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American Journal of Dermatopathology:
August 2010 - Volume 32 - Issue 6 - pp 603-605
doi: 10.1097/DAD.0b013e3181ca4a13
Brief Report
Intraoral Morgellons Disease or Delusional Parasitosis: A First Case Report
Dovigi, Allan J DDS, MS
Article Outline
Author InformationFrom the Midwestern University School of Dental Medicine, Glendale, AZ.
Reprints: Allan J. Dovigi DDS, MS, 19555 N 59th Avenue, College of Dental Medicine, Midwestern University, Glendale, AZ 85308 (e-mail: adovig@midwestern.edu).
AbstractMorgellons disease is a new emerging disease that is still controversial and believed to be, by some practitioners, as nothing more than delusional parasitosis. The Center for Disease Control has recently launched an epidemiological investigation into this disease due to the increased number of reports. A first case is reported of an oral lesion and symptoms consistent with Morgellons disease. The nature of the characteristic fibers associated with the intraoral lesion is investigated. Research has started at a number of institutions to elucidate the nature of this emerging disease.
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INTRODUCTION
In the 1600s, a disease reported by Sir Thomas Browne described that hairs on the back of children was called the Morgellons, and this term has been coined to describe a recent emerging disease/syndrome with similar skin lesions. From these lesions emerge hairs or fibers, which are associated with excoriation by the patient and a complaint of itching or parasites crawling under the skin.1,2 Up until recently, this syndrome has been diagnosed as delusional parasitosis by dermatologists, when confronted with the bizarre lesions and symptoms patients presented with and it was treated as such.3-7 Delusional parasitosis is a term used by psychologists to describe a false belief by patients that parasites or “bugs” are crawling under their skin where in reality, there are no parasites present. Individuals with Morgellons disease report disturbing sensations of itching, worms or bugs crawling, and biting under the skin, as well as nonhealing wounds in the skin from which emerge hairs or fiber-like materials or black specks or crystal-like materials. Patients also suffer chronic fatigue and symptoms of depression, obsessive-compulsive disorder, and attention deficit disorder (Morgellons Foundation 2007).8,9 Up to 94% of patients suffering from this “Morgellons syndrome” also test positive for Lyme disease by Western blot.4,9 Research has started at a number of institutions to elucidate the nature of this disease.10 A letter has been issued by researchers at Oklahoma State University informing practitioners of the symptoms associated with this emerging disease and caution them that the disease may not be purely a psychological problem.10
These symptoms are listed below:
Distinct and poorly healing skin lesions with unusually thick membranous scarring upon eventual healing.
Moderate to extreme pruritus at sites of lesions and unerupted skin lesions.
Microscopic examination of these lesions will most often reveal the presence of unusual fibers, which may be black-blue or red. These fibers, which many health care providers initially thought to be textile contaminants, are often present in the deep tissue of biopsies obtained from unbroken skin of individuals.
Careful examination of these fibers further reveals that they are frequently associated with hair follicles and are definitely not textile in origin.
Most of these patients suffer from a host of neurological symptoms, which can vary in severity from mild to severe. These neurological symptoms include tingling, paresthesias, and varying degrees of motor involvement, which seem to progress.
Intermittent cognitive and behavioral status changes are often observed and also seem to progress with the severity of the disease. This is often referred to as “brain fog” by the patient as they experience waxing and waning of this symptom.
Laboratory findings in these patients are variable but often reveal eosinophilia and elevated levels of immunoglobulin E.
Other symptoms of varying severity and frequency have been described.
These researchers are making a case for this disease and cautioning practitioners not to simply diagnose delusional parasitosis, as there are more symptoms, which need further investigation and explanation. The Center for Disease Control (CDC) has recently launched an epidemiological investigation into this emerging disease due to the increased number of reports (up to 5000 in the United States to date).11,12
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CASE REPORT
A 61-year-old white woman presented to her periodontist for treatment of an oral lesion of 2-years duration. She has a history of hyperthyroidism and osteoporosis (she is taking Fosamax for her osteoporosis). She has an allergy to latex and Inderal. At age 20, she had mononucleosis and hepatitis. She reports that she travels a lot. She is otherwise healthy with no other symptoms (no neurologic symptoms or skin lesions).
The patient's periodontist reports a solitary oral lesion on the mucosa distal tuberosity of tooth 2. No intraoral photographs are available, nor was the area biopsied. The periodontist reports a small amount of bone breakdown in this area. No other oral lesions or skin lesions are reported. There is no pain, inflammation, or other sensations, and there is no history of surgery in this area.
The patient reports the emergence of very fine fibers from this lesion over the past 2 years, “numerous fibers.” The patient estimates 10-20 fibers from this lesion over the period reported. She complains of intense itching and irritation from this area and is constantly scratching the area with her finger (verbal consult with the periodontist).
Three fibers were removed and sent to pathology, 1 placed in formalin and 2 attached with adhesive tape to a paper card. The fibers were removed by the periodontist with cotton pliers from the lesion. The surrounding soft tissue has not been biopsied. On numerous occasions, the patient has removed fibers as well. They were submitted with a laboratory requisition form that contained a short clinical history and the provider's name.
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PATHOLOGY REPORT
Each of the 3 fibers submitted for pathology are approximately 2.5 cm in length and the same diameter as a human hair. Under light microscopy, the fibers appear to be of the same shape and size as a human hair fiber. The shaft of the fiber is not as uniform in diameter as a hair fiber. They are monofilaments that are generally nonpigmented and clear, but they do have some inclusions and they have tapered rounded ends. They do not appear the same as hair fibers under polarized light. They polarize differently than human hair and present as a synthetic monofilament (Fig. 1).
Figure 1
Image ToolsThe 2 fibers taped to a paper card were sent to Arizona State University for scanning electron micrographs (SEMs) and analysis (Figs. 2, 3). They reveal monofilaments with little microstructure and a homogenous cross section. They are irregular in diameter along their length and reveal some artifact due to handling (a flattened spot where the fibers were clamped).
Figure 2
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Figure 3
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The spectrum profile shows predominantly carbon based with a small amount of oxygen. A small artifact was produced with a spike at Au (gold), which is used to make the object conductive for the electron microscope. There are no other elements visible on this spectrum profile. The single fiber in formalin is retained and archived for future investigation.
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DISCUSSION
Bight field and polarized light microscopy show a monofilament that lacks pigmentation. It has a slightly nonuniform diameter along its length. It polarizes differently than a human hair and presents as a synthetic fiber with a knurled surface appearance refracting the polarized light in a uniform pattern. This is consistent with a synthetic fiber of some type of polymer.
SEMs show a monofilament with little microstructure (Figs. 2, 3). It appears homogenous in cross section and is not of uniform diameter along its length. It appears deformed and flattened in focal areas where it may have been clamped during handling.
The x-ray spectrum shows a composition of primarily carbon with a small amount of oxygen supportive of a possible hydrocarbon polymer (Fig. 4). The small spike of gold (Au) is artifact introduced when making the fiber conductive for the SEM. There are no indications of nitrogen or other elements that would support a protein composition for this fiber.
Figure 4
Image ToolsInvestigation reveals that these fibers are synthetic and possibly implanted into the tissues by the patient. This patient did not report any of the other symptoms associated with the Morgellons disease listed above other than itching and irritation at the lesional site. This supports the commonly held belief that most of these cases of Morgellons disease are nothing more than delusional parasitosis and should be treated as such. A correct diagnosis must be rendered before an accepted treatment can be expected to yield some results and alleviate symptoms. In this case, the findings support a diagnosis of delusional parasitosis due to evidence supporting the fact that the fibers are synthetic and must have been introduced into the lesion by the patient.
Due to the diverse number of symptoms by patients who experience these skin (and now mucosal) conditions, the CDC is undertaking a measured and thorough scientific investigation. The CDC is conducting this study along with the Kaiser Permanente's Northern California Division of Research with the study designed and led by the CDC.
The study will determine the clinical and epidemiological features of this condition looking at skin biopsies from affected patients, characterizing foreign material such as fiber and threads obtained from patients with this condition. A summary of findings of the peer review panel will be presented to CDC's coordinating center for infections diseases Board of Scientific Counselors in November of 2009 and made available on the CDC web site.
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REFERENCES
1. Kellett CE. Sir Thomas Browne and the disease called the Morgellons. Ann Med Hist. 1935;7:467-469.
Cited Here...
2. Koblenzer CS. The challenge of Morgellons disease. J Am Acad Dermatol. 2006;55:920-922.
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3. Murase JE, Wu JJ, Koo J. Morgellons disease: a rapport-enhancing term for delusional parasitosis. J Am Acad Dermatol. 2006;55:913-914.
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4. Savely VR, Leitao MM, Stricker RB. The mystery of Morgellons disease: infection or delusion? Am J Clin Dermatol. 2006;7:1-5.
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5. Koblenzer CS. Pimozide at least as safe and perhaps more effective than olanzapine for treatment of Morgellons disease. Arch Dermatol. 2006;142:1364.
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6. Harvey WT. Morgellons disease. J Am Dermatol. 2007;56:705-706.
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7. Waddell AG, Burke WA. Morgellons disease? J Am Dermatol. 2006;55:914-915.
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8. Morgellons Foundation. Available at:
www.morgellons.org.
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9. Paquette M. Morgellons: disease or delusions? Perspect Psychiatr Care. 2007;43:67-68.
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10. Oklahoma State University center for Health Sciences. Available at:
healthsciences.okstate.edu/morgellons/.
Cited Here...
11. Marris E. Mysterious “Morgellons disease” prompts US investigation. Nat Med. 2006;12:982.
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12. Center for Disease Control. Available at:
www.cdc.gov/unexplaineddermopathy/.
Cited Here...
Keywords:
Morgellons; delusional parasitosis; intraoral
© 2010 Lippincott Williams & Wilkins, Inc.
Article OutlineAbstract:INTRODUCTIONCASE REPORTPATHOLOGY REPORTDISCUSSIONREFERENCES
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