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History of Morgellons Disease: from Delusion to Definition

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History of Morgellons Disease: from Delusion to Definition Journal name: Clinical, Cosmetic and Investigational Dermatology Article Designation: REVIEW Year: 2018 Volume: 11 Clinical, Cosmetic and Investigational Dermatology Dovepress Running head verso: Middelveen et al Running head recto: Morgellons disease open access to scientific and medical research DOI: http://dx.doi.org/10.2147/CCID.S152343 Open Access Full Text Article REVIEW History of Morgellons disease: from delusion to definition Marianne J Middelveen1 Abstract: Morgellons disease (MD) is a skin condition characterized by the presence of Melissa C Fesler2 multicolored filaments that lie under, are embedded in, or project from skin. Although the Raphael B Stricker2 condition may have a longer history, disease matching the above description was first reported in the US in 2002. Since that time, the condition that we know as MD has become a polemic 1Atkins Veterinary Services, Calgary, AB, Canada; 2Union Square Medical topic. Because individuals afflicted with the disease may have crawling or stinging sensations Associates, San Francisco, CA, USA and sometimes believe they have an insect or parasite infestation, most medical practitioners consider MD a purely delusional disorder. Clinical studies supporting the hypothesis that MD is exclusively delusional in origin have considerable methodological flaws and often neglect the fact that mental disorders can result from underlying somatic illness. In contrast, rigorous experimental investigations show that this skin affliction results from a physiological response to the presence of an infectious agent. Recent studies from that point of view show an association between MD and spirochetal infection in humans, cattle, and dogs. These investigations have Video abstract determined that the cutaneous filaments are not implanted textile fibers, but are composed of the cellular proteins keratin and collagen and result from overproduction of these filaments in response to spirochetal infection. Further studies of the genetics, pathogenesis, and treatment of MD are warranted. Keywords: Morgellons disease, dermopathy, Lyme disease, Borrelia burgdorferi, spirochetes Introduction Morgellons disease (MD) is a disfiguring and perplexing skin condition associated with spirochetal infection and tick-borne illness.1–7 This poorly understood condition has a worldwide distribution, with estimated self-reported cases numbering over 14,000 in Point your SmartPhone at the code above. If you have a 2009.5 Since that time, there has been an increasing number of individuals reported QR code reader the video abstract will appear. Or use: http://youtu.be/PAP5zPh57SI to be afflicted with this disorder (C Casey, Charles E Holman Morgellons Disease Foundation, personal communication, 2017). The distinguishing diagnostic feature of MD is spontaneously appearing ulcerative skin lesions that contain unusual filaments lying under, embedded in, or projecting from the skin. The characteristic filaments are microscopic, visually resembling textile fibers, and are white, black, or a more vibrant color, such as red or blue.1–7 In addition to fiber production, some patients may experience formication, described as stinging, biting, creeping and crawling sensations. Correspondence: Raphael B Stricker The symptoms of MD are not limited to the skin. MD patients experience a variety Union Square Medical Associates, 450 Sutter Street – suite 1504, of systemic manifestations, such as fatigue, joint pain, cardiac complications, cogni- San Francisco, CA 94108, USA tive difficulties, and neuropathy, all symptoms that are commonly reported by Lyme Tel +1 415 399 1035 Email [email protected] disease (LD) patients.1–7 submit your manuscript | www.dovepress.com Clinical, Cosmetic and Investigational Dermatology 2018:11 71–90 71 Dovepress © 2018 Middelveen et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://dx.doi.org/10.2147/CCID.S152343 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Middelveen et al Dovepress History and “it is perhaps too simple that the parasitophobias should The name “Morgellons” (pronounced with either a hard or be considered as mental illness and nothing more”.20 Interest- soft “g”) comes from a letter written in 1674 by Sir Thomas ingly, like Vié, Ekbom found that spirochetal infection was Browne, an English physician. The letter contains a brief present in his patient cohort, and three of Ekbom’s seven description of a skin disease in French children: patients had documented cases of syphilis. Despite the fact that syphilis was considered rare in Sweden, Ekbom did not Hairs which have most amused me have not been in the believe that spirochetal infection was a contributing factor.20 face or head, but on the back, and not in men but children, Ekbom reported that the skin sensations consisted mostly as I long ago observed in that endemial distemper of little of itching, but also that there was a feeling that something children in Languedock, called the Morgellons, wherein was crawling on or under the skin, and that stabbing and bit- they critically break out with harsh hairs on their backs, ing sensations could also occur. He mentioned that in such which takes off the unquiet symptoms of the disease, and cases, “little animal” specimens were sometimes brought in 8 delivers them from coughs and convulsions. by patients to show to physicians and that such collections Browne’s description of “the Morgellons” and other histori- consisted of “little hairs, little threads, grains of sand, and cal accounts of similar maladies date from 1544–1884 and skin scales”. He noted that apart from delusional ideas of were found in Browne’s library in 1935 by Kellett, who then infestation, no consistent mental problems were present.20 summarized and discussed them.8 Although Ekbom could not find any arthropods, parasites, The accounts by Browne and others were likely referring or other microscopic animals, it is important to note that he to a heterogeneous group of skin conditions that may have found hairs, “little threads”, and “grains of sand” in patient differed from the skin condition that we refer to as MD today. specimens. His description is consistent with the findings of These early accounts describe primarily childhood illnesses, unusual hairs, fibers, and hardened comedo-like dermatologi- many of which were associated with convulsions. There is cal objects that we see in MD specimens.20 Such objects will mention of hairs, worms (with black protruding heads), or be discussed in depth later in this report. comedones that protruded from the skin, primarily on the It is possible that patients in the case studies written by arms, legs, and back, and at that time there was much debate other physicians and mentioned by Ekbom had syphilis or as to whether these objects were animate or inanimate.8 other spirochetal infections. The causative agent of syphilis Ettmüller, for example, provided a drawing of infesting was first reported in 1905 by Fritz Schaudinn and Erich organisms that look like various arthropods, some resem- Hoffmann, who used dark-field microscopy and described bling scabies mites, while the famous Dutch microscopist spiral-shaped bacteria – Spirochaeta pallida – now called Leuvenhoeck concluded that such objects were inanimate.8 Treponema pallidum.21 The first test for syphilis was devel- In 1894, Thibierge described patients who had erroneous oped shortly afterward in 1906 by German physician and and unshakeable beliefs of skin infestation by parasites, and bacteriologist August von Wassermann. The Wassermann proposed the name “acarophobia”.9,10 In 1946, Wilson and test was a complement-fixation test that detected antibodies Miller suggested that “acarophobia” should be replaced by reactive to the syphilis spirochete. The Wassermann tests the name “delusions of parasitosis” (DOP).10,11 performed in the 1920s and 1930s lacked accuracy,22,23 and From 1902 to 1938, case studies describing “parasitopho- cases of syphilis among patients with delusional parasitosis bias” or “dermatological hypochondriasis” that resulted in (DP) may have gone unacknowledged as a result. delusional interpretation of skin sensations were published Regardless of the test accuracy for syphilis, it is possible sporadically.12–20 However, as early as 1935, an association that some of the patients described in these historical case between spirochetal infection and DOP was documented by studies may have been infected with Borrelia spp., other the French physician Vié, who reported that six of eight of the treponemes or Leptospira spp. B. burgdorferi (Bb) is not subjects in his case studies had syphilis.18 In 1938, a pivotal a new organism: the earliest known case dates back 5,300 narrative of DOP was published by Ekbom, a series of case years in the mummy dubbed Ötzi,24 and Borrelia DNA was studies describing patients who had sensations of movement also detected in two museum specimens of the white-footed and the belief that insects were crawling on or under skin. mouse, Peromyscus leucopus,
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