Ekbom syndrome (delusory parasitosis): ponderations on two cases.

Two persons met one of us to ask for medical advice. On the basis of the clinical picture, we established the diagnosis of Ekbom syndrome, fundamentally related to skin lesions. We judged it relevant to communicate these occurrences, particularly for the reason that, in spite of our vast experience in dealing with clinical and assistance practice, we had not until now come into contact with patients in such situation. There is no doubt that this subject deserves specific commentaries, as it connotes speculation, doubts, and a wide range of opinions. The first account of a complex set of symptoms later known as the restless legs syndrome (anxietas tibiarum) was given in 1685 by Sir Thomas Brown, an English physician. The same investigator wrote a monograph under the title “Letter to a Friend” describing a condition observed in children of Languedoc, characterized by the periodic extrusion of stiff “black hairs” observed on their lumbar region. These children were called “morgellons” in the local language. Even now, such fundamental aspects of both conditions, as etiology, clinical picture and therapy, are the object of doubts. The symptoms of the restless legs syndrome are at first felt when the patient is at rest: an unpleasant sensation in the legs (rarely in the arms) accompanied by uncontrollable movements which become less intense when there is voluntary activity, to return when this activity ceases. Serious sleep disturbance results. Both syndromes: the restless legs (Wittmaak -– Ekbom) and the morgellons are now identified as two distinct entities, but there are some authors who still consider them as two aspects of the same entity because neuropsychiatric symptoms considered to be analogous can be observed in both cases. The persistence of such doubts is an indication of scarcity of information available about the causes of symptoms that, for lack of proper investigation, are inexplicable as to their origin and persist interfering with people’s normal daily activities. A better fate was not in prospect for those with morgellons disease. They sense the migration of mysterious “parasites” under their skin. Sometimes skin fragments together with structures defined as “fibers” are extruded. Such cases are often diagnosed as delusory parasitosis. As yet their etiology has not been defined. In the consultation room these patients describe the feeling that they have migrating parasites and, as evidence to prove their case, they bring for examination small boxes containing fragments of apparently normal skin in which can sometimes be found filaments which are not identified as pieces of cloth. The frequency of this occurrence led medical students to coin the expression “matchbox syndrome”. Atrocious suffering is associated with the presence of such “parasites”. Sometimes the diagnostic hypothesis of “larva migrans” is accepted and anthelminthic treatment is prescribed. On consulting a dermatologist, the patients are usually referred to a psychiatrist. The paucity of convincing information about their causes has led to the acceptance of the hypothesis that the symptoms of the morgellons disease are a manifestation of Lyme disease, even though no epidemiological or laboratory data confirm such diagnostic assumption. There is a tendency to judge the accounts of patients as illogical, resulting from neuropsychiatric problems which do not correspond to a true clinical picture. In view of such hypothesis, prophylactic measures against this syndrome would be pointless. A tendency has been recently observed to oppose the notion that the Wittmaack-Ekbom syndrome is exclusively the result of a neuropsychiatric disorder; various medical research institutions are showing interest in identifying its possible causative agents, devising new laboratory research techniques and eventually finding a suitable therapeutic project. Basic data concerning the two cases observed are specified below: