Ironing out a diagnosis

Rachel called about her elderly father, Blaine, better known to me as Bucky. She requested a ‘nerve pill’ to calm him down at night and a referral to a neurologist to test for dementia.

The triage nurse spoke to Rachel to get more details. They thought he was developing Alzheimer’s dementia and were distraught. Since moving in with them a few months earlier, he was not doing well. He said he couldn’t sleep, often refused to even go to bed and try, and spent much of the night pacing the house and muttering. He told them he was being attacked by bugs that lived in his bed and recliner and the couch. He would fall asleep for a few hours in the early morning and often had several brief naps during the day (often at the table or watching TV) and was irritable and declined doing things with the family during the day because he was too tired. They said he had had a ‘thing’ about bugs for many years, but that it was now worse than it had ever been.

I declined to attempt phone management. ‘Nerve pills’ should never be prescribed over the phone without a careful evaluation, and sleeping medication is rarely safe in the elderly. I suggested they bring him in so we could evaluate his skin and better assess his concerns. I wondered about dry skin, or medical conditions like renal failure that could cause chronic itching.

Bucky came in with his daughter, son-in-law, and a grand daughter. He was his usual self: clean, neatly attired, moderately hard of hearing, but otherwise a good conversationalist. What I saw did not look like the agitated, irritable and disorganized person I was expecting based on the phone call. Their first questions were about blood tests, an MRI, nerve medications and sleeping pills, and a neurology referral. I suggested we start with a careful history so we would be able to pick the right kind of tests.  (I have written here and here about how important the history is and here about how a bad history can lead you astray.) 

He said the problem was that he was being attacked by insects at night and that it had begun recently, in the last 6 months. He had broken his hip and then spent some time in a local rehab facility before returning home to an apartment on the second floor in downtown Lewiston. He had found the stairs too much to manage and had happily agreed to live with his daughter and son-in-law in a neighboring small town. Since their four children were grown and raising families of their own, they had plenty of room, he was looking forward to being able to go outside in their yard when winter was over, and it gave him a chance to spend more time with grandchildren and great grandchildren.

His daughter interrupted impatiently to point out that it had started a long, long time ago. As a young man he had once lived in a building infested with fleas and bedbugs and ever since he had had ‘a thing’ about bugs.  She pointed out that over the years he had had exterminators come at least three times, though no insects were ever found. He had replaced furniture several times. He had moved once to get away from the bugs.  He had seen two dermatologists about bug bites; one had told him he had dry skin and the other told him he had neurodermatitis from itching. 

He was clearly embarrassed by this but did not argue about it.  He freely said that there was something abnormal about his chemistry, because the bugs only attacked him and never anyone else in the house, not even his late wife who shared the same bed.  He noted that the bugs seemed to come and go, and that he had tried different diets, soaps, even incense but had not found a solution.

When I asked what the bugs looked like, his response was that they were too small to see, but that they got into his skin and burned and bit, and the only thing that helped was to get out of the bed or chair where they lived. 

I asked him to describe exactly what it felt like, as if he were writing a book or a movie, so the audience would know everything about it.

“It’s like the bugs get into my skin. They mostly like my legs, but also my arms.  I can feel them inside my skin, it’s a terrible creepy-crawly burning sensation. (His daughter rolled her eyes at this.) It happens worst when I lay down at night. The bugs must sleep in the early morning because they usually leave me alone from about 4 a.m. to maybe 8 or 9. And the bugs can’t fly, because if I get up and walk around, they can’t follow me.  If I sit down, they find me again in a few minutes. It’s awful. I can’t sleep, and it makes me frantic.  I’m beginning to be afraid of my bedroom. And I don’t want my daughter to kick me out because I’m keeping everyone up at night. Even the Benadryl I’m taking isn’t helping me sleep.”

Ahhhh. We might have a solution!

Examination of his skin showed expected changes of age, some excoriations from scratching, but nothing that looked even remotely like a bug bite. Brief mental status testing with a MMSE gave a score of 29/30. Anything over 27 is normal.

I explained to Bucky and his family that he definitely did not have dementia, that there was no evidence of any mental illness other than anxiety from a chronic symptom that was disrupting sleep, that nerve pills and sleeping pills would expose him to potentially serious side effect risks, but that I was pretty confident we could make things much better.  I explained Restless Legs Syndrome (RLS) and suggested that it was worse now because it often worsens after surgery, because after his hip fracture he was more sedentary, and because the rehab facility had sent him home on Benadryl for sleep - which is known to worsen RLS.

I suggest we stop the Benadryl. I prescribed a 30 minute walk every day, and the granddaughter said she would make sure that happened. I explained that there were some good medications for RLS, but that about 1 in 5 cases of RLS (I never use percentages when talking to patients) are related to iron deficiency and that blood loss and iron deficiency can happen after hip surgery. I suggested we do some lab to make sure his kidney and liver function and thyroid were normal and check a ferritin to see about his iron.  If this was all normal, we could treat with RLS medications, but if the lab showed other things, then we should treat them as well.  They were polite but clearly skeptical.

The next day his lab came back. His sugar, thyroid, and renal and liver function were fine.  His ferritin was 6, which reflects very low iron, and his hematocrit was 29, a moderate anemia.  Both of these were consistent with recent blood loss from his recent surgery in the setting of a diet with little replacement iron. We started him on ferrous sulfate 325 mg twice daily with fruit juice. Three weeks later he reported he was much better and at eight weeks his anemia was resolved, his ferritin was 48, and the bugs were gone. At his follow-up, the family told my nurse to please thank me for ordering the right tests (though the right test was actually taking the time to do a thorough history) and he remarked, “The bugs must be allergic to iron.”


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