Being Thorough and Curious

A doctor examining the patient's skin on the left cheek

Last week, a young man came into the clinic for his annual full skin examination. He’s vigilant about getting examined because his family has a history of skin cancer. Both his parents are patients of ours, and his father has actually had multiple basal cell skin cancers removed, including Mohs surgery on his nose and several with straight excisions on his back.

During my examination, I noticed an odd, creamy white-looking skin tag (soft skin growth) located on his lateral left knee. It was the size of a pencil or pen point and appeared to be hanging by a thin stalk, which is very typical for skin tags. When I pulled it off, I noticed fuzzy-looking, hair-like tentacles protruding from it.

Since our fully equipped in-office lab can process skin biopsies in as little as thirty minutes, instead of waiting weeks at times, I engaged my histology tech to place this little item on a slide with some media to look at it under the microscope.

To my surprise, a moving six-legged structure presented itself under the microscope!

It was still alive!

I am not an expert in diagnosing insects; however, I was quite curious to determine what this bug was. Given that the weather was good, and the patient may have been outdoors, I was concerned this may be a tick.

Back at the lab, my tech and I used the internet to compare photographs of ticks we found on Google Images. This indeed appeared to be a brown, red-bellied deer tick. The head, however, remained embedded in my patient’s skin, visible only by a small red inflamed bump.

Fearing my patient could be at risk of acquiring Lyme disease, I called to inform him of what I had discovered and put him on doxycycline at a 100 mg dose, twice a day for 10 days.  I also advised that he should not attempt to get the head out, but, rather, allow his own body to eventually expel the tick’s head.

Later that evening, I decided to double-check my advice by contacting a fellow at the University of Washington’s Infectious Disease Department. Upon hearing the facts of this case she stated that my advice was indeed correct because it would cause more damage to the patient to attempt to get the head out. She also stated that although the antibiotic I prescribed for him was optional, it was a good precaution to take given the disease risk.

This fascinating case was an important lesson to remind all my students to always carefully and thoroughly examine a patient’s skin during checkups.  It was also an important lesson to never lose one’s intellectual curiosity at any stage of one’s career. You never know what you’ll find!


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