state.ga.us.
LAIV should be considered for healthy persons who are aged 549 years and are not pregnant, including health-care workers (except those who care for severely immunocompromised patients in special care units) and persons caring for children aged <6 months.
The Division of Public Health is currently working with local health officials and health-care providers to assess the vaccine supply in Georgia. We will facilitate redistribution of available vaccine to target the approximately 2.5 - 3 million Georgians who fall into one of these priority groups. However, the vast majority of influenza vaccine is purchased and administered privately, not in public health. Therefore, to ensure that vaccine reaches these priority groups, we are asking for your cooperation.
We ask that providers who have received vaccine contact their district health office (http://health.state.ga.us/regional/ index.asp) to let us know that vaccine has been received. For providers that are looking for vaccine, please contact your district health office (http://health.state.ga.us/regional/index.asp) to let us know that vaccine is still needed. This voluntary communication is critical to help state and local public health officials determine: which facilities and providers have vaccine and where gaps in vaccine distribution exist so that we can
allocate vaccine to areas it is still needed.
Georgia participates in the nationwide influenza surveillance network that is coordinated by CDC. Georgia surveillance data are available at http://health.state.ga.us/epi/flu/ fluupd04.asp. National surveillance summaries are available at http://www.cdc.gov/flu/weekly/fluactivity.htm.
Thank you for your cooperation. Updated information is available from the Division of Public Health at http:// health.state.ga.us and from CDC at http://www.cdc.gov/flu.

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor
Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer

Division of Public Health Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517

Georgia Department of Human Resources

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The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

December 2004

Volume 20 Number 12

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 2004

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for September 2004
2004 57
2440 31 0 58
1125 1 36 41 0 0 3 1 2 0
254 47 0 4 4 13 0 13

Previous 3 Months Total

Ending September

2002

2003

2004

211

233

186

9017

9432

8255

39

37

83

14

11

1

306

274

220

5224

4755

3784

14

20

15

90

323

88

122

238

160

6

12

10

2

1

3

7

6

3

0

2

1

11

10

5

0

0

0

849

908

877

440

217

155

26

32

6

96

98

32

190

165

28

192

200

71

3

1

0

165

134

68

Previous 12 Months Total

Ending in September

2002

2003 2004

609

687

560

34375

36288

33360

130

123

191

57

32

22

905

873

813

18989

18117

15067

100

82

111

559

744

472

460

669

618

15

36

39

5

10

13

41

31

25

3

3

1

27

33

27

0

0

1

1895

1999

2052

1532

1757

697

104

118

107

311

436

366

746

769

362

782

850

563

18

11

2

622

522

463

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period

Total Cases Reported* <13yrs >=13yrs Total

Percent Female

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

Latest 12 Months: 12/03-11/04 Five Years Ago: 12/99-11/00 Cumulative: 07/81-11/04

9

1,711 1,720

27.5

12

1,164 1,176

28.0

229

28,572 28,801

19.0

33.5

6.3

2.2

13.7

1.7

42.5

31.0

11.6

3.3

19.4

2.6

32.1

45.8

16.2

5.1

14.4

1.9

16.6

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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Race Distribution (%) White Black Other

22.2 75.1

2.8

19.0 77.6

3.5

32.4 65.0

2.6