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array:23 [ "pii" => "S2387020618305473" "issn" => "23870206" "doi" => "10.1016/j.medcle.2018.03.038" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "4482" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2018" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Clin. 2019;152:118-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "formatos" => array:2 [ "HTML" => 1 "PDF" => 2 ] ] "itemSiguiente" => array:19 [ "pii" => "S2387020618305345" "issn" => "23870206" "doi" => "10.1016/j.medcle.2018.03.036" "estado" => "S300" "fechaPublicacion" => "2019-02-01" "aid" => "4484" "copyright" => "Elsevier España, S.L.U." 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"documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2019;152:115-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "The problem of the fragmentation of hospital medicine" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "115" "paginaFinal" => "117" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El problema de la fragmentación de la medicina hospitalaria" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eduardo Montero Ruiz, Luis Manzano Espinosa" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Montero Ruiz" ] 1 => array:2 [ "nombre" => 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"paginaInicial" => "118" "paginaFinal" => "119" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carmen Maura Carrillo de Albornoz Calahorro, David López-Delgado, Luis Gutiérrez-Rojas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Carmen Maura" "apellidos" => "Carrillo de Albornoz Calahorro" "email" => array:1 [ 0 => "carmens_maura@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "David" "apellidos" => "López-Delgado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Luis" "apellidos" => "Gutiérrez-Rojas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Psiquiatría, Complejo Hospitalario Granada, Servicio Andaluz de Salud, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología, Complejo Hospitalario Granada, Servicio Andaluz de Salud, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la enfermedad de Morgellons con quetiapina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 1200 "Tamanyo" => 129245 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Occipital injury in the initial and final phases.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Morgellons disease is a condition in which the patient has the delusional belief that is infected by unhealthy agents such as insects, parasites, hairs and fibres.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with this disorder often have a wide range of skin lesions, due to the insistence of scratching and biting, due to tingling sensations.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Most of these patients do not seek psychiatric care at the onset of the disease, but rather go to their family doctor or dermatologist instead.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Frequently, a period of several months of unnecessary dermatological treatments and frequent emergency care elapse before a contact occurs between the dermatologist and the psychiatrist. This cooperation prevails fundamental in the treatment of this disease.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The symptoms are similar to those of delusional parasitosis/delusional infestation and it is therefore commonly considered to be a monosymptomatic delusional disorder, somatic type.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We present a 33-year-old white male patient who entered a psychiatric unit as a result of a skin lesion. He had the firm idea that he was infected by organisms with <span class="elsevierStyleItalic">roots</span> that penetrated his skin and that it itches so he could not stop scratching.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He has been in follow-up at the mental and community health unit in his rural area since 2006 due to continuous paranoid schizophrenia with good therapeutic adherence to date. He has had three previous admissions in a psychiatric unit due to psychotic paranoid episodes in the context of toxic consumption. There were no skin lesions on these occasions or any type of somatoform disorder. For the past two years, he has started this scraping injury in the occipital region. His family doctor has tried various topical and oral treatments at this time because of an infection of the lesions, but the patient continued to manipulate the area and the lesion did not heal properly. The psychiatrist agrees the need for an urgent involuntary admission for hospital control of the injury and supervision by the dermatology department.</p><p id="par0035" class="elsevierStylePara elsevierViewall">On arrival at the emergency room, the patient had been receiving treatment with depot risperidone 50<span class="elsevierStyleHsp" style=""></span>mg every 2 weeks and 40<span class="elsevierStyleHsp" style=""></span>mg clotiapine before bed during 13 months. An emergency blood test was performed without any pathological findings.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Physical examination showed a deep ulcer in occipital region, with abundant fibrin and granulation tissue and other smaller ulcers in the right shoulder could be appreciated. Previous scars on the upper side of the back could be seen. Cultures for bacteria and fungus were negative and a skin biopsy was performed showing a neutrophilic non-specific infiltrate compatible with the clinical diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment with mupirocin and hydrocolloid dressing every 24–48<span class="elsevierStyleHsp" style=""></span>h was prescribed with improvement of the lesions.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient remained in the psychiatric unit for 4 weeks. During his stay he proceeds in exchange for antipsychotic being the current replaced by quetiapine starting at 25<span class="elsevierStyleHsp" style=""></span>mg per day and reaching 450<span class="elsevierStyleHsp" style=""></span>mg a day before hospital discharge. With this new drug, scratching was reduced considerably (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Assuming that parasites are not involved, chronic pruritus and delusional infestation arise from an underlying physiological or physical cause that triggers an itch pathway. Underlying psychiatric conditions may be linked to this pathway as well.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment of patients suffering from delusional infestation or from chronic pruritus is largely based on the patient's interpretation of the cause and the physician's response to that interpretation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Within the medical community, Morgellons disease it is generally held to be a variation of delusional infestation, which is usually treated with antipsychotics.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The classic treatment included typical antipsychotic agents but their extrapyramidal adverse effects at therapeutic doses make such treatments less practical. More recently, several reports suggested the atypical antipsychotic agents as potential alternatives because of their more favourable adverse effect profile.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Quetiapine seems to offer several advantages in the treatment of delusional disorders. In fact, it does not seem to increase the risk of extrapyramidal or anticholinergic symptoms and cardiovascular adverse effects. The most common side effects of quetiapine are drowsiness and dizziness. These side effects can be harnessed to decrease the sensation of pruritus and avoid permanent scratching.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Dermatologists and psychiatrist should collaborate closely to make an appropriated diagnosis and treatment of these cases. Diagnosis of delusional infestation is always an exclusion diagnosis and many other cutaneous diseases should be excluded previously.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contribution</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors of this paper were responsible for conceiving and designing the evaluation, clinical data collection, clinical data interpretation, and drafting the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 1200 "Tamanyo" => 129245 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Occipital injury in the initial and final phases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delusional infestation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.W. Freudenmann" 1 => "P. Lepping" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2012.10995.x" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "690" "paginaFinal" => "732" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19822895" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delusional parasitosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Madoz-Gurpide" 1 => "E. García Rees" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin" "fecha" => "2004" "volumen" => "123" "paginaInicial" => "66" "paginaFinal" => "69" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Information, consent and treatment of patients with Morgellons disease: an ethical perspective" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. Söderfeldt" 1 => "D. 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Walter-Ryan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Clin Psychiatry" "fecha" => "1986" "volumen" => "47" "paginaInicial" => "188" "paginaFinal" => "190" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3957878" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delusional parasitosis associated to mild cognitive impairment of vascular causation. good response to low doses of quetiapine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Pías-Peleteiro" 1 => "J.M. Aldrey" 2 => "G. Fernández-Pajarín" 3 => "B. Ares Pensado" 4 => "I. Jiménez-Martín" 5 => "A. Sesar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Neurol" "fecha" => "2015" "volumen" => "61" "paginaInicial" => "334" "paginaFinal" => "335" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26411279" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000003/v1_201901290746/S2387020618305473/v1_201901290746/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000003/v1_201901290746/S2387020618305473/v1_201901290746/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618305473?idApp=UINPBA00004N" ]
