Hi, everyone. Welcome to Febrile, a cultured podcast about all things infectious disease. We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management. I'm Sara Dong, your host and a MedPeds ID doc. Welcome to season five. We are back today with a StAR episode. These focus on the State of the Art Reviews from CID. So I have two guest stars today. First, let me introduce Dr. Alexandra Mendelsohn.
She is a psychiatry resident at the Dell Medical School at University of Texas, Austin. She completed her medical school training at Tufts. Joining her today is Dr. Alysse Wurcel, who just moved to Boston Medical Center, where she is in the Division of General Internal Medicine and the Division of Infectious Diseases. She completed her internal medicine residency at Massachusetts General Hospital, and her ID fellowship at Columbia Presbyterian Hospital and Tufts Medical Center.
In addition to her work as an inpatient I. D. doctor, she has an outpatient clinic where she specializes in HIV, hep C, and substance use disorder care. Thank you both for being here, we have to kick it off like usual. As everyone's favorite cultured podcast, I would love to hear a little piece of culture, really just something that you like that makes you happy.
Um, I love golden retrievers. I have one, and, um, I, I am, like, she is everything to me. I mean, I also have children, so they're important, but, um,
Oh,
um, a really interesting side note as it relates to microbiology in golden retrievers is that their paws often smell like Fritos, which I guess is because they're colonized with Malassezia furfur. Um, and so, like, I've always really loved I've heard people call golden retriever and labrador retrievers like the smell of their paws. And someone told me, asked me if I thought they smelled like Fritos and I said, absolutely. Um, and they said it's because of Malassezia furfur.
So, mean, the intersection between being an ID doctor and a golden retriever and a dog lover, but specifically a golden retriever lover is, is me.
That's some pretty good party trivia have to say. Alex, what about you?
Yeah, so I moved to Austin for residency. There's a ton of cool stuff to do here, but what I've really enjoyed has been going to the UT women's basketball games. Um, I got season tickets and I am so excited to go. I think about it all the time and I will talk to anyone that's willing to listen to me about it.\
Well, I always like to start by thanking anyone who comes on to do these StAR episodes, because you're often covering these huge topics. And this one in particular, delusional infestations, is quite challenging. I am sure there are many people listening that, you know, when this comes up, or they see it on their schedule, maybe they're dreading that visit or conversation, or, apprehensive.
You have a really nice introduction to the topic in the paper, even actually giving a little bit of historical context and how we can think about the definitions and terms that get used when we're trying to describe delusional infestation. So before we talk through an example case, I was hoping you could actually give us a little bit of introduction to the topic, other thoughts you might have had, and sort of how this paper came to be.
I think I definitely was a person at one point that dreaded this type of interaction, probably because I felt really unprepared, and I think also because, maybe as an ID doctor, it was almost maybe like humorous to think about this person as, um, someone who's, you know, taking your time without reason. I don't know if it was a coping strategy. But I, I started being really interested in it. I just saw a lot of patients with it. I just kept on seeing patients with it.
And, one of my friends from medical school who's acknowledged on the paper as one of the only dual boarded psychiatry dermatology attendings. And so I knew he had a specific interest in it as well. So I, when I floated the idea by him, he thought it was a good idea to write something about it. And I was also surprised about how little is written about it, actually. I was really surprised by that.
And so all those things and working with Dr. Mendelsohn, who is now a psychiatrist, was a medical student at the time, all converged to bring us together to write this.
I was already planning to work with Dr. Wurcel on a research project. When we first met, I was interested in going into infectious disease, but during my clinical rotations and medical school, I really fell in love with psychiatry. When I told Dr. Wurcel I was interested in applying to psychiatry, she let me know she had been invited to write this review paper on delusional infestation and it just felt like it was a really good fit between the 2 of us to work on it together.
So, for a long time, the condition was mostly called delusional parasitosis. That's one of the common delusions is that people are infested with parasites. More recently, there's been a transition in the literature to using the term delusional infestation to include different types of perceived infections or infestations. To define a delusional infestation as a disorder where people have a fixed and false belief that they're infested with a living thing.
So a couple key points there is that it's a fixed belief, so they kind of by definition continue to believe in the infestation despite being presented with evidence that disputes that. Um, and it's a false belief, meaning that we can't actually diagnose a delusional infestation until after we've ruled out a true infection or contamination, the most common being something like mites.
We are going to walk through a clinical vignette that is mentioned in the paper, but also just give us a framework to talk about some of the information that you covered in the paper. So I will start with that. We have a 53 year old cisgender woman who is referred to the ID clinic because of concerns for a parasite infection. Her past medical history is significant for diabetes, hypertension, and a scabies infection a couple years ago that she contracted while living in a shelter.
She reports that a few months ago, black stringy creatures started emerging from her scalp, and now it seems like they're coming from other parts of her skin as well as her mouth and vagina. She has tried over the counter oils. She's tried some lotions. Nothing really seems to be helping. She's actually visited two dermatologists before this and she says, I was told it's all in my head. And today she brings you some samples that she would like sent to the lab for identification.
So I know I've certainly encountered similar stories like this in clinic. It seems very familiar, but can you walk us through, how do you approach this in clinic when you were sitting with that patient?
Yes, I think in initially evaluating this patient, important pieces of the history that I would want to know are, are there any environmental causes of infestation? So, where has the patient been living? Have they done any international travel for patients that are from an immigrant population? Where are they coming from? Are there any places that they traveled through on the way to see you? You want to be particular in ruling out, like, true infestations.
So looking for characteristic signs of bed bugs or scabies when you're doing your skin examination, and then any thing that's changed in their history recently.
So any new medications, medications coinciding with the onset of symptoms, any nutritional deficiencies that you might suspect any untreated medical conditions because any medications or medical conditions that cause side effects of neuropathy or itchiness could possibly trigger this delusion for someone with kind of, like, an underlying paranoia. So resolving those physical symptoms for the patient could make a huge difference in quality of life for these people.
And then lastly, you want to elicit if there's any history of psychiatric conditions or substance use, those obviously can both cause delusional infestation, but I do want to also note that patients with psychiatric conditions or substance use are disproportionately represented in places like shelters or jails, places that might be more likely to have true infestations of bed bugs or things like that.
The first thing is to really put aside anchoring that this is someone with a delusional disorder, and really trying to figure out is there something going on here other than delusions? Has that fully, fully been worked out? And I learned that skill actually from, from Lyme doctors who were seeing people who you know felt that they had a sort of a post Lyme situation but were actually presenting with lymphoma or babesia or other things.
So putting aside that and saying okay, has the correct work-up been done? Can you really convince yourself that this whole workup has been done, to convince you at least as much as possible from data that this is not a true, quote, infestation?
And then there's always this debate about whether you send the sample of the worm or other things, and I remember it used to be kind of routine that you would send it and then you would show the patient the sort of the laboratory report and you'd say "See? Here you can see it's not it" and and I've done that and that's often not effective because there is a concern that that was the wrong spot.
I do think it's worth doing if the person's never had it done before and not taking it to excessiveness to say you know this is it. Because otherwise, we're not really engaging the patient in the entire compass of care . um, we heard from some people that actually have microscopes in a multidisciplinary setting where the actual sample can be removed and it seems optimal for everyone to look under the microscope together. I know that seems a little bit kind of far fetched.
Not everyone knows how to look under a microscope, but those are just some ideas that came up in the discussion, so basically if she said this is a worm or this is something, I, I probably, would send it for analysis. Although I do think sometimes that's kind of a debated topic.
So let's say, you have this visit, we send it off, the patient's now coming back, this is their first follow up visit. The patient provided samples that were sent to the lab, say no organisms identified. And her lab workup is also unremarkable, there are no things like eosinophilia, for example. And so at this point she, She's shaking out her shirt and points to some debris that falls on the ground. You look at this and tell her, these don't look like worms.
But at this point, she strongly disagrees. She's really frustrated. She begins to cry and says, they're right here. Why can't you see what I see? And so, how, how do you think about approaching this interaction in a way of maintaining that therapeutic relationship? Because I, I do think that it's those later visits that sometimes are where even more frustration comes out, because I think their hope of getting an answer in the first visit is tempered a little bit.
Yeah, a big thing that we wanted to emphasize in the paper was how important that therapeutic relationship is with with these patients, because of kind of the definition of delusional infestation.
They're not going to be swayed against this delusion if you present evidence, um, so we know that, the therapeutic relationship that you build with that patient, the physician patient relationship is really important for the prognosis of these patients, because it's going to affect their follow up and their buy in with any recommendations that you provide.
There's kind of a debate on whether you want to, like, withhold your suspected diagnosis or not, but I think most clinicians treating these patients would agree that directly challenging the delusion is not very likely to be helpful. So, what we recommend in the paper is finding some kind of common goal that you and the patient can share. So, something like, if we can't find this bug, would you be interested in talking about ways that we can reduce your symptoms?
Or, I've treated patients with your symptoms before, and I haven't been able to find the bugs, but I do know some medications that can be that can make people feel better. Would you be interested in trying one of those? Something like that, finding some kind of common goal and, um, kind of working towards it together.
Yeah. I think I try to do the same thing, like setting, setting the, the framework being, I want to do what I can to make you better.
Mm hmm. I, I don't often feel bad walking out of that room in the first visit because there's analysis planned, there's engagement planned, there's a, there's a plan that to help this person. There's hope maybe is the right word, you know, anyone who comes to you with an illness and they feel bad, when we give them hope that we can identify it, or treat it, or make them feel better.
Um, so it is often the second time that you see the person when the, the information that you've gathered is such that, you know, you're pretty convinced there's at least not something you could offer treatment for in terms of a medicine to kill a bacteria, or a medicine to kill a parasite. There are downsides and good sides to all antibiotics. I would say ivermectin is one of the safest antibiotics if used correctly in terms of dosing.
So if it, you know, if there's the action of giving someone ivermectin once to help alleviate them, I, I, I would do that too, or an itching cream, but at the point that they come back, And they're sort of shaking out or someone's like, can you see this? Can you see this? I think you can kind of agree that you're, agree to not, agree not to just sort of disagree. So actually like saying like, this is not a worm is not helpful. Um, I don't see it. Like, I, I don't, I'm so sorry. I don't see it.
Um, um, it seems like you're suffering. I am so sad you're suffering. I often use that as a way to figure out what else is going on in their life.
I, I actually wanted to write about this more in the paper, but there is no evidence to show this, at least in my experience when I've discussed with this, this is a predominantly female presenting illness and people have sexual trauma or trauma historically and maybe there's some sort of coping mechanism in place where someone can say a bacteria or a bug or a worm is a representation of shame or regret or things like that. I really do find that a lot.
I do try to do a trauma informed discussion of, of what happened in their life. And eventually bring that back. It doesn't always work to bring it back to say, wow, you've been through so much. Um, maybe this is how one of the ways that your brain is dealing with it. So I definitely do that. And I basically just acknowledge the suffering because some people have at this time lost so much.
They sometimes have lost their job, their housing, sleep, relationships, and just acknowledgement of the suffering, even without acknowledging that you can identify the living organism that's causing the pain, I think is a bridge of empathy, that has worked. And so, as much as possible, just, I'm so sorry you're suffering, how can I help you?
How, I, I, you know, we've taken away, we've done everything we could with at least ivermectin or anti itch creams or anti itching medicines, kind of, how can I help you? And kind of try to brainstorm together outside of medications that would kill, um, a living organism.
Yeah. I also wanted to point out for people who are looking at the manuscript, there's a couple bullet points in there with examples of some of the different types of language that you could use, which I always think is really helpful when there's examples for folks to look at.
Sometimes having that in the back of your mind, like how do I start this sentence?
Yeah.
is helpful. I'm not going to lie, like sometimes I've, I recently was on service and I had a patient with this and I could find myself falling into the trap of doing the things that is not recommended, out of frustration, out of fatigue. I can't say that I followed this algorithm directly.
I also want to give empathy to the providers or the clinicians or the nurses who, you know, feel, frustrated with the situation and, and show my vulnerability in that my interactions are not uniformly like 100 percent great.
Absolutely. And, and so let's say we're in this visit, you spend some time listening to their concerns. You have offered some of these affirmations, acknowledging these feelings of frustration that they're having. And after about 20 minutes or so, the patient says, I am so sick of feeling this way. I am seriously willing to try anything that will help.
And so here's an opportunity, we've talked a little bit about trying to avoid medications, but also kind of using them cautiously in certain settings where it might make sense.
Yeah, I guess I mentioned permethrin or I mentioned ivermectin, but I'm pretty, pretty liberal with giving out permethrin cream or even chlorhexidine washes. So anti itch creams, you know, within reason, just hoping the person doesn't getting too much corticosteroids.
So Alex, maybe you can help us out and talk a little bit about what are some of the other medications and how you might use them as a resource in this type of setting.
So the mainstay of treatment for delusional infestation is 2nd generation antipsychotics, which are the newer antipsychotics that have less what we call extrapyramidal effects. So less effects on musculoskeletal movements, like Parkinsonism and things like that. Getting buy in for these medications is going to be important that you build that strong therapeutic relationship.
And in one part of the paper, we actually recommended kind of preempting the patient saying, if you, if you look this medication up, you'll see that it's used to treat schizophrenia. I don't think you have schizophrenia, but this is a medication that's been shown to relieve itching in patients with your symptoms or something along those lines.
When we wrote this paper, we recommended using either aripiprazole (Abilify) or risperidone (Risperdal), um, based on a combination of evidence in case reports and also tolerability. Since we submitted this review, there was actually a study done in Europe, comparing the efficacy of different antipsychotics. It was the first paper to actually do that.
And they recommended either risperidone or amisulpride, which is a medication that's not available in the U. S. But historically clinicians used to use a medication called pimozide that's fallen out of favor because of its side effect profile and drug interactions.
Yeah, I actually hadn't heard of pimozide before
Yeah, it used to be like, on like psychiatry board exams, that was like the medication that you were supposed to choose for delusional infestation.
Fortunately, there's so many uses for a lot of these medications. Some people I've spoken to talk about, there's a, this is a little bit of an ethical conundrum, but you can say, you know, we have nerves and organisms have nerves and you know, there are, depending on how deep you want to get into it, like calcium channels on the edges of our cells and a lot of organisms.
And so, this medicine is interacting with our ability to feel things in the outside world, potentially, and like kind of creating it as a therapeutic alliance that this medicine would, would dim down the experience rather than eradicate the actual, you know, bacteria or fungus or parasite.
I like how you mentioned thinking about how to deal with when patients either Google the medications or maybe just anytime you approach that word that is therapy that there's an immediate sort of reaction to that. Is there anything else that you use to help when you're faced with that?
I, I do, I don't know if anyone would do this. I think there's, You know, there's a, there's a kind of an old school where you don't talk about your own problems with patients. I'm kind of in a new school that like, me dealing with depression or anxiety is a way for patients to know that they're not alone. That like, you know, fancy doctors have this too.
Um, and so I do share with them experiences when I felt really ill in a feeling that, maybe I thought it was something that needed, antibiotics, but I didn't. And it was just like sort of the circumstances around me causing me to feel ill. So, I sometimes share how this, there's a really incredible brain body connection that I don't think we understand entirely in medicine yet.
And so when people feel something and I say, oh, that's not true, that, like, I don't believe, I don't want to be the person that tells someone that they're not feeling what their body's feeling. Um, the body's a tricky place. It's not straightforward. Science is evolving. We have told patients, people in the past, that they didn't have things, and they did. I mean, time and time and time again. So I try to lead with, I do not know the full story of everything.
This is my best attempt to help you. I have been in a spot where I felt really sick, and I didn't know what was going on, and it was just that I was really sad. I think that helps people to, to, to make them feel that they're not alone. I know it's not what everyone feels comfortable doing, and I, I hope you know I'm not, like, that's not my intent. Just, I think the minute we start calling, they think, they don't think they are quote unquote crazy, but everyone is saying that.
They're hearing people talk about them, potentially. You know, the nurse outside the room or the resident outside the room, oh, I can't believe, you know, it's happening that they're feeling this, so. So, it could be that they're feeling something that I don't entirely have an explanation for, , but that doesn't mean that I can't help them or I can't talk with them. Also, one of my colleagues that's really good at this schedules frequent follow ups.
Um, I think they're, I got an idea sort of for this also because I posted on one of the IDSA website, web things about this. And people were upset at me how, you know, that I was wasting ID doctor's time, and a lot of clinics don't allow these people in, and I guess they have short staffing and there's a lot of reasons why. Um, I think it's an investment on ID doctor's part to take care of these patients. They will come back. They will continue to come back.
If, if you can't, this is like not the kick the can type situation. You and maybe if you don't want to specialize in that, that's fine, but I feel like ID clinics should have someone. If you're having someone who takes care of other illnesses, that, you know, potentially need a multidisciplinary team, there should be someone in your, who you can refer to. It is our problem. Just like addiction is something that we can treat, um, that's different.
But it's just, I, I worry that ID doctors are like, no, that's not my thing. I didn't learn about that in school. That's not my thing. And I, I, it makes me incredibly sad when I hear that.
Yeah. And I think that's actually a really nice transition because one of the key messages for a lot of the reviews has been the multidisciplinary approach. And, um, you actually have a specific figure in the paper about just thinking about like patient centered approach and, and to such a challenging diagnosis. So what are other gaps in care or, or thoughts that you have as far as thinking about that team and, um, trying to be mindful of ways that we can help these patients?
I think something we talk about is the, the availability of our notes to people, and how to, to get around that. And I. You know, I'm rereading it, you know, the idea of unspecified pruritus is a great idea instead of potentially the ICD 10 for delusional parasitosis. The researcher in me, when I try to do searches for the incidence of delusional parasitosis, I'm stymied because I don't think anyone's putting it or actually using the ICD 10 code.
So, even before the transparency occurred with the charts. So, I guess that's one thing to discuss, you know, how are you going to talk about it and know if the person's going to see it, beforehand. I also think I was not prepared for, I mean, People are mad at you and will do things in, in terms of like someone called the head of the hospital on me or, you know, someone high up to report me.
So you, it is to be anticipated that people may be mad at you for your, the way, um, and, um, that's why I think quick documentation as soon as possible. I know a lot of places are putting that into play anyway. As soon as you can get that note written on that patient, showing empathy, showing, I spent 60 minutes, you know, that's the note to put, I spent 60 minutes in, right?
I, I spent 60 minutes, we discussed this and this, and this is how the patient left, and we had good terms and things like that. Obviously, honestly reflecting if it didn't go well, if the patient left, reflect that too, right?
You know, I did this, the patient felt that it was not in line with and left the room and and left and and that was how the patient and so honesty through the notes to show that you cared And then depending on what you want to do for the coding, I guess but also get, get the money you're owed because this is, this is a, you know, this isn't, this is not heart surgery, but maybe some heart surgeons wouldn't want to do this, right? This is a talent that ID doctors should do.
You know, often people ask for a referral somewhere else, or I'm going to see somewhere else, or I'm going to do somewhere else. Um, I don't think people realize that a lot of the doctors that you're seeing have actually worked in other hospitals and trained other hospitals. I find it's helpful to say, well, I've not only worked at this hospital, I've worked at this hospital, this hospital, and this hospital. Um, so just, just so you know.
You know, I feel like that's going to be the same kind of evaluation that you're going to get. Oh, the other thing I often tell people is I warn them that there will be someone who will give you something, and if they charge you for it, or you make you pay for it, or make you buy it, you know, at the back of a house or something, I'm scared about that. They're preying on you and it could do harm.
So, someone is out there to, you know, this is the same thing with people with Lyme disease, you know, I'm worried about you being taken advantage of, um, so just be careful to, and potentially run medicines by someone or some doctor or a pharmacist at least to make sure that they are what they are, um, and they're not going to interact with your other medications because after they leave us, They will potentially find someone else who doesn't actually have their health in mind.
There are actually some multidisciplinary clinics in the United States, and I think in Europe that are actually dedicated to treating psychodermatological conditions. And I think that's a really great environment because it allows for really close collaboration between different providers.
Yeah, it's interesting because, um, you know, since writing this paper and sort of switching jobs to another place, I've talked a lot about how I would love to do this, how I would love to be part of a multidisciplinary clinic.
And it's interesting when I see the faces of people when I say that, they're not like, happy, you know, like for the people in power, and I think there's like an activation, energy sort of thing that we have to get through to all of the operations that would be necessary to put this into place.
Which may be in the sense of, I have so many work items to do that this idea of creating a multidisciplinary clinic, all the meetings that would need to happen, all the, you know, space considerations are overwhelming.
But I kind of hope, I see that as sort of like a sprint view, not a marathon view, um, in that these patients need care, they take up, they, they need resources and sort of saying that we don't have time to invest in that will bite us later on financially, um, or come back at us financially and hurt the patient too. So I guess.
This is for anyone in the operations side who has the power to say yes, this is a commitment from the institution Because it will need someone in the c suite to commit to this and we are not in the c suite And so we can say this is important and we can present evidence, but it will need Someone with power to have vision, um, or, or, you know, and say, this is something that our hospital, our clinics need to invest in to improve the lives of everyone to improve the lives of the clinicians.
the nurses, everyone, the patients.
And the last thing I want to do is just leave it open and see if there's any closing thoughts or take homes that you guys have
if there's one thing that I hope you take away from this, is that, any patient that walks into the, your room as someone you can help, any patient, and it may not be with a prescription for doxy[cycline], or, an MRI, but I do think we can help people, and I think that's sometimes a lost art in, especially in ID. I know there's some, a lot of champions across the country doing that. So I guess that's, that's the way, um, I think about these patients.
I think Dr. Wurcel's takeaway point is so lovely. I think what I fear the most with this patient population is that they just get referred to someone else and are lost to follow up. So I think I'd want people to hear that you don't need to be a psychiatrist to be able to treat a delusion.
And then I just really want to thank the people that I wrote this with. Ankita Subedi is an ID fellow, now an ID attending up in Boston. Taisuke Sato, who is a medical student, um, in Kansas City right now and is going to go on to incredible things as a clinician, and I just want to thank Alex because she really rocked this. And, she like really paid it forward to future medical students. One of the most beautiful parts of my job is mentorship. And it's like the gift that keeps on giving.
And, when you're a researcher or a clinician and you see a medical student or a research assistant, sometimes you're kind of like you're at a crossroads where you're like, I am booked to the rim, but, I believe in this person. And it just as a plug for, for those mentors out there who feel a little bit overwhelmed that that next med student that writes you that email could be the one that writes a killer article just like this.
Thanks again so much to Alex and Alysse for joining Febrile today. You can find their article, State of the Art Review, Evaluation and Management of Delusional Infestation, linked on the webpage and in the episode notes. Don't forget to check out our website, febrilepodcast. com, where you will find the Consult Notes, which are written supplements to the episodes with links to references, our library of ID infographics, and a link to our merch store.
Febrile is produced with support from the Infectious Diseases Society of America. Please reach out if you have any suggestions for future shows or want to be more involved with Febrile. Thanks for listening, stay safe, and I'll see you next time.