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A case of pet rescue for practice nurse

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

Sathya's dad is a consultant psychiatrist. I first met her last summer, in minor illness clinic with a urine infection; she was 14 then, and rang first to see whether I would see her unaccompanied. When she arrived she gave me a note on which was written the word "Septrin", saying, "Dad thinks he's helping, he doesn't mean any harm. When I told him I was seeing a nurse he said this is what I needed. He doesn't realise you make decisions by yourself nowadays." (I gave her trimethoprim.)
She rang again some months later, saying I had to help, her cat's life was in danger. She explained that she had persuaded Dad to agree to a pet cat, only on the understanding that it remained free of worms, fleas and any other infestation. Sathya had developed a circular red, flaky patch on her neck and Dad had diagnosed ringworm. He declared it to have originated from the cat, and consequently, if his diagnosis was confirmed, the cat had to go. The thinly disguised message was clear: tell him it's not ringworm and he'll believe you. I asked her to come round to the surgery, while I considered my options.
I didn't want her to lose the cat - moreover, I didn't want the loss of the cat to be my fault! It was likely to be tinea, I uncharitably reasoned, as it was easy enough to diagnose, even for a psychiatrist. I probably wouldn't get away with calling it tinea corporis and disguising it as a different disease, or with arguing that there could be several responsible organisms, only one of these zoophilic -  Microsporum canis. The acute disease is usually red, inflamed and itchy, sometimes pustular, sometimes dry and scaly, developing a ring with a clear centre.(1,2) If we were lucky there was just the chance of her circular scaly lesion being a "herald patch" for pityriasis rosea. This would not require treatment, and would not be from the cat, but then that would usually occur on her chest ... and just a chance it could be a sudden onset of isolated discoid eczema ... or maybe a local sensitivity reaction? Perhaps there was scope for her dad to have misdiagnosed after all.
I considered the ethical code; if it was tinea corporis, would it be ethical to deny it to save the cat? I didn't think so. Respect for the individual meant I would have to be frank with Sathya and her family. First, beneficence and nonmaleficent care - doing the most good for least harm - might call for feline rehousing measures with visiting rights. And secondly, justice - well sometimes there just is no justice.
Sathya arrived with her mum. She pulled down her scarf and high-necked sweater to reveal the irregularly shaped plaque, of pinkish brown, slightly scaly appearance, on her neck, which, she said, was mildly itchy. I said I'd need to see a bit more of her than that, in order to give a full assessment.(3) With enormous relief on my part, she undressed to reveal similar patches scattered over her shoulders, upper arms, chest and back. They had all appeared together, but she'd only admitted to the one on her neck when quizzed by her father, thinking he would be more inclined to get rid of the cat if he saw dozens of them. She was otherwise well. Sathya had been studying me for a reaction as I looked, and she grinned at her mum. It was certainly fungal because of the circular flat patches, but looked to me like pityriasis versicolor. The spread was right; it rarely affects other parts of the body. The faded colour, the size and shape of the lesions (being 1-2cm roughly oval or circular) almost running into each other, and their slightly flaky and slightly itchy characteristics were typical. Her age was also indicative. (Of course, dermatological texts will recommend inspecting scrapings from the scales under a microscope, or the use of a Wood's lamp.(3,4) Unfortunately this was the real world of general practice - I had neither!)
I found the Dermnet NZ page on the internet to show Sathya and her mum, and printed it off for them to take home as proof for Dad; the pages can be used as reference as well as care plans, since they outline management and treatment options, and give colour pictures to help clinical diagnosis. Sathya was greatly impressed that her skin disease came in three colour variations. It usually clears with treatment, but can recur.
The BNF advises using ketoconazole 2% shampoo as a skin cream, daily for five days,(5) and I prescribed this for Sathya, having previously found it successful.
She rang a week later: the rash had cleared, though the shampoo had been slimy and made her cold. I tried the "no pain, no gain" argument - at least the cat had survived!

References

  1. DermnetNZ. Pityriasis versicolor. Available from URL: http://www.dermnetnz.org/fungal/pityriasis-versicolor.html
  2. Fpnotebook. Tinea versicolor. Available from URL: http://www.fpnotebook.com/DER95.htm
  3. Hughes E, Van Onselen J, editors. Dermatology nursing: a practical guide. Edinburgh: Churchill Livingstone; 2003.
  4. Hunter JAA, Savin JA, Dahl MV. Clinical dermatology. 2nd ed. Oxford: Blackwell Science; 1995.
  5. British National Formulary 49. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2005.