Skin Deep

Jen is a pleasant 68 year-old homeless woman who frequents the day shelter and shelter clinic.  She is familiar face to the Women of Means staff and has regular follow-up with one of our nurses for supplies.  Two weeks ago, as I was talking with another shelter guest, I noticed that Jen had a large 3inch x 3inch piece of gauze covering the left posterior-lateral region of her neck.  Concerned, I asked her if there was anything wrong and she informed me that she yet another methicillin-resistance Staph. aureus (MRSA) abscess for which she was being treated with the oral antibiotic Bactrim (trimethoprim-sulfamethoxazole).  Today, she approaches me to tell me that her neck infection has cleared up, but expresses extreme concern that “this just keeps happening over and over again” and asks me why and how she can make it stop.

MRSA is a strain of bacteria that is highly resistant to antibiotics, and therefore, very difficult to treat.  Jen has had multiple infections with this nasty bug over the 9 months, which include cellulitis (an infection of the superficial layers of the skin) of her left lower leg and a right groin abscess that have each taken over a month to resolve.  Last winter, she had multiple bouts of bronchitis, and one episode of pneumonia for which she had to be hospitalized. On top of this, Jen has a complex medical history that includes poorly-controlled hypertension currently being treated with clonidine (a antihypertensive drug), hypothyroidism on levothyroxine (thyroid replacement hormone), and eczema currently being treated with topical steroids. 

Jen is embarrassed by her continued MRSA infections, as she considers herself a clean person despite living in a shelter.  She describes to me her nightly routine of using hand sanitizer to wipe down her mattress – however, she has been unable to do so over the last 2-3 weeks due to the outbreaks of Norovirus in her shelter.  To compensate, she has been washing her hands more frequently, but this in turn, exacerbates her eczema and dry skin, now with multiple cracks in them.

Jen’s situation is an example of the web of medical complexities that many homeless women live in. While homeless individuals tend to have similar chronic medical problems as the general population, they are also plagued with additional dermatiologic disorders due to their living conditions.  This ranges from infestations by lice, bed bugs, and scabies to dermatitis from cold or chemical exposure.  Not only does Jen’s prior skin infectious predispose her to further skin infectious, her eczema and dry skin provide the small sites for bacteria innoculate an infection.  Jen’s question is a good one – with her living situation and skin condition, preventing further infections is a difficult task.  The best thing I can offer her today is my support and empathy, and together we agree to start with some baby steps – education and some lotion/hand sanitizer – to improve her health.

Everyone Has a Story

            Paola is an 81 year old Ecuadorian woman who I met for the first time 6 months ago.  Today, I noticed her enter the shelter and eye the clinic sign-in sheet from a distance before proceeding to the breakfast line.  Wondering if Paola had a medical issue but was too reticent to sign up, a common situation among some of the homeless women, I approached her in line and asked her how she was doing.  She gave me a big smile, and exclaimed, “Doctor, you remember me? That is so nice!” 

Turns out, Paola did had a reason to come see us.  She reported itching of her both feet that started 2 months ago with burning when she takes a shower.  In the clinic, her foot examination revealed bilateral clearly-demarcated, erythematous, plaques with central clearing on the soles of both feet extending up the medial aspect of the feet.  She had associated thickening and cracking of her toenails characteristics onychomycosis, a fungal infection of the toenails.  The diagnosis was tinea pedis, more commonly known as Athlete’s foot, which is a fungal infection of the feet readily-treatable with antifungal cream and hygiene.

            While applying Paola’s cream and helping her put on a new pair of socks, I took the chance to get to know her better. I found out that Paola came to Boston close to 20 years ago with her husband for tourism.  They did not speak the language, nor did they have families in the country, which made it extra devastating when her husband became ill and required a long hospital stay that they could not afford.  By the time Paola’s husband had recovered, they had used up all their travel money and were without means of returning home.  As such, this brave elderly couple remained in the Boston, in and out of homelessness, until they were able to learn English, apply for a Green Card, rent an apartment in their ethnic neighborhood, and establish medical care at a prestigious hospital. 

            Beyond being an inspiring story of overcoming adversity, Paola and her husband are an example of the cycle of homelessness.  Traditional teaching delineates personal versus economic reasons for homelessness.  Personal factors include mental illness, substance abuse, domestic violence, and illness itself while economic factors include extreme poverty that makes rent and health insurance out of reach.  However, I think the most important thing to understand is that all these factors are interlinked.  Paola and her husband lack most factors leading to homeless, but an acute illness resulted in enough financial destitution to render these two people helpless and homeless.  Six months ago, I had no idea where Paola came from, but I am so grateful to have been able to hear her story.

Mastering the Art of Prioritization

             Donna is a 45 year old woman with a past medical history of HIV infection, IV drug use, and anal cancer who was escorted to the clinic by a shelter staff member after complaining of a fall.  The staff member states that Donna reported right knee pain and “torn ligaments,” and was asking for “some percs” (Percocet: acetaminophen+oxycodone) to ease the pain.  When I initially question Donna about her fall, she tells me with pressured speech that she slipped while walking indoors, but denies landing on her knee.  However, a few minutes later, when asked the same question, she says she fell out of her chair in the dining room and did hit her knee.

            Donna has a history of IV drug use (heroin) from which she claims 6 months of sobriety and for which she is on 70mg of methadone daily.  Likely from her IV drug use, she has HIV infection, for which takes daily triple antiretroviral therapy and has steady follow-up with her HIV specialist at a local academic medical center.  She also reports a history of anal cancer, for which she is currently undergoing radiation therapy.  Notably, Donna denies any history of musculoskeletal problems or surgeries.  She undergoing the housing process with the help of shelter advocates, and currently lives with her boyfriend, who she adamantly insists “does not do drugs, and is going to be lawyer.” 

            On exam, Donna is initially alert and irritable with psychomotor agitation.  However, while sitting in the exam room, she becomes progressively more somnolent with slurred speech to the point of dozing in and out of sleep.  Examination of her bilateral lower extremities reveals multiple linear scars over her anterior lower extremities and knees that Donna admits are from “shooting up.”  Her right knee is slightly more erythematous and enlarged compared to the left, with a small effusion over the anterior/proximal aspect of the knee but without bruising or deformity.  Passive and active range of motion in the right knee is otherwise normal, and Donna is able to bear weight without significant pain or presence of antalgic gait.  The most likely diagnosis was a ligamentous sprain.

            Donna is a woman with an acute medical complaint in the context of a complex medical background including IV drug abuse.  In fact, her symptoms suggest continued drug use despite claims of sobriety.  From her, I learned the importance of prioritization.  Oftentimes with intoxicated patients, medical, social, and psychological issues cannot be adequately addressed on the spot.  While it may be appropriate to assess Donna’s desire to achieve sobriety and her barriers to success, such matters should be addressed when a patient is sober and lucid.  Luckily, Donna is well-connected to her HIV specialist, as she knew both her doctor’s name and location.  Therefore, in this specific situation, we decided to address Donna’s acute medical issue by resting and icing her right knee and providing non-steroidal anti-inflammatory medication.  However, knowing that she frequents the shelter, I made a mental note to check-in with Donna the next time I see her.  I’ll keep my fingers crossed that next time she will be more able and willing to talk about some of the important medical issues in her life…