LAUSR

The patient was diagnosed with crusted scabies infection, as confirmed by microscopic examination of skin scrapings, which showed eight-legged scabies mites (Sarcoptes scabiei). Topical therapy with sulfur ointments produced no dramatic improvement. The rash gradually subsided after the first application of 1% lindane solution, although the patient eventually died of Enterobacter aerogenes septicemia and multi-organ system failure days following discharge from the hospital. Crusted scabies, also known as Norwegian scabies, is a rare, severe, and highly contagious form of scabies infestation (1) characterized by extensive psoriasis-like scaling, hyperkeratotic lesions, and nail thickening. It is seen often in frail and immunocompromised patients, including elderly patients and those with human immunodeficiency virus, human T cell lymphotropic virus type 1 infection, leprosy, lymphoma (2), Down syndrome (3), and long-term use of topical corticosteroids (4). Crusted scabies presents more severe symptoms, milder pruritus, and a higher abundance of mites, which can reach millions in number, compared to classic scabies which presents fewer than 100 mites over the entire body (5). Laboratory abnormalities may include peripheral eosinophilia and elevated serum immunoglobulin E levels (5). A diagnosis of crusted scabies may be strongly suspected based on physical examination and medical history and can be confirmed by microscopic examinations for scabies mites, eggs, and scybala (feces). Microscopically, S. scabiei mites measure 0.3 0.4 mm microscopically (6), with short and stubby legs. The anterior two pairs of legs end in discs, and the posterior two pairs end in long bristles. The entire life cycle requires 10 to 14 days (7). Differential diagnoses comprise other disorders characterized by hyperkeratotic patches or plaques; namely, psoriasis, seborrheic dermatitis, Darier disease, palmoplantar keratoderma (8), and fungal and mycobacterial infections. Early diagnosis and appropriate therapy contribute to preventing sizeable community-wide outbreaks of crusted scabies and secondary bacterial infections and sepsis (9). The treatments available for crusted scabies treatments are consistent with those for classic scabies, focusing mainly on killing the mites and relieving pruritus. Combination treatment with permethrin and oral ivermectin is recommended as the initial agent of choice. Other treatment options include topical benzyl benzoate, sulfur-containing compounds, ivermectin, and lindane (10, 11). The ability to identify and treat crusted scabies is essential to decrease the spread of this infection. The public health department should be contacted immediately, and relevant contact patients should be immediately instructed to isolate and treated simultaneously. In addition, the clothing and bedding of the affected patient should be washed in a washing machine with hot water, and the room should be thoroughly cleaned (12).