HIV Patient’s Nose Vanishes in Extreme Itch Disorder

Key Takeaways

A 35-year-old man presented to the hospital with diffuse oral pain. He reported the pain intensity on a 10-point scale and rated it as “9” on the maxillary right and an “8” on the mandibular left. His medical history included HIV infection and chronic misuse of unidentified drugs for pain relief. During the physical examination, the patient reported experiencing tactile hallucinations, often described as itching or the sensation of insects crawling, which caused him to constantly scratch his nose.

The case reported by Michele White, DDS, an associate professor of restorative dentistry at the University of Texas Health Houston School of Dentistry, Houston, and colleagues described a rare case of excessive destruction of the nasal septum due to differentially diagnosed formication and physical effects of methamphetamine use.

The Patient and His History

The patient presented to the dental urgent care clinic with a chief complaint of generalised oral pain of 8 and 9 on a 10-point scale 3 weeks prior.

The patient’s medical history included an HIV infection diagnosed 10 years ago and treated with poor HIV medication compliance over the past 5 years, as well as a history of drug and pain medication abuse.

The patient reported regularly taking more than 10 extra-strength paracetamol tablets and 10 ibuprofen tablets daily for pain relief. He also stated that he may have hepatitis B. The patient was unaware of his CD4 T-cell count and HIV medication.

Other family, medication, allergy, social, drug, and travel histories did not provide any relevant information.

Findings and Diagnosis

On admission, the patient’s vital signs were as follows: Blood pressure, 144/90 mm Hg; pulse rate, 74 beats/min; respiratory rate, 26 breaths/min; and temperature, 38.3 °C. A clinical oral examination confirmed several decayed teeth with severe caries and missing teeth.

His skin was dry and discoloured. Further examination revealed a deviated nasal septum and formication lesions on both arms, face, and nose.

The destruction, deviation, and loss of the outer end of the nasal septum appeared to be due to excessive scratching and differentially diagnosed delusions of parasitosis.

Dental intervention was not possible because of the financial constraints. Furthermore, surgery was considered risky due to his unclear medical history.

“The dental urgent care clinic at our institution attends to persons with urgent dental needs. However, patients present with comorbid medical conditions that may affect the ability to safely receive dental care at that time and, consequently, require medical consultation,” the authors wrote.

Because the patients are not patients of record, many of them are lost to follow-up, as this patient was. The treating dental providers chose not to proceed with treatment and opted for referral to the local county hospital, where the patient could be provided dental treatment with medical support. The patient was lost to follow-up.

Discussion

“Many healthcare providers, including family physicians, general dentists, med-peds, ear nose and throat, emergency room physicians, and ophthalmologists, are well positioned to recognise and report orofacial perforations and other possible associated signs of cocaine and methamphetamine abuse such as cardiovascular effects. This is important to assist patients in making appropriate referrals that aim to optimise patients’ healthcare. Goals should be to establish or support patients by seeing their medical or dental providers regularly, rather than through an urgent care clinic setting,” the authors concluded.

This article was translated and adapted from Univadis Germany.