FREQUENCY AND AETIOLOGY OF PRURITIS IN ADMITTED PATIENTS IN A MEDICAL WARD OF MAYO HOSPITAL, LAHORE

Fatima Mahboob

Department of Medicine, King Edward Medical College, Lahore

Background: Prutitis or itching is a common complaint. It can be due to many dermatological and medical illnesses. This study was conducted to find out presence of pruritis in different diseases in patients admitted in a medical ward and to determine whether pruritis is more common due to medical causes or dermatological causes. Methods: All patients admitted in North Medical Ward, Mayo Hospital, Lahore during March 2002 to November 2002 were included in the study. Complete medical history especially history of pruritis was taken. Physical examination was performed to diagnose the primary illness and to find cause of pruritis when present. Results: 740 patients were included in the study. Sixty (8.1%) patients complained of pruritis. 5.4% had pruritis due to skin conditions. 2.7% had pruritis due to medical illnesses. Conclusion: The patients admitted in medical ward are having pruritis mainly due to medical diseases but skin conditions should not be ignored.

KEY WORDS: Pruritis, itching, scabies


INTRODUCTION

Pruritus or itching is an irresistible desire to scratch. It is a distressing symptom causing a lot of discomfort. It can be due to many dermatological conditions but it is also associated with many systemic medical disease.1-4 some times it precedes the actual illness. It is a common health problem which should not be taken lightly. Persistent itching causes breaks in the skin predisposing it to infection. The patient is more concerned about pruritis ignoring other symptoms which may cause wrong or missed diagnosis.

Itch receptors are unmyelinated, unspecialized free nerve endings found near to the dermoepidermal junction. Itch transmitting poly modal, unmyelinated C fibers enter the posterior horn of gray matter of spinal cord.5 These synapse there with secondary neurons which cross over to the other side and ascend to the thalamus. The tertiary neurons relay the sensation of itch to the cortex. The peripheral mediators are histamine, neuropeptides, Platelet activating factor, vasoactive peptides and proteases.6

Pruritus can be due to many causes like allergy, seborrhic dermatitis, neurodermatitis, psoriasis7, pemphigus, hay fever, mite infestation eczema, low or high humidity, polycythemia vera, pediculosis, insect bite, uremia8,9, chronic liver disease, primary biliary cirrhosis10, detergents, urticaria, malignancy, obstructive jaundice11, iron deficiency anemia, drugs, diabeters mellitus12, hypothyroidism, hyperthyroidism, sicca syndrome and many more.

This study was conducted with an objective to determine the frequency of medical and dermatological causes of pruritis in patients of medical wards.

MATERIAL AND METHODS

North Medical Ward, Mayo Hospital, Lahore consists of both male and female sections. The bed strength is 25 beds in the male ward and 15 in female ward. Extra beds can be added when required. The patients admitted from March 2002 to November 2002 were included in the study to see the effect of seasonal variations on itching.

Apart from medical history, history of pruritis was taken in all patients keeping in mind the following factors.

*      Pruritus is localized or generalized

*      Present on exposed area or generalized

*      History of pruritis in other family members

*      Occupation

*      Chemical or animal exposure

*      Provoking or relieving factors

*      Time relationship

*      Seasonal variation

*      Emotional stress

Complete physical examination was done keeping in mind possible diagnosis and differential diagnosis. The laboratory investigations were advised accordingly.

Complete blood picture, serum electrolytes, blood urea, blood sugar, serum creatinine, liver function test, x-ray chest and gastroscopy were performed when needed.

RESULTS

740 patients were admitted during March 2002 to November 2002, Male patients were 520 (70.3%) female patients were 220 (29.7%). The final diagnosis in 740 patients is given in table-1. Sixty patients were having pruritis. Thirty five patients were having generalized pruritis. Twenty five patients complained of localized pruritis. Sixteen patients had itching only on exposed parts.

DISCUSSION

The treatment of pruritis depends on its etiology4,9. The etiology of itch may or may not be related to the primary illness.

The patients admitted in a medical ward with pruritis may be evaluated properly6. In difficult cases the opinion of a dermatologist may be taken to avoid wrong diagnosis. The wrong treatment may aggravate the patient symptoms12 or unnecessary medication may worsen the primary illness.

Table-1: Final Diagnosis

Diagnosis

n=

%age

Left ventricular failure

48

6.48

Chronic obstructive lung disease

38

5.13

Acid peptic disease

12

1.62

Ischemic heart disease

50

6.75

Chronic liver disease

80

10.81

Meningitis

15

2.02

Malaria

10

1.35

Chronic renal failure

55

7.43

Drug addiction

05

0.67

Cerebrovascular accident

60

8.10

Hypertensive heart disease

08

1.09

Malignancy of gastrointestinal tract

04

0.54

Diabetes mellitus

80

10.81

Poisoning

20

2.70

Acute renal failure

12

1.62

Pulmonary tuberculosis

50

6.75

Snake bite

04

0.54

Space occupying lesion of brain

02

0.27

Congestive cardiac failure

18

2.43`

Tetanus

20

2.70

Bronchial asthma

20

2.70

Hemotological malignancies

10

1.35

Typhoid fever

05

0.67

Bacterial endocarditis

02

0.27

Drug induced hepatitis

04

0.54

Cellulitis

02

0.27

Obstructive uropathy

02

0.27

Arthritis

11

1.48

Dilated cardiomyopathy

15

2.02

Diabetic ketacidosis

12

1.62

Subarachnoid hemorrhage

05

0.67

Bleeding disorders

08

1.08

Septicemia

14

1.89

Liver abscess

04

0.54

Acute viral hepatitis

06

0.81

Obstructive jaundice

02

0.27

Epilepsy

20

2.70

Miscellaneous

20

2.70

Table-2: Etiology of pruritis

Disease

n=

Percentage

Seborrheic dermatitis

02

3.3

Allergic dermatitis

02

3.3

Pediculosis

02

3.3

Insect bite

08

13.3

Uremia

03

5.0

Malignancy gut

01

1.6

Liver disorders

11

18.3

Diabetes mellitus

04

6.6

Scabies

22

36.6

Hematological disorders

01

1.6

Prickly heat

04

6.6

In the present study we concluded that pruritis is quite common. It is usually due to skin conditions like dermatitis, prickly heat, insect bite etc. Scabies is an important condition to be remembered in this regard. Some times the patients give history of pruritis in the past and some times they develop itching during their stay in the ward which may be acquired during their stay in the ward. The patients may be responsible for spreading the infection.

Table-3: Facts in the history (n=60)

History

Present

Absent

Pruritus in other family members

12 (20%)

48 (80%)

Relevant occupational history

04 (6.6%)

56(93.4%)

Chemical exposure

02 (3.6%)

58(96.4%)

Provoking f actors

04 (6.6%)

56(93.4%)

Relieving factors

10 (6.6%)

50(8.3%)

Time relationship

21(35%)

39(6.5%)

Seasonal variation

15(25%)

45(7.5%)

Emotional stress

05(8.3%)

55(91.7%)

Multiple factors may be present in the same patient.

Different studies reveal that pruritis in medical patients is due to diabetes mellitus, uremia and liver disorders1,3,4,12,14. The present study points out that even in medical cases skin conditions are common and scabies is very common among skin disorders. Therefore proper diagnosis should be made and appropriate treatment should be given which is a must and rewarding.

REFERENCES

1.                    Botero F. Pruritus as a manifestation of systemic disorders. Cutis 1978; 21: 873-80.

2.        Denman ST. A review of pruritis. J Am Acad Dermatol 1986; 14(3): 375-92.

3.        Kantor GR, Looking bill DP. Generalized pruritis and systemic disease. J Am Acad Dermatol 1983; 9: 375-82.

4.        Krajnik M, Zylicz Z. Understanding pruritis in systemic disease. J Pain Symptom Manage 2001; 21: 151-68.

5.        Ekbolom A. Some neurophysiological aspects of itch Semin Dermatol 1995; 14: 262-270.

6.        Tuckett RP. Neurophysiology and neuroanatomy of pruritis. In: Bernhard JD et al. Itch: Mechanism and management of pruritis. New York: Mcgraw-Hill 1994:1.

7.        Yosipovitch G, Goon A, Wee J, Chan YH, Goh CL. The prevalence and clinical characteristics of pruritis among patients with extensive psoriasis. Br J Dermatol 2000; 143(5): 969-73.

8.        Murphy M, Carmichael AJ. Renal itch. Clin Exp Dermatol 2000; 25: 103-6.

9.        Robertson KE. Uremic pruritis. Am J Health Syst Pharm 1996;(53): 18: 2159-70.

10.     McGill JM, Kwiat Kowski AP. Cholestatic liver disease in adults. Am J Gastroenterol 1998; 93: 684-91.

11.     Jones EA, Bergasa NV. Evolving concepts of the pathogenesis and treatment of the pruritis of cholestasis. Can J Gastroenterol 2000; 14: 33-44.

12.     Scribner M. Diabetes and pruritis of the scalp. JAMA 1997; 237:1559-61.

13.     Hagemark O, Wahlgren C. Treatment of itch. Semin Dermatol 1995; 14: 320-5.

14.     Lober CW. Should the patient with generalized pruritis be evaluated for malignancy? J Am Acad Dermatol 1988; 19: 350-2.

15.     Kantor GR, Bernhard J. Investigation of the pruritic patient in daily practice. Semin Dermatol 1995;14:290-6.

16.     Nowak MA, Tsoukas MM, Delmus FA, Falangov, Brodell RT. Generalized pruritis without primary lesions. Differential diagnosis and approach to treatment. Postgrad Med 2000; 107(2): 41-2 45-6.


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Address for Correspondence

Dr. Fatima Mahboob, Assistant Professor, Department of Medicine, King Edward Medical College, Lahore.Pakistan