Scabies in the immunocompromised patient: a case report

Abstract

Introduction The patients who are hospitalized over 12 weeks have a high risk of immunorestitution disease, including scabies [1]. Scabies is a highly contagious skin infestation caused by the mite, Sarcoptes scabiei var. hominis. Diagnosis can be challenging, due to improved sanitation and similar features with other dermatological skin diseases [2]. Aims and Objectives We report the first case in Lithuania of scabies in an allogeinic hematopoietic cell transplant (HCT) recipient, initially suspected of skin graft versus host disease (GVHD). Scabies were diagnosed 40 days after onset of symptoms. Materials and methods A 51 – year – old female patient with acute myeloid leukemia was hospitalized in hematologic department and underwent allogeneic hematopoietic stem cell transplant (HSCT) on March 3, 2021., she received myeloablative conditioning including total body irradiation for 3 days and cyclophosphamide for 2 days. On posttransplant day 7, the patient developed severe itching, erythematous papular rash on the face and trunk, grade 3 mucositis, febrile fever and infectious complications: Staphylococcus epidermidis sepsis, BK virus cystitis, positive urine culture for Escherichia coli and Enterococcus faecium. Treatment with broad – sprectrum antibiotics, oral methylprednisolone, topical steroids and antihistamine agents was started. During the treatment fever regressed, itching and rash slightly decreased and on hospitalization day 29, April 2, 2021 the patient was discharged. On the April 5, 2021 the patient was admitted to HSCT unit because of severe diarrhea, renal dysfunction, rash all over the body and intense pruritus Acute GVHD reaction was suspectedLaboratory tests showed anemia (Hb 101 g/l), thrombocytopenia 78 x 10 9/l, normal white blood cell count 11,2 x 10 9/l, elevated C reactive protein 17,3 mg/l and increased creatinine 159 mcmol/l. Due to suspision of skin GVHD, but no response to the treatment with topical steroids and antihistami nes, after a consultation with dermatologists skin biopsy was performed. In histological examination of affected skin hypergranulosis, apoptotic keratinocytes, vacuolar degeneration of the basal membrane, vasodilatation in dermal layer, perivascular and interstitial lymphocyte infiltration were observed. Acute skin GVHD was diagnosed. Treatment with antihistamine agents and topical steroids continued but the patient still complained of severe itching sensation and erythemous papular rash. On hospitalization day 51, a repeated dermatological consultation was requested for the evaluation of intense itching and suspected cytomegalovirus infection (CMV). The polymerase chain recation (PCR) of skin biopsy for CMV was negative. During repeated consultation of dermatologists very itchy erythematous not – lichenoid paired papules and nodules on the legs, hands, abdomen, and back were observed. Skin biopsy was repeated. Histological examination, revealed lymphocytic infiltration, histiocytes and eosinophilic granulocytes in dermal layer, as well as Sarcoptes mite in the stratum corneum. Results Treatment with topical 4% permethrin cream was prescribed. The patient improved with treatment, after one week complete resolution of all skin lesions was observed. Conclusions Scabies should be considered in immunosuppressed patients with severe itching and maculopapular rash, although diagnosis can be delayed due to resemblance with other dermatological diseases [3]. A prompt diagnosis and treatment are necessary to prevent complications, such as secondary skin infections [4]. There is relatively low indicence of such clinical cases worldwide, most commonly diagnosed in pediatric patients. First choice treatment for scabies is oral ivermectin, but in our case treatment with permethrin cream was particularly successful.