Bug's life: a woman tends to a shelf full of cockroaches in jars in a lab, c.1955. Photo: Getty
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The patient complained of insects crawling on her skin. Then she handed me a glass jar

The “matchbox sign” describes the tendency of a particular sort of patient to bring spurious evidence in a small container to show the doctor.

Erica was hugely frustrated. “I’ve had the council round several times, they’ve fumigated the whole place twice, and still I’m getting bitten.” I peered at her lower legs. There were scattered red lumps and lots of scratch marks. The pest control officer, having exhausted his insecticidal repertoire, had sent Erica along to me.

The commonest reason for someone being eaten alive in their own home is the death of a cat. Fleas live in carpets, hopping on to the resident pet when in need of food. As long as Tiddles remains hale and hearty, human beings are bitten only sporadically. But a few weeks after a feline departure, the now-starving fleas start to feast on the grieving owner. Erica, however, denied any previous pet ownership. And flea bites are typically clustered around the ankles and lower shins, whereas Erica said she was affected all over.

I scrutinised the skin of her wrist and the web spaces between her fingers. Infestation with scabies is surprisingly common, and those areas are favourite locations for the mites. There was nothing to see, though. And while most of her torso was scratched and bump-strewn, her mid-back was blemish-free. This pattern suggests something called prurigo. Incessant scratching of normal skin results in raised red prurigo lumps, which can easily be mistaken for insect bites. The area between the shoulder blades remains unaffected, though, because it is impossible to scratch there concertedly.

Numerous conditions can cause generalised itching, from iron deficiency to an underactive thyroid. I took blood samples and gave Erica a prescription for a bottle of Eurax – a fantastic lotion that will suppress itching, whatever the cause. A week later the blood tests were back, and normal. Erica was back, too. And this time she’d brought specimens of the offending insects to show me. “There!” she announced, handing me a little glass jar. Inside were a couple of wisps of dark fluff and some indeterminate bits of debris. Not even tapping the contents on to my palm for a sift-through could produce any evidence of life forms.

Something about the little glass jar rang a bell. The “matchbox sign” describes the tendency of a particular sort of patient to bring spurious evidence in a small container to show the doctor. I looked at Erica afresh: in her late fifties, a trifle eccentric, but absolutely no history or indication of any mental or physical illness. I wondered if she might have Ekbom syndrome, or delusional parasitosis.

Delusional parasitosis is a belief that one is infested with some sort of parasite. In all other respects the patient is functioning normally, and so presents a convincing account of his or her troubles to pest control personnel, doctors and veterinarians. A big problem with Ekbom’s is the characteristic refusal of the sufferer to accept that he or she is suffering from a mental illness. Antipsychotic drugs, more often used for treating schizophrenia, can be very effective, but most patients reject them out of hand.

“I’d like you to try these tablets,” I told Erica. “They’re usually used to treat schizophrenia, but bizarrely enough they’re also quite likely to reduce the itch and the rash you’re experiencing.” I smiled, hoping she wouldn’t probe my explanation. I wasn’t lying as such; just being careful which bits of the picture I painted.

She returned to the surgery a month later and, to my relief, had taken the tablets. “It’s amazing,” she told me, “it’s completely better.” She showed me a few areas of pristine skin, and then she fell silent for a few moments. When she spoke again her voice was lowered, embarrassed. “Doctor, was I psychotic?”

“Well, yes,” I told her, and explained about Ekbom syndrome. With recovery had come full insight, and she recounted, with something akin to awe, how she now looked at the specimens she’d collected and could see that they were nothing but fluff, but could clearly remember perceiving them as dead insects. And the persistent sensation of things crawling over her skin had been utterly real to her.

Ekbom’s is fascinating and rare; I doubt I’ll see another case. Pest control officers probably encounter it more often. I imagine they have a cut-off – perhaps two failed fumigations, or when the homeowner starts to present them with bits of debris in a matchbox – when they suggest that a doctor might be better placed to help with this particular infestation. 

This article first appeared in the 06 August 2014 issue of the New Statesman, Inside Gaza

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It's Gary Lineker 1, the Sun 0

The football hero has found himself at the heart of a Twitter storm over the refugee children debate.

The Mole wonders what sort of topsy-turvy universe we now live in where Gary Lineker is suddenly being called a “political activist” by a Conservative MP? Our favourite big-eared football pundit has found himself in a war of words with the Sun newspaper after wading into the controversy over the age of the refugee children granted entry into Britain from Calais.

Pictures published earlier this week in the right-wing press prompted speculation over the migrants' “true age”, and a Tory MP even went as far as suggesting that these children should have their age verified by dental X-rays. All of which leaves your poor Mole with a deeply furrowed brow. But luckily the British Dental Association was on hand to condemn the idea as unethical, inaccurate and inappropriate. Phew. Thank God for dentists.

Back to old Big Ears, sorry, Saint Gary, who on Wednesday tweeted his outrage over the Murdoch-owned newspaper’s scaremongering coverage of the story. He smacked down the ex-English Defence League leader, Tommy Robinson, in a single tweet, calling him a “racist idiot”, and went on to defend his right to express his opinions freely on his feed.

The Sun hit back in traditional form, calling for Lineker to be ousted from his job as host of the BBC’s Match of the Day. The headline they chose? “Out on his ears”, of course, referring to the sporting hero’s most notable assets. In the article, the tabloid lays into Lineker, branding him a “leftie luvvie” and “jug-eared”. The article attacked him for describing those querying the age of the young migrants as “hideously racist” and suggested he had breached BBC guidelines on impartiality.

All of which has prompted calls for a boycott of the Sun and an outpouring of support for Lineker on Twitter. His fellow football hero Stan Collymore waded in, tweeting that he was on “Team Lineker”. Leading the charge against the Murdoch-owned title was the close ally of Labour leader Jeremy Corbyn and former Channel 4 News economics editor, Paul Mason, who tweeted:

Lineker, who is not accustomed to finding himself at the centre of such highly politicised arguments on social media, responded with typical good humour, saying he had received a bit of a “spanking”.

All of which leaves the Mole with renewed respect for Lineker and an uncharacteristic desire to watch this weekend’s Match of the Day to see if any trace of his new activist persona might surface.


I'm a mole, innit.