Parasites

I saw a patient recently for parasites.

I get a sinking feeling when I see that diagnosis on the schedule, as it rarely means a real parasite.  The great Pacific NW is mostly parasite free, so either it is a traveler or someone with delusions of parasitism.

The latter comes in two forms: the classic form and Morgellons. Neither are likely to lead to a meaningful patient-doctor interaction, since it usually means conflict between my assessment of the problem and the patients assessment of the problem.  There is rarely a middle ground upon which to meet. The most memorable case of delusions of parasitism I have seen was a patient who  I saw in clinic who, while we talked, ate a raw garlic clove about every minute.

“Why the garlic?” I asked.

“To keep the parasites at bay,” he told me.

I asked him to describe the parasite.  He told me they floated in the air, fell on his skin, and then burrowed in.  Then he later plucked them out of his nose.

At this point he took out a large bottle that rattled as he shook it.

“I keep them in here,” he said as he screwed off the lid and dumped about 3 cups with of dried boogers on the exam table.

To my credit I neither screamed nor vomited, although for a year I could not eat garlic.  It was during this time I was attacked by a vampire, and joined the ranks of the undead.

I have seen the occasional earthworm thought to be an intestinal parasite. Sometimes people start to pay attention to their stool, often for the first time, and note  tube like structures  that move in the water.  Most likely mucous or undigested fiber wafting in the gentle currents of the toilet water.  Doesn’t that sound romantic? The contents of the average stool, like hot dogs and laws, are better left unexamined.  In those patients, an examination of the stool for worms and worm eggs is usually unrevealing and makes me glad I am not a microbiology technician.

Morgellons is, as best I can tell, a variant of delusions of parasitism.

Here is a thing about germs in general and parasites specifically: they have patterns and can be seen. There are patterns of disease and patterns of their life cycle.  You can tell when a disease is probably delusional because the “organisms” have no understandable pattern in the life cycle, the disease, the physiology, the anatomy or the epidemiology.

And germs can be seen. Well, most germs.  Single celled organisms can be tricky and may require special stains to be seen under the microscope.  Viruses are, of course, too small to be seen by a lab microscope. But parasites? Worms? These wee beasties are multicellular.  They are big. Not a long way to the chemists big, but sizable, not hard to see with a microscope unless they have Romulan cloaking technology.

So what is Morgellons?

Before we continue, I would like to clarify one thing. I see patients self diagnosed with Chronic Candida Syndrome or Morgellons or Chronic Lyme or some other process.  I do not doubt these people are ill and have symptoms that can be severe and life altering.  What I may disagree with the patient is the reason for these symptoms.  As best I can tell none of the above are due to an infectious disease.

Unfortunately when the patient is convinced they have an etiology for their symptoms and I think that their reason is nonsense, it does not lead to a therapeutic physician-patient interaction.  I try and phrase it as gently and non-judgmentally  as possible, but it rarely leads to a good time in the clinic.

Morgellons has existed as a disease since about 2002 and is an internet phenomena right up there with Rebecca Black.  See.  For a 54 year old man, I am hip. Morgellons received its name from a paper from 1935 called SIR THOMAS BROWNE AND THE DISEASE CALLED THE MORGELLONS By C.E. KELLETT, M.D., M.R.C.P. and published in Annals of Medical History, n.s., VII (1935), 467-479,  where it refers to a disease from the 1600’s (yes 1600’s) described by said Thomas Browne.

“Hairs which have most amused me have not been in the face or head, but on the Back, and not in Men but Children, as I long ago observed in that endemial Distemper of little Children in Languedock, called the Morgellons, wherein they critically break out with harsh Hairs on their Backs, which takes off the unquiet symptoms of the Disease, and delivers them from Coughs and Convulsions.”

Who know what these hairs/worms really were; the 1600’s were not a time noted for its diagnostic accuracy. Unlike the modern disease, it was usually a disease of children and often fatal, so whether these “hairs”  had anything to do with the disease or were actual living creatures, one cannot say.

In  1715 when the first microscopist, Leuvenhoeck, took a look at the bristles and thought them “inanimate”, starting a long tradition of looking at the detritus presented by Morgellons patients and seeing nothing.  I, for one, always look at the fluff brought in by Morgellons patients and have yet to see anything resembling a living creature. Diseases have come and gone in the past, like the English Sweating Sickness, so maybe there was a plague of virulent hairs (that’s hair not hare, it was not a virulent bunny, for which Hef is undoubtedly grateful), but no longer.

Fast forward 400 years.  Round about 2002 this disease was described on the net in regards a child with the symptoms now referred to as Morgellons, and since others have had the disease.  It is transmissible as an internet meme, but not spread person to person.

What are the distinguishing characteristics of Morgellons?  Here are features as noted from the Morgellons Research Foundation

1. “Filaments” are reported in and on skin lesions and at times extruding from intact-appearing skin. White, blue, red, and black are common among described fiber colors. Size is near microscopic, and good clinical visualization requires 10-30 X. Patients frequently describe ultraviolet light generated fluorescence. They also report black or white granules, similar in size and shape to sand grains, on or in their skin or on clothing. Most clinicians willing to invest in a simple hand held commercial microscope have thus far been able to consistently document the filaments.
2. Movement sensations, both beneath and on the skin surface. Sensations are often described by the patient as intermittently moving, stinging or biting. Involved areas can include any skin region (such as over limbs or trunk), but may be limited to the scalp, nasal passages, ear canals, or face…and curiously, legs below the knees.
3. Skin lesions, both (a) spontaneously appearing and (b) self-generated, often with pain or intense itching. The former (a) may initially appear as “hive-like”, or as “pimple-like” with or without a white center. The latter (b) appear as linear or “picking” excoriations. Even when not self-generated (as in unreachable regions of babies’ skin), lesions often progress to open wounds that heal incompletely (e.g., heal very slowly with discolored epidermis or seal over with a thick gelatinous outer layer.). Evidence of lesions persists visually for years.
4. Musculoskeletal Effects and Pain is usually present, manifest in several ways. Pain distribution is broad, and can include joint(s), muscles, tendons and connective tissue. Both vascular and “pressure” headaches and vertebral pain are particularly common, the latter usually with premature (e.g., age 20) signs of degeneration of both discs and vertebrae.
5. Aerobic limitation is universal and significant enough to interfere with the activities of daily living. Most patients meet the Fukuda Criteria for Chronic Fatigue Syndrome as well (Fukuda, Ann. Int. Med., 1994). Cardiology data and consistently elevated heart rates suggest a persistent myocarditis creating lowered cardiac output that has been partially compensated for by Starling’s Law.
6. Cognitive dysfunction, includes frontal lobe processing signs interfering with logical thinking as well as short-term memory and attention deficit. All are measurable by Standard Psychometric Test batteries.
7. Emotional effects are present in most patients. Character typically includes loss or limitation of boundary control (as in bipolar illness) and intermittent obsessional state. Degree varies greatly from virtually absent to seriously life altering. “

It is the filaments.  Over the years I have  seen a smattering of Morgellons and they bring in the filaments and I look at them under the microscope. I see hairs, and threads, and non-specific detritus, but never anything that resembles the results of a living creature. I have looked carefully at the skin of these patients, and have never seen an intradermal fiber.

So you can see why I am skeptical that this is anything but a version of delusions of parasitism.  In one series of 25 patients

Most patients in this study (23 out of 25) had prior psychiatric diagnoses (most determined by specialists) as follows: 11 out of 25 bipolar disease; 7 out of 25 Adult ADD; 4 out of 25 Obsessive Compulsive Disorder (OCD); and 1 out of 25 Schizophrenia.

The same study had a hodgepodge of lab abnormalities, but there were not compared to matched controls. It may well be that the patients have some underlying inflammatory process that causes skin lesions and a feeling of the creepy crawlies and are misidentifying standard environmental material as associated with the diseases.  But I am skeptical.

Against this hypothesis are the case reports where Morgellons is cured with Pimozide, an antipsychotic.  Delusions of parasitism is often treated with olanzapine, another antipsychotic, but others have suggested pimozide is superior.  Most infections would be unlikely to respond to antipsychotics, but I have never been satisfied with response to treatment as a means for confirming a diagnosis, that is a path better not followed without good reason. In my world docs often think if patients are improving on antibiotics the response is considered evidence of infection.  I know better. But given the lack of a demonstrable parasite, a response to psychiatric medications is certainly suggestive.

So response to anti-psychotics would suggest patients with Morgellons could have  a psychosis, but I keep in mind it does not necessarily extrapolate to all patients.  I try to bear in mind that when patients present with odd symptoms that they attribute to worms and parasites, it may be simple misunderstanding.

As of this entry, no one has fulfilled Kochs postulates with Morgellons.

For those not immersed in infectious diseases, Koccs postulates were a series of criteria to demonstrate the causality of infections,  Here there are, with the word filament substituted for microorganisms:

1) The filament must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.
2) The micro filaments must be isolated from a diseased organism and grown in pure culture.
3) The cultured filament should cause disease when introduced into a healthy organism.
4) The filament must be re isolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.

So far proponents of the disease are 0 for 4.

But if this disease is due something that can be visualized with the naked eye or a magnifying glass, it should be simple enough to characterize.  Lets say you are a DNP and a member of ILADS. Well, I have to admit that you have lost some credibility with me.  But lets say you saw a series of patients with Morgellons and you could see the fibers.  There, right there. You can see them.  Would you not biopsy the fibers?  Would you not try to characterize them?  Nope.  So aggravating. It boggles the mind that someone could have a diagnostic coup right in front of them and let it pass.

Delusions of parasitism can be nosocomial. Well, not truly delusions, but patients can be convinced they have parasites when, in fact, they do not, and waste serious amounts of time and cash in pursuit of an imaginary diagnoses.

I recently saw a patient who had unexplained abdominal pain for a year and a half.  The patient had an extensive evaluation and no explanation for the symptoms, and,  looking for answers,  eventually wandered into the arms of a naturopath.

One of the shows my eldest liked to watch was I Love the 80’s on VH1.  The 80’s was the decade I was in medical school, residency and fellowship.  When I watched I Love the 80′s I recognized virtually nothing of popular culture of time.  Not the TV shows, the hair styles, the music. Nothing.   It really brought home how consuming becoming a doc and a subspecialist is.  A decade of my life was spent understanding medicine and infectious diseases. I am not complaining, mind you.  There are lots of reasons people go to an alt med provider, but I do not think gullibility is on the list.

The patient with the abdominal pain and their spouse are educated people, why would they see a naturopath?

Looking for answers.  Their areas of knowledge are totally removed from medicine and science, and while it is popular to bemoan the science illiteracy of the US population, and it is sorry, if your career arc was law, or finance or auto repair, or stoner at the 7/11,  are you going to find time to become literate in medicine?  Doubt it.  I can’t design a bridge or fly a jet.  Why would I expect someone who has mastered these tasks to understand medicine?  There are just so many hours in a day to accomplish tasks.

I have, as a further example, zero idea if my mechanic is giving me good diagnostic and repair advice on my car.  I have to take everything he says on faith.  I have neither the time or inclination to become expert in car repair, and most people do not have the time to become fluent in medicine.  Am I gullible?  I do not think so.

I had my epiphany years ago when I told a father of a meningitis patient, your daughter has an infection in the fluid that surrounds her brain and he replied, could you phrase that in a way I can understand it?  He had no idea of basic brain anatomy or infections, and why would he? So I drew him a picture.  It helped.

So anyway, the patient wandered  into the lair of a naturopath and was diagnosed with parasites.  Now mind you, the patient did not have symptoms that could be reasonably ascribed to parasites or worms, and, more importantly, had no risks for parasites or worms.  The industrialized West is reasonably free of worms and their brethren.  The naturopath did not do serology or blood work or even a simple stool study looking for the eggs of various worms.  It is how I, along with a history and physical looking for the pattern of disease that marks a parasite, come to a diagnosis. No, he or she (I do not remember the pronoun used at the time) proudly used electrodiagnosis.

Proudly.  As my patient related it to me, the naturopath, a graduate of Bastyr, (if there is an legitimate opportunity for a deliberate mispronunciation, it is with Bastyr) considered herself to be an expert in parasite treatment and diagnosis.

What is electrodiagnosis you ask?

There are many devices out there, so I do not know precisely which one the patient used.

My patient said they held an electrode in each hand, the naturopathic expert in parasitology twirled a dial, and told them that the reading indicated parasites. Really.  I am proud that I did not burst out laughing during the interview, as from my perspective it was a  ludicrous joke.  But, as I mentioned, not everyone knows what I do, and EEG’s and EKG’s can also diagnoses a variety of medical problems, so why not parasite infestation?

Electrodiagnosis are said to measure disturbances in the body’s flow of “electro-magnetic energy” along “acupuncture meridians” but are expensive galvanometers that measure electrical resistance of the patient’s skin when touched by a probe. Two pseudosciences in one.  I have seen better.   It is sometimes called electroacupuncture according to Voll, or EAV, and was pulled out of Dr. Volls backside in the 1950’s.

“The basic concept for all of the ElectroDermal screening devices, was the invention of Dr. Reinhardt Voll[1], who in the 1940s, discovered that the electrical resistance of the human body is not homogenous and that meridians existed over the body which may be demonstrated as electrical fields. Furthermore, he showed that the skin is a semi-insulator to the outside environment. By the 1950s Voll had learned that the body had at least 1000 points on the skin which followed the 12 lines of the classical Chinese meridians. Each of these points, Voll[2] called a Measurement Point (MP). Working with an engineer, Fritz Werner, Voll created an instrument to measure the skin resistance at each of the acupuncture points, patterned after a technique called Galvanic Skin Resistance (GSR). This was named Point Testing. In 1953, Voll had established the procedure that became known as Electro-Acupuncture according to Voll.”

There is zero validity to making any diagnosis this way. Except, of course, the E-Meter of Scientology.  I wouldn’t want to cross the them there Scientologists. Oh no, uh uh. No way.  E-meter forever. But those other electronic diagnostic devices? Pure bunkum.  I could not say it better than Quackwatch:

“The devices  are used to diagnose nonexistent health problems, select inappropriate treatment, and defraud insurance companies. The practitioners who use them are either delusional, dishonest, or both.”

That the  American Association of Naturopathic Physicians has a position statement on electrodiagnosis that considers it experimental is another sign that naturopaths have no business taking care of people.  To quote their position paper

“There are three levels of electro-diagnosis:
a. Meridian testing: Readings are interpreted in indicate strength of specific meridians, organ strength or physiologic function.
b. Remedy testing: Variations in readings are interpreted when remedies are given to the patient either orally, to hold or put on a “testing plate” wired to the electrodiagnostic equipment. Interpretations may include sensitivities, nutritional enhancement, or improved function.
c. Energy medicines: Electrodiagnostic equipment interprets information and manufactures an energy medicine which is given to the patient to take orally.
THEREFORE IT IS THE POSITION OF THE AANP THAT:
It is appropriate that the naturopathic profession pursue scientific research regarding the reproducibility and reliability .”

There is nothing on the Pubmeds on the validity of electrodiagnosis, and, on basic principals and prior probability, to suspect that electrodiagnosis would have any utility in the diagnosis of parasites  or anything other disease.

Despite this, my patient received prolonged courses of mebendazole, thiabendazole and praziquantel, all at half doses, and all out of pocket.

Uncertain of which parasite to kill, the naturopath tried to kill them all with under-dosed medications.  Good thing, come to think of it, that he did not use his infernal contraption to diagnose cancer, who knows how many anticancer treatments would have been prescribed.

And what is an energy medication and how does one manufacture them? Besides a triple shot of espresso?  The principals of EAV have been expanded for

“BioScan (remote DNA resonant testing) – This procedure utilizes extremely sensitive EAV computerized equipment to accurately measure stressors in the body. It bombards the clients sample DNA (usually hair) with up to 10,000 frequencies to locate bacteria, viruses, pesticides, heavy metals, industrial pollutants, chemicals, parasites, foods, allergies, dental materials, trees, weeds, pollens, inhalants, molds, yeast, fungus and many other substances that poison the environment today. These stressors and related deficiencies are identified in print form for the client along with the organs and glands affected by the stressors. Supplements are suggested that resonate with the test subject and homeopathics are customized to support the body to remove the stressors and return to homeostasis.”

Only 275 dollars, plus 5 dollars shipping and handling.  And they recommend a minimum of 4 evaluations.

Try as I might, I cannot write a satisfying concluding paragraph to this entry, so I will just stop.