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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Is defeat in Stoke the beginning of the end for Paul Nuttall?

The Ukip leader was his party's unity candidate. But after his defeat in Stoke, the old divisions are beginning to show again

In a speech to Ukip’s spring conference in Bolton on February 17, the party’s once and probably future leader Nigel Farage laid down the gauntlet for his successor, Paul Nuttall. Stoke’s by-election was “fundamental” to the future of the party – and Nuttall had to win.
 
One week on, Nuttall has failed that test miserably and thrown the fundamental questions hanging over Ukip’s future into harsh relief. 

For all his bullish talk of supplanting Labour in its industrial heartlands, the Ukip leader only managed to increase the party’s vote share by 2.2 percentage points on 2015. This paltry increase came despite Stoke’s 70 per cent Brexit majority, and a media narrative that was, until the revelations around Nuttall and Hillsborough, talking the party’s chances up.
 
So what now for Nuttall? There is, for the time being, little chance of him resigning – and, in truth, few inside Ukip expected him to win. Nuttall was relying on two well-rehearsed lines as get-out-of-jail free cards very early on in the campaign. 

The first was that the seat was a lowly 72 on Ukip’s target list. The second was that he had been leader of party whose image had been tarnished by infighting both figurative and literal for all of 12 weeks – the real work of his project had yet to begin. 

The chances of that project ever succeeding were modest at the very best. After yesterday’s defeat, it looks even more unlikely. Nuttall had originally stated his intention to run in the likely by-election in Leigh, Greater Manchester, when Andy Burnham wins the Greater Manchester metro mayoralty as is expected in May (Wigan, the borough of which Leigh is part, voted 64 per cent for Brexit).

If he goes ahead and stands – which he may well do – he will have to overturn a Labour majority of over 14,000. That, even before the unedifying row over the veracity of his Hillsborough recollections, was always going to be a big challenge. If he goes for it and loses, his leadership – predicated as it is on his supposed ability to win votes in the north - will be dead in the water. 

Nuttall is not entirely to blame, but he is a big part of Ukip’s problem. I visited Stoke the day before The Guardian published its initial report on Nuttall’s Hillsborough claims, and even then Nuttall’s campaign manager admitted that he was unlikely to convince the “hard core” of Conservative voters to back him. 

There are manifold reasons for this, but chief among them is that Nuttall, despite his newfound love of tweed, is no Nigel Farage. Not only does he lack his name recognition and box office appeal, but the sad truth is that the Tory voters Ukip need to attract are much less likely to vote for a party led by a Scouser whose platform consists of reassuring working-class voters their NHS and benefits are safe.
 
It is Farage and his allies – most notably the party’s main donor Arron Banks – who hold the most power over Nuttall’s future. Banks, who Nuttall publicly disowned as a non-member after he said he was “sick to death” of people “milking” the Hillsborough disaster, said on the eve of the Stoke poll that Ukip had to “remain radical” if it wanted to keep receiving his money. Farage himself has said the party’s campaign ought to have been “clearer” on immigration. 

Senior party figures are already briefing against Nuttall and his team in the Telegraph, whose proprietors are chummy with the beer-swilling Farage-Banks axis. They deride him for his efforts to turn Ukip into “NiceKip” or “Nukip” in order to appeal to more women voters, and for the heavy-handedness of his pitch to Labour voters (“There were times when I wondered whether I’ve got a purple rosette or a red one on”, one told the paper). 

It is Nuttall’s policy advisers - the anti-Farage awkward squad of Suzanne Evans, MEP Patrick O’Flynn (who famously branded Farage "snarling, thin-skinned and aggressive") and former leadership candidate Lisa Duffy – come in for the harshest criticism. Herein lies the leader's almost impossible task. Despite having pitched to members as a unity candidate, the two sides’ visions for Ukip are irreconcilable – one urges him to emulate Trump (who Nuttall says he would not have voted for), and the other urges a more moderate tack. 

Endorsing his leader on Question Time last night, Ukip’s sole MP Douglas Carswell blamed the legacy of the party’s Tea Party-inspired 2015 general election campaign, which saw Farage complain about foreigners with HIV using the NHS in ITV’s leaders debate, for the party’s poor performance in Stoke. Others, such as MEP Bill Etheridge, say precisely the opposite – that Nuttall must be more like Farage. 

Neither side has yet called for Nuttall’s head. He insists he is “not going anywhere”. With his febrile party no stranger to abortive coup and counter-coup, he is unlikely to be the one who has the final say.