There’s a key pararagraph in Brigid Schulte’s excellent Washington Post article on Morgellons:

At the Mayo Clinic in Rochester, Minn., doctors are beginning to discover how imprecise a diagnosis of “delusions of parasitosis” can be. In the past five years, 175 people have been admitted to the clinic with that diagnosis. After thorough evaluations, however, with doctors taking the time to search for underlying problems, only half of those patients left the clinic with that diagnosis intact. Doctors found a very real cause of the itching in the other half.

It’s key both because it illustrates the false dichotomy of “disease or delusion” that the media and the MRF have forced upon Morgellons, and because it offers a way out of this dead end debate.

Let’s say somebody itches. That’s all, they just itch, but really badly, so it’s a problem. They go to the doctor, and the doctor does a lot of tests to try to find out why they are itching. They do all kinds of tests, and discuss possible environmental causes with the patient, they keep at this for a long time but they can’t find out why the patient is itching.

Is the patient delusional?

No. Clearly not. They are just itching, and they can’t find out why. Now, this obviously would be a horrible situation to be in. Painful itching, and no solution in sight. Horrible. But just because the doctor can’t find a cause for their itching, it does not mean they are delusional.

Now consider the 175 people mentioned above. They were diagnosed with delusions of parasitosis, but after doctors looked for underlying problems, only half of them retained that diagnosis. Consider what this means.

For someone to be diagnosed with delusions of parasitosis (DOP), they have to have an unshakable false belief that they are infested with parasites. Now our hypothetical itching patient does not have this belief, they just itch, so they would not be diagnosed as delusional, since they hold no strange beliefs about their itching. No, to have itching and be diagnosed with DOP, you need TWO things:

  1. Itching
  2. Delusions of Parasitosis

Of course, one cause of itching is scratching (the itch-scratch-itch cycle), and one cause of scratching is DOP. But that’s just one cause. Just because someone has DOP does not mean that their itching is caused by their DOP. There are hundreds of causes of itching. Lots of non-delusional people have itching for which no cause can be found.

DOP, on the other hand, can certainly be caused by itching. It’s called secondary organic DOP.

Now, of the Mayo’s 175 people, 88 of them had a cause found for their itching, presumably this was addressed, and their itching was reduced (or at least explained), and so those people saw conclusively why they were itching in the first place, and were either cured of it, or no longer had false beliefs about it. Were they misdiagnosed? Not if they started out with fixed false beliefs about the cause of their itching. They were not misdiagnosed, they were cured.

Itching is not a delusion. Itching is a physical sensation. Formication is a physical sensation. A delusion is a fixed false belief. Saying someone is delusional does not in any way invalidate their itching. They still itch. It still could be caused by any of hundreds of illnesses, physical conditions or environmental factors. The fact that they hold some odd beliefs about it does not mean they don’t actually itch.

So, no, there is no evidence that Morgellons is a distinct disease, and no, the fibers are nothing to do with anything. But just because someone thinks they have Morgellons does not automatically mean they are crazy. They itch, they suffer from formication, they scratch. In many cases there are probably reasons behind this besides “delusions”.

In their recent paper, Stricker and Savely said:

“[...] the apparent response to antibiotic therapy supports the concept that Morgellons disease may be triggered by an infectious process”

Morgellons is not a recognized disease, it’s a list of symptoms. Some people have self-diagnosed with some those symptoms, and some doctors (a very small number) think that this means that the list of symptoms is indicative of a distinct disease. The above statement is typical of the reasoning they use.

So if “Morgellons” is not a distinct disease caused by an infectious agent, then why would antibiotics help people who have some of this list of symptoms? Let’s look at the symptoms again, from the above paper:

# Skin lesions accompanied by intense itching
# Crawling sensations on and under the skin, often compared to insects moving, stinging or biting (cutaneous dysesthesia)
# Fibers, which can be white, blue, red or black, in and on the lesions
# Fatigue significant enough to interfere with daily activity
# Musculoskeletal pain
# Inability to concentrate and difficulty with short-term memory
# Behavioral changes

Fibers, we have dealt with before. Nobody has shown they are anything other than normal environmental contaminants (hair, lint, clothing fibers, paper fibers). After five years of looking at them, it seems fairly clear that this is all they are. No new evidence is presented, so let’s look at the other symptoms.

Musculoskeletal pain, intense itching and crawling sensations are obviously going to seriously interfere with your sleep (disrupted sleep is another commonly listed Morgellons symptom). Sleep deprivation leads to fatigue, difficultly concentrating, and behavioral changes. Sleep deprivation can cause other problems, even leading to diabetes.

So what we might have is people with intense itching and crawling sensations, and other pain, that keeps them awake at night, so they develop “brain fog”.

So where do antibiotics fit in?

Well, for one things, the cause of the itching/crawling might in fact be an infection such as staph or folliculitis, which is treated by antibiotics. But an often overlooked property of many antibiotics is that they are also anti-inflammatory. They can also, apparently, “Inhibit Staphylococcal Exotoxin-Induced Cytokines and Chemokines“, which is interesting since the MRF states that elevated cytokines is a common laboratory abnormality for Morgellons. If they hence judge reduced cytokines to be an indicator that antibiotics are addressing an infectious source of “Morgellons”, then they might be jumping to conclusions.

The point here is that it is entirely possible the antibiotics provide purely symptomatic relief to people who have some of the symptoms on the Morgellons list. Morgellons patients and Morgellons doctors almost invariably note that the relief ends when the antibiotic treatment stops. What if these extreme doses of antibiotics are not actually addressing some underlying infectious agent, but instead are simply suppressing the symptoms via their mild anti-inflammatory effects? If this is so, then those doctors provide their patients a grave disservice.

Virginia R Savely and Raphael B StrickerThere’s a new article on Morgellons by Savely and Stricker – the authors of the original Morgellons paper, and proponents of long-term antibiotics for both late stage Lyme and “Morgellons”

Expert Review of Dermatology
October 2007, Vol. 2, No. 5, Pages 585-591

Morgellons disease: the mystery unfolds
Virginia R Savely and Raphael B Stricker

http://www.future-drugs.com/doi/abs/10.1586/17469872.2.5.585

Abstract:

Morgellons disease is a mysterious skin disorder that was first described over 300 years ago. The disease is characterized by fiber-like strands extruding from the skin in association with dermatologic and neuropsychiatric signs and symptoms. Although Morgellons disease has been confused with delusional parasitosis, the occurrence of the disease in children, the lack of pre-existing psychopathology in most patients and the presence of subcutaneous fibers on skin biopsy indicate that the disease has a somatic origin. The association with Lyme disease and the apparent response to antibiotic therapy supports the concept that Morgellons disease may be triggered by an infectious process. Recent studies suggest that infection with Agrobacterium may play a role in the disease. Further clinical and molecular research is needed to unlock the mystery of Morgellons disease.

The full article was posted to various Morgellons mailing lists, and is available here:

http://nielsmayer.com/morgellons07.pdf

Overall the paper is very disappointing. There is very little (if anything) in the way of new information. It seems very much a re-working of the old paper, with some additions of various things that have already been mentioned in the popular press. There is no new science. No real studies, and nothing in the way of case studies.

Here I’ll focus on the more obvious (and sometime imponderable) flaws.

The disease was first described in French children in 1674 by a British physician, Sir Thomas Browne

No, it was not. A totally different disease with the same name was described. Browne writes about a local disease of children characterized by coughs and convulsions that is capped by “harsh hairs on the back”. There is nothing to suggest any link, and the MRF does not claim one.

In 1682, Dr Michel Ettmuller’s microscopic drawings of objects associated with what was then believed to be a worm infestation of children (Figure 1) appear similar to microscopic views of fibers from present-day sufferers of this disease

No, they don’t. Mites E are scabies mites, B is some kind of insect larvae (mosquito maybe) C and D are just some other mites, or perhaps a fuzzball from clothing. Fibers look like fibers, especially 300 years ago. There is no connection here.

Morgellons disease was rediscovered in 2001 by a Pennsylvania housewife, Mary Leitao

Maybe they should have checked with her first. She’s said all along that this was just a label, and nothing to do with the original “Morgellons”.

Morgellons disease was initially considered to be a form of delusional parasitosis (DP) by most dermatologists [3–11]. However, as the disease has become more widely recognized, significant clinical differences from DP have become apparent (as discussed later) [12,13,102]. The recent discovery of a putative infectious cause of the disease supports a somatic etiology of this bizarre skin condition.

Dermatologists options have not changed, and they are not as simple as suggested here. If there is something wrong with a patient’s skin, then it’s not DP. Delusions might play a part, but people can have skin problems, and also have delusions at the same time.

A network of blue, red, white and black fibers under the skin of these patients as well as blue, black and white fibers protruding from the lesions can be visualized using a 30× hand-held digital microscope [...] The fiber-like material can be observed in skin lesions as either single strands or what appear to be balls of fibrous material that may demonstrate autofluorescence (Figure 4) [1]. Patients frequently describe this material as ‘fibers’, ‘fiber balls’ or ‘fuzz balls’.

Here note they are trotting out the same descriptions that have been going around for years. Red, white, blue and black fibers on and under the skin, and fuzz balls. This is the crux of the matter here. What could these fibers be? After several years nobody has been able to identify any fibers EXCEPT those fibers which were clothing fibers.

Typically, patients have sought help from 10–40 physicians who often make a diagnosis of DP without a thorough examination and interpret the obvious open sores on the patient’s skin as attempts at self-mutilation

Now this might hold some weight if they had a cohort of patients that they could actually demonstrate had some skin problems that 10-40 doctors had simply dismissed. Unfortunately they are unable to do this. If there are over 10,000 patients, then that’s around 200,000 times that doctors had “dismissed” the lesions as self-inflicted. A better word might be “diagnosed”. 200,000 diagnoses, and all 200,000 wrong? Clearly not. In fact, this large number of similar diagnoses seems to suggest that the diagnoses is correct. If you go to 20 doctors, and they all tell you the same thing, then does this make it more or less likely that your self-diagnosis is correct?

We currently follow more than 200 Morgellons patients in our practice in San Francisco.

So they diagnose Morgellons. And treat it.

The male to female ratio is approximately 1:1 according to the Morgellons Research Foundation. The disease affects all age groups including children, but the prevalence in children is unknown at present. There is often a history of traumatic exposure to plants, dirt or soil, such as gardening, landscaping, farming, camping or other outdoor activities. The association with plant exposure has implications for the etiology of the disease (as discussed later).

This is getting silly. Who has not had “a traumatic exposure to plants, dirt of soil” in the last ten years? Scuffed a knee? Grazed a knuckle? Potted a plant? What was the questionnaire question for this? It’s not mentioned on the MRF survey. What is the sample size?

It appears that skin lesions and fibers may not be present in all individuals with this disease, since family members of patients often report similar systemic symptoms without skin lesions

Brilliant, you don’t even need lesions or fibers to have Morgellons. So what, then, is the case definition for? If you just had the symptoms of Menopause, you would qualify for Morgellons. If you were simply getting old, you could quite easily diagnose yourself with it.

Patients have reported symptoms of this disease in their pets [1]. The majority of reports involve dogs, but cats appear to be increasingly affected. Skin lesions fitting the description of Morgellons disease have also been reported in horses, and horse owners have observed fibers associated with skin lesions on their animals by using a lighted 30× hand-held microscope [1].

What are we to make of this? Dogs and cats? Horses? Reported by the patients? This is getting ludicrous.

Skin biopsies of patients typically reveal nonspecific pathology, or an inflammatory process with no observable pathogens [1]. Several biopsies have shown fibrous material projecting from inflamed epidermal tissue. Often the biopsies are reported to contain ‘textile fibers’ located in the dermal region rather than being adherent to the skin. How these fibers arrive at a subcutaneous location remains unexplained.

This is called an “argument from ignorance” – we can’t figure out how those fibers got there, so it much be some freaky bacteria! A more sensible approach would be to first question these reports. How many, and from whom? Then you might consider the thousand ways that fibers MIGHT get under unbroken skin. Start with light neurotic excoriations which healed over. Then perhaps consider fibers inside follicles. Anyway, you do the math.

Recent studies indicate that Morgellons fibers are resistant to chemical solubilization and heating, making analysis difficult by conventional means [...] There is preliminary information that some Morgellons fibers are made of cellulose, but this information has neither been formally evaluated nor confirmed

So which is it? Resistant to heating, or cellulose? There’s also studies that indicate they are wool and cotton. How do you pick which study to choose? Simply the one the fits your facts best. Better be careful and not pick too many.

In a preliminary study, skin biopsies from Morgellons patients revealed evidence of infection with Agrobacterium, which causes crown gall disease in plants [20]

[20] here is “Stricker‌ RB, Savely VR, Zaltsman A, Citovsky V. Contribution of Agrobacterium to Morgellons disease. J. Invest. Med. 55, S123 (2007). • First description of Agrobacterium in Morgellons patients.” What happened here was Stricker sent Citovsky TWO samples from sick patients with open sores on their skin. Citovsky tested them, and also six samples from health patients with nothing wrong with their skin. The sick patients with skin problems were found to test positive for Agrobacterium. The healthy patients did not.

That’s it. Samples of dubious origin with no appropriate control group, in a statistically meaningless amount. At best it suggests that people who have constant open lesions on their skin due to neurotic excoriations tend to have agrobacterium in the tissue around those lesions. Possibly due to dirt under fingernails. If you itch, you will scratch, if scratch for years then it’s not at all unlikely you would scratch some dirt into your skin.

We then get to “differential diagnosis”, where they purport to show that “Morgellons” cannot be Delusional Parasitosis (DP), Drug induced formication, Scabies, tropical dermatoses (Harvey’s theory) or perforating dermatoses. These arguments seem to be neat little tautologies, which I’ll summarize for flavor:

  • Morgellons cannot be DP because the patients were not delusional before they got Morgellons.
  • Morgellons cannot be drug induced formication, because the patients don’t take drugs.
  • Morgellons cannot be tropical dermatoses, because the patient has not been to the tropics.
  • Morgellons cannot be perforating dermatoses because the patients don’t have the genes or the symptoms

The reasoning here is either irrelevant or wrong. Nobody is making any claim that “Morgellons is X”, so demonstrating that “Morgellons” is not filarial worms does not make any real statement about the population of people who have self-diagnosed with Morgellons. Since the most likely explanation for “Morgellons” is that it is a random mixture of physical and mental conditions, varying by individual, that the sufferer’s have self-diagnosed as Morgellons, then you will ALWAYS be able to find many in that group about whom you can say “they do not have X, so Morgellons is not X”. Contrariwise, you can always find some who actually DO have X, but this also does not mean that “Morgellons is X”, it just means X explains the symptoms for that particular patient.

Take “Drug-induced formication”. Some people who think they have Morgellons actually DO have drug-induced formication. It’s not clear how many, but that’s a bit a of straw man, because formication is a symptom of a HUGE range of conditions, including menopause. Of course Savely and Stricker could say “Morgellons is not Menopause, because some of the patients are men”. But that’s just as disingenuous as their other differentials. Some people who have self-diagnosed with Morgellons MUST have menopause-related formication. It’s a statistical certainty. And given that there are around a million regular meth users in the US, it’s almost certain that some of them have drug-induced formication. If you take into account the users of Ritalin, Adderall and Lunesta (all of which have formication as a side effect), then the proportion is much higher.

Then saying that Morgellons is not onchocerciasis because “tropical travel and eosinophilia are not commonly reported in Morgellons patients” is almost funny. Funny because it’s quite true. Funny because it’s the theory that the MRF are about to promote. And funny because it’s the kind of reasoning that Stricker derided the CDC and the IDSA for when they say it’s unlikely that you have Lyme disease if you don’t live in a region where it is endemic, or if your tests come back negative.

It is unfortunate that this paper will be taken seriously when it really boils down to “We don’t know what these people have, but we think that large quantities of antibiotics help some, and doctors should be more open minded.” The publication of this paper will only perpetuate the misunderstandings regarding Morgellons and further drive vulnerable patients into the clutches of quacks and charlatans.

279pill_man_lores.jpgSuppose you have 10,000 people who have self-diagnosed themselves with a mysterious disease that causes horrible itching, and makes you think fibers are emerging from your body. In many cases they have been diagnosed as delusional, and have been unable to work with their doctors in finding effective treatments. These people have very frustrated, and angry at the medical system.

Suppose then an organization comes along, and tells them that they are absolutely not delusional, and they actually have a “newly emerging infectious disease“, and if they are “given appropriate antibiotics long enough” it will “resolve most symptoms“. and that “the treatment presently most successful is antibiotics.”

Two members of this organization even run a clinic to sell these antibiotics for “long enough“, but their services are very expensive, and these two people are just about the only people in the country who sell this treatment, so most of the sick people either can’t afford it, or can’t travel to see them, so these two only sell their treatment to perhaps 200 people out of the 10,000 who self-diagnose.

So what are the other 9,800 going to do? Many of these people were diagnosed as delusional (in addition to whatever other physical symptoms they have), they then self-diagnosed as having “Morgellons”, after reading about it on the internet. They then read on the internet that “Morgellons” can be effectively treated with antibiotics.

So it’s quite obvious what self-diagnosing people are going to do. They are going to self-treat. They are going to buy antibiotics, and they are going to take them. They are most likely going to harm their health in the process.

Sure, antibiotics are prescription only, and with good reason. But creative minds can find them on the internet, or other places. Take this recent thread titled “how do u get antibiotics for so long“. Some of the answers were:

Find a MD to prescribe tetracycline for “ROSEA” then you can get on it long term.
Most women have it. The MD would not prescribe ATB’s for me for LYME or Morgellons,
but said, OK, you have Rosea and I can do it for that.

Also, from mexico, I order Flagyl (NAME BRAND) which fights protozoa and used in ob/gyn settings for chlymadia. Tetracycline and Flagyl [Metronidazole] work together and compliment each other.
——————————————-
medsmex.com
——————————————-
Here are a couple of more sites for antibiotics without a script:

http://www.aclepsa.com/

http://www.drugdelivery.ca/

I have ordered from both places, you should just do a search for the type of antibiotic you are looking for, there are a bunch I found on Google.
——————————————-
I talked my old doctor into prescribing doxycycline for two years based upon Dr. Garth Nicholsons treatment for CFS, I have FMS. I took it for 1 year 9 months. If helped a lot but hard on stomach. All my symptoms are back.
——————————————–

and in another thread:fish-cillin.jpg

I haven’t tried [Tetracycline ] but I know I can get it at the Feed Store (morgellons pharmacy)

Note that the “Feed Store”is referred to as the “Morgellons Pharmacy”, because you can buy antibiotics at the feed store that are intended for livestock. This is something that is well known in the chronic Lyme community, and has hence been transferred over to the Morgellons community. Anti-parasite drugs such as ivermectin can also be found at the local feed store, and are also consumed by people who think they have Morgellons. You can buy some antibiotics (like Ampicillin, sold as “Fish Cillin”) at the pet store in the mall. You can even get these antibiotics on Amazon.com, see also: “Fish Cycline” (Tetracycline), “Fish Zole” (Metronidazole) and several other types of “Fish” antibiotics. Read the comments, nobody seems to be buying it for fish (or birds, if you want Sulfamethoxazole)

So what you have here is a lot of sick people who do not know what is wrong with them, who have somehow self-diagnosed themselves with a disease that practically no doctor thinks is real, and then are self treating themselves with a treatment that almost no doctor would recommend. They find ways to buy these drugs, either from Canada or Mexico, or they take antibiotics nominally labeled for fish.

It’s a major public health problem. Self-diagnosis and self-treatment (for months) with antibiotics for these 10,000 people means:

1) Their actual conditions, physical and/or mental, are going untreated
2) They will suffer from side effects from the antibiotics, possibly serious, which will add to their sickness, further complicating correct diagnosis, as they are taking these antibiotics covertly.
3) They increase their risk of developing antibiotic resistant infections, such as MRSA, and contribute to the overall growth of these “superbugs”.

Sadly the Morgellons Research Foundation, the New Morgellons Order, and Oklahoma State University are greatly contributing to this problem by promoting antibiotics as a treatment, before anyone has even discovered a disease.

Related Links:

http://aquaticpath.umd.edu/news/#anchor14215930

http://www.defenselink.mil/news/newsarticle.aspx?id=43579

http://www.cbc.ca/news/story/2002/07/18/fish_antib020718.html

http://abc.go.com/primetime/accordingtojim/episodes/2007/11.html

The CDC today released a “Request for Quotations” for their Morgellons investigation, which is basically a formality, as the only entity they would qualify to do the work is Kaiser. They also listed the lab tests that would be done (basically all the standard systemic tests).

http://www.fbo.gov/spg/HHS/CDCP/PGOA/Reference%2DNumber%2D2007%2DMorgellons/Attachments.html

They give a list of the work to be done:

2.1. Describe the clinical and epidemiologic features of persons who have reported themselves as having this unexplained skin condition, including assessing the frequency of co-morbid conditions (e.g., neurocognitive deficits, neurologic conditions, major psychiatric disorders).
2.2. Collect information to generate hypotheses about possible risk factors for this condition.
2.3. Assess the histopathologic features of the skin condition based on skin biopsies from a sample of affected patients.
2.4. Characterize fibers or threads obtained from patients with the condition to determine their potential etiology.
2.5. Describe the geographic distribution and estimate rates of illness.
2.6. Describe health care utilization among persons with the condition.

And a timeline:

4.1. IRB [Independent Review Board] Clearance October 30, 2007
4.2. Database of potential cases (study cohort) November 30, 2007
4.3. Database containing all results of clinical evaluations, Including recorded histories and physicals, laboratory tests (See Attachment 001 for required laboratory tests), chest x-rays, digital photos, neuorcognitive/neuropsychiatric examinations. March 1, 2008
4.4. All skin biopsy specimens and fiber samples collected from case-patients . March 1, 2008
4.5. Electronic database containing demographic information, zip code of residence, relevant past health history, such as medications, provider visits, and hospitalizations for cases. Database should include a unique patient identifier to allow linkage of clinical and other test results with demographic, healthcare utilization, and survey data. April 30, 2008
4.6. Database with denominators for all visits (total and by specialty) and hospitalizations during study period to allow estimation of disease rates in the population. May 30, 2008

That’s exactly what you should do if there is some evidence of a new infectious disease, parasite or environmental contamination. You get a patient population (the “study cohort”), and you investigate their symptoms, and see what they have in common, and look for common risk factors and diagnostic markers that might indicate a cause.

What’s a bit unusual here is that the patient population is “persons who have reported themselves as having this unexplained skin condition”, in other words: “people who think they have Morgellons”. This entire study is simply of people who THINK they have Morgellons. Very interesting.

The CDC are investigating Morgellons because it is an “emerging public health problem” and they have “received an increased number of inquiries from the public, health care providers, public health officials, Congress, and the media“, and “some who suffer from this condition appear to have substantial morbidity and social dysfunction, which can include decreased work productivity or job loss, total disability, familial estrangement, divorce, loss of child custody, home abandonment, and suicidal ideation“. All true, but with contested causation.

But wait a moment, why is the CDC getting ready to spend millions of dollars investigating Morgellons, when they simply could go to Oklahoma State University, where:
http://www.healthsciences.okstate.edu/morgellons/vision.cfm

OSU-CHS physicians/researchers have physical evidence of Morgellons Disease
– Morgellons is not psychiatric in origin
– Morgellons is an emergent disease

No only that, but they already have a patient population all of which can be instantly diagnosed by the appearance of fibers under the skin.
http://www.healthsciences.okstate.edu/morgellons/docs/Wymore-position-statement-2-19-07.pdf

Of the thirty or so patients claiming to have Morgellons disease, that clinical faculty have examined in facilities associated with OSU, only one patient likely did not have Morgellons.

100% of the patients, that were felt to genuinely have Morgellons Disease, have large microscopic-to small macroscopic fibers visible under their outer layer of skin.

There are doctors and professors there who have been looking at this for years, and have sufficient evidence to convince themselves 100%:
http://www.mysanantonio.com/news/medical/stories/MYSA072406.morgellons.KENS.1e13fade.html

“I am 100 percent convinced that Morgellons is a real disease pathology,” said Dr. Randy Wymore, an assistant professor of pharmacology and physiology at OSU.

Dr. Rhonda Casey has examined more than 30 Morgellons patients.
“There’s no question in my mind that it’s a real disease,” she said.

So if Oklahoma State University has already figured this out, why don’t they help out the CDC? Do they actually have any evidence? Could it be they’ve been a little hasty in their certainty? Perhaps a little unscientific? Or could they save the CDC some money?

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