Rash of itching spreads through schools in seven states

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http://www.ama-assn.org/sci-pubs/amnews/pick_02/hlsa0311.htm

HEALTH & SCIENCE

Rash of itching spreads through schools in seven states

No one is really sure why kids are scratching from an affliction that seems

to disappear almost as fast as it appears.

By Stagg Elliott, AMNews staff. March 11, 2002. Additional

information

Norman Sykes, MD, the only dermatologist in the Quakertown, Pa., area, heard

about the outbreak in early February.

A few days before, more than 50 children at a local school had developed a

rash. It presented within a two-hour period and the students were bused to

the emergency department of St. Luke's Quakertown Hospital. They showered,

dressed in scrubs, and turned over to health officials their clothing, which

was then placed in plastic bags and taken away.

Before much else could happen, the rash vanished.

In more than half of the cases here, the rash disappeared before the

students even saw a physician.

But over the next two weeks, the rash reappeared daily -- finding new

victims as well as returning to previous targets. By the middle of February,

it had touched nearly 170 people in this locality and eventually turned up

in the next county.

And then it was gone.

" The itch, " as it is being called around the country, had come to

Quakertown.

Since September 2001, a mystery rash has afflicted children in seven states

without warning -- turning cheeks, arms and bellies bright red and itchy. It

often strikes in the school setting, disappearing after the child goes

elsewhere. It infiltrates large groups at once, and then slowly peters out.

And only rarely does it appear on teachers or relatives of the school-aged

victims.

" This was unprecedented, " said Dr. Sykes, assistant professor of dermatology

with the Jefferson Medical College in Philadelphia, who has met with nearly

all those affected in a hunt for the cause. " I'd never seen anything like

it. "

Schools have closed. Worried parents, fearing a possible bioterrorist

attack, have called the police and other authorities. Community leaders have

hosted forums. The Centers for Disease Control and Prevention and state and

local health departments have been dispatched to the scenes. Physicians have

inspected the children's skin and swabbed their throats in search of a viral

cause. And the Environmental Protection Agency has tested schools' air,

water, cleaning fluids, carpets, the heating ducts -- trying to detect any

possible environmental toxin.

" We don't know what it is, but the best proverbial wisdom is [that] this

does not match any bioterrorist agent, " said Elliott Friedman, MD, director

of pediatric emergency services at Jamaica Hospital Medical Center in New

York, who treated a number of cases in his area during February. " Nothing is

known to cause just itching. The thought of inventing something that just

makes you itch doesn't really make any sense. "

Piecing together the puzzle

Some consider the mystery solved, though there is not a clear consensus on

how. The Florida Dept. of Health, for instance, which investigated outbreaks

in four counties earlier this year, has decided that it was fifth disease.

This finding was based on a clinical assessment but not confirmed with

laboratory tests. Meanwhile, the Washington State Dept. of Health determined

that their January school-based outbreak in Gig Harbor was environmental,

triggered by construction work in the school.

But state and local health officials in Pennsylvania, New York, Ohio,

Oregon, and Virginia, are still mystified by the illness, which cannot

clearly be attributed to a specific viral or environmental cause.

Specifically, most victims recovered once they left the site of the

outbreak. And, for many, only the exposed skin was affected, indicating an

environmental trigger. But, in some cases, the rash spread beyond the

original outbreak, indicating a viral cause. Environmental pathogens also

tend to affect those with allergies and asthma more acutely. This scenario

did not happen, adding fuel to the argument that it is a virus -- possibly a

new one that cannot be detected by the currently available tests.

" We went initially from believing that this was most likely environmental to

much more of a consideration that this could be viral, " said A.

Jahre, MD, chief of medicine and the infectious disease section at St.

Luke's Hospital Network. He was called in to investigate viral possibilities

related to the Pennsylvania outbreak. " But there are things on either side

that you could make a case for. "

Then again, viruses rarely attack large groups of people in such a short

period, and the symptoms of a viral infection are usually systemwide, rather

than just a single symptom such as a rash.

" They had no sore throats, no fever, no chills, no other symptom except

being itchy, " said Trask, MD, a dermatologist in private practice in

Medford, Ore. He treated some of the children in the outbreak there in

February. " They were well otherwise, " he said.

Or it could be a viral infection aggravated by the environment.

But the situation is complicated by the nature of the condition. High school

students in Pennsylvania, for example, were found sandpapering their skin in

an effort to fake the rash and get their school closed. Many believe there

is also a psychosomatic aspect to the situation -- an itch being as

contagious as a yawn.

Trying to tie it together

The CDC is looking for links among the states, but there may be none. The

rash outbreaks may have the same cause across the country or may have as

many reasons as cases. But the benign nature of the outbreak is also

hampering the investigation. Parents are less willing to allow blood or skin

samples once the young patients are fine.

Dealings with the relatively mild condition are also being aggravated by the

higher levels of anxiety left over from last year's anthrax scare. Children

in the New York case, for example, were kept in the school, while anxious

parents were kept outside. They also were not taken to the emergency

department of the local hospital until a couple hours later when it was

clear that it was not a bioterrorist attack and they would not be spreading

an infectious agent.

But many also say the rashes would have hardly caused notice prior to last

fall. There are many conditions that pass through schools, and the cause is

never found.

" Perhaps if Sept. 11 hadn't occurred, it wouldn't quite be the issue that it

is, " said Alison Ansher, MD, a clinician with the Prince County

(Va.) Dept. of Health, which faced its own outbreak in November 2001.

" There's a lot of children who get childhood rashes from viral infections.

They go away, and it's not a big issue, " Dr. Ansher said. " In part,

understandably, there's some concern that something else is going on. "

ADDITIONAL INFORMATION:

Weblink

Bucks County (Pa.) Health Dept. statement on the mystery rash

(http://www.buckscounty.org/news/mysteryrash.htm)