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Incorrect Diagnosis: Morgellons disease is most likely delusional parasitosis

The following view is opposed by the research of this website. For more on the incorrect diagnosis of Morgellons, visit Morgellons Research

Orac of Scienceblog

One of the stranger Internet-based quackery phenomena of the last decade is Morgellon’s disease. This is a topic I haven’t visited that much on this blog, its having last come up in a big way a little more than a year ago, when I discussed it in the context of Dr. Rolando Arafiles and the other quackery he was promoting. This led to extreme unhappiness on the part of self-proclaimed Morgellons disease “expert” Marc Neumann, who later bombarded me with threatening e-mail rants. In any case, whatever Morgellons disease is, its cause is almost certainly not what patients think it is, namely the presence of tiny organisms in the skin leading to a chronic itch that leads to chronic scratching. Its adherents describe it thusly:

Morgellons is a multi-symptom disease that is just now starting to be researched and understood. It has a number primary symptoms:Physical

  • Sponanteously Erupting Skin lesions
  • Sensation of crawling, biting on and under the skin
  • Appearance of blue, black or red fibers and granules beneath and/or extruding from the skin
  • Fatigue

Mental

  • Short-term memory loss
  • Attention Deficit, Bipolar or Obsessive-Compulsive disorders
  • Impaired thought processing (brain fog)
  • Depression and feelings of isolation

It is frequently misdiagnosed as Delusional Parasitosis or an Obsessive Picking Disorder.

Except that delusional parasitosis is probably not a misdiagnosis. The “fibers” or “granules” found in the skin virtually always turn out to be consistent with fibers from clothing or other sources. At least, no advocate of Morgellons disease has ever demonstrated them to be anything mysterious. This concept has led to treatments for Morgellons that resemble those of chronic Lyme disease, namely chronic antibiotic use. Indeed, interestingly, Morgellons advocates frequently link Lyme disease to Morgellons, with some even asking whether Morgellons disease is the “Lyme disease of our time.”

I was reminded of this frustrating (for both patient and physician) phenomenon by a couple of things recently. First, Mark Crislip wrote an excellent discussion of Morgellons disease and delusional parasitosis (which, of course, appear to be basically the more or less the same thing). The second was the publication of a study in the Archives of Dermatology by a group from the Mayo Clinic entitled Delusional Infestation, Including Delusions of Parasitosis: Results of Histologic Examination of Skin Biopsy and Patient-Provided Skin Specimens. Basically, what investigators Hylwa et al did was something very obvious. They retrospectively reviewed the pathology results of patient-provided specimens and physician-ordered skin biopsies in patients with Morgellons and diagnoses akin to Morgellons. Their search strategy was as follows:

A computerized search of patients seen at Mayo Clinic’s site in Rochester, from 1996 through 2007, was performed using the following search terms: delusion of lice, delusional disorder with parasitosis, delusion(s) of parasitosis, delusional parasitosis, delusion(s) of parasitism, delusion(s) of parasites, parasitosis (delusional), delusional infestation, delusory parasitosis, psychogenic parasitosis, neurogenic parasitosis, neurotic parasitosis, Ekbom syndrome, formication and parasites, chronic tactile hallucination(s), dermatophobia, parasitophobia, toxic psychosis, tactile psychosis, monosymptomatic hypochondriacal psychosis, Morgellon(s), psychogenic dermatitis, neurotic dermatitis, neurogenic dermatitis, self-induced excoriations, and psychogenic excoriations.

From this, the authors chose cases thusly:

All patients who were seen at Mayo Clinic and whose final assessment was consistent with the criteria for diagnosis of delusional skin infestation as described by Freudenmann and Lepping12 were identified as having the disorder and were evaluated for inclusion in this study. The 2 inclusion criteria were (1) the patient’s conviction that he or she was being infested by pathogens (animate [eg, insects or worms] or inanimate [eg, fibers]) without any medical or microbiological evidence for this, ranging from overvalued ideas to a fixed, unshakable belief; and (2) the patient’s complaint of abnormal sensations in the skin explained by the first criterion. When a diagnosis was uncertain, the case was discussed between the reviewers and a final decision to include or exclude the patient was agreed between them.The general term delusional infestation was chosen because it embraces the 2 main categories in which patients present: delusions that they are infested with animate material (such as parasites) and delusions that they are infested with inanimate material (such as fibers).

So what were the results?

Basically, out of the 80 cases of patients who underwent skin biopsy, Hylwa et al found not a single patient had objective evidence of parasite infestation on skin biopsy, although 61% did reveal dermatitis, including 33 cases of chronic dermatitis, 10 cases of subacute, and 6 cases of lichen simplex chronicus. This last diagnosis is a thickening of the skin with scaling that arises secondary to repetitive rubbing or scratching. In actuality, I’m rather surprised that only 60% of biopsies showed this result; I would have expected it to be higher. I am not surprised that the skin biopsies were in essence nondiagnostic. A number of patients had skin cultures. These, too, were all nondiagnostic, being either negative or yielding common contaminating organisms that couldn’t possibly account for the patients’ symptoms.

Read more Still more evidence that Morgellons disease is most likely delusional parasitosis

The Morgellons Cure

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