Tractor accident holds answers to severe pruritic rash years later

As a family nurse practitioner in an allergy and immunology practice, I see many atopic conditions and complaints. My most memorable patient was a gregarious 86-year-old farmer with a chief complaint of a generalized pruritic rash that he had had for about six months.

This severe rash was notable for its purpuric characteristics and excoriated appearance ­– caused by the patient's furious scratching ­– over eczamatoid changes to the skin surface, and covered approximately 70% of his body surface. He was sent to our practice after several dermatology evaluations, without much symptom improvement. At each of his four visits, he wore old overalls and a very worn white t-shirt. He shaved every two to three days and had a short beard all the time. Despite his advanced age, he continued to help work the farm he passed onto his children, and his disposition was delightful.

That such a happy soul was so agitated by a near-debilitating itchy rash encouraged me to spend quite a bit of time getting a complete history and perform a physical exam. It was during the exam that I had the surprise of my roughly ten-year clinical life. When he removed all of his clothes except his shorts, the imprint and indentations of a tractor tire were unmistakable!

I have no doubt that my mouth was open in amazement. So the patient explained the story of “where the tire tracks came from.” Years earlier, he had just completed mowing some grass using a large tractor. Dismounting the tractor, he unhooked the drag-behind mower without realizing he was on a slight decline towards a wooded area. Unfortunately, he also left the tractor in neutral with the wheels freely moving, so both the tractor and the mower began drifting downhill towards the woods. With the mower and tractor separated, he became stuck between them as they moved. He lost his footing and fell into the path of one of the rear tractor tires.

The tire ran him over “stem to stern,” as he put it, with the predicted severe damage to his torso and internal organs. This had occurred about three or four years before the onset of the rash that brought him to our office. My curiosity was piqued, and I pressed on gathering information about what happened subsequently.

He described how after he had been run over, the mower and tractor rolled into the woods and out of sight. He lay prone, injured and unable to move. He could hear his family members calling for him, but could not respond. Every time he stood up he would pass out for a few minutes and “blood would spurt from somewhere.”

Over the course of several hours he very slowly crawled toward the house, which was about a football field away. Finally his daughter spotted him, and he was airlifted to shock trauma. The treating clinicians predicted that he would only live “a few days, at best” and were amazed that he was even alive.

Gradually, over the next few weeks and months the tubes and drains were removed one at a time. As he healed, his case was pronounced a miracle and he was released home after three months with instructions not to drive the tractors anymore. The internal damage caused by the incident led to insulin-dependent diabetes shortly afterward.

Eventually, during probably the longest and most entertaining history that I've ever taken, the patient gave me the clue that would lead to the cure for his rash.

He had been on animal insulin for about seven or eight years and related an intense increase in itching, both generalized and at the injection site. The itching was somewhat variable, but was always present and had began a few months before his rash appeared.

The patient had reported the itching to both his endocrinologist and dermatologist. Both dismissed his insulin as a possible cause, given the long period of time he had been on the drug and the variability in symptomatology. But it was enough for me to order a skin test for the insulin, which came up positive.

Replacement therapy for the offending agent resulted in a near complete resolution of the patient's itchy rash in just a few weeks and immediate cessation of itching. Once cured, he was lost to follow up, but I think of him often, especially when I am evaluating severe pruritic rashes.

 Tell us about your most memorable patient by December 15, 2010, and you'll be eligible to win an Apple iPad!

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