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This 65-year-old woman presented with an intensely pruritic, month-long skin rash that started beneath her right breast, thenspread quickly to involve multiple sites, including her face. Some of the lesions were maculopapular, others were psoriasiform, and still others weresolitary, rounded, and erythematous. She spent six weeks in the hospital undergoing studies before the diagnosis finally emerged.
A skin biopsy shortly after admission showed nonspecific findings. A repeat biopsy five weeks later uncovered numerous Sarcoptes scabiei mites. After several courses of scabicidal therapy, the rash resolved. But the story didn’t end there.
Thirty-five hospital workers acquired scabies from this patient. The incubation period for those virgin cases ranged from five to11 days, a distinctly shorter time frame than the 10 days to a month or more cited in textbooks. Many other personnel who came in contact with this patientnever got the disease, including her personal physician, who examined her twice daily. A consultant, however, who had had scabies as a medical student, acquiredit from this patient and became symptomatic 24 hours after examining her.
Observations in this case teach several lessons: 1) in some patients, diagnosing scabies requires more than one attempt; 2)susceptibility to scabies varies considerably; 3) the incubation period for virgin cases can be much shorter than what the textbooks cite; 4) in cases ofrepeat infection, the incubation period is only 24 to 72 hours; and 5) any unexplained, persistent, intensely pruritic skin rash should be considered asscabies until proved otherwise.
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