ABSTRACT An Interesting Case of Multifactorial Pruritus Chaozer Er1, Navin Kuthiah1, Sandeep Gohar2 Mr. TCS, a 63-year-old Chinese gentleman, with significant past medical history of diabetes mellitus, mitral regurgitation with ejection fraction of >55%, pseudogout, chronic kidney disease (baseline creatinine level of 130 umol/L, eGFR 47ml/min) and chronic alcoholism, presented to us with worsening of background chronic pruritus for the past 5 months. He had been having chronic pruritus for the past 10 years and was prescribed anti-histamine repetitively by multiple doctors. He had no previous dermatological condition. There was no skin rash, change in medication, recent travel, fever, diarrhoea or other discomfort. He described the itch as there were tiny insects crawling all over his body, usually began from legs then spread to the rest of his body. He was unable to see the insects but could feel them as “tiny dots” when he scratched his skin. He felt that “the insects” were scared of water and would hide beneath his skin when he splashed himself with water. On examination, he had bronze tanned appearance with mild xerosis, minimal excoriation without active dermatitis or blister. He was euthymic with no evidence of delirium or hallucination. Further investigations (table1) showed that he had subclinical hypothyroidism, iron overload, fatty liver and Stronglyloides stercoralis infection. He was seen by our dermatologist and psychiatrist. It was concluded that his pruritus was multifactorial: secondary haemachromatosis from alcoholic steatohepatitis, subclinical hypothyroidism, Strongyloides stercoralis infection, xerosis from diabetes mellitus and possibly underlying delusional parasitosis. His itch was treated with moisturiser, topical menthol cream and anti-histamine. He was discharged with follow up appointment with our dermatologist and internist. This case highlighted a) The importance of recognising pruritus as a manifestation of underlying systemic disorders b) The importance of having a systematic approach to investigate the aetiology of pruritus c) That pruritus can have more than one aetiology. Table 1
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