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In this channel I shall provide you with information and thoughts to stimulate you. Dr EV Rapiti
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Посты канала
Misdiagnosis as psychiatric illness is a real risk when sensory symptoms occur without visible pathology.
Undiagnosed medical conditions can lead to psychological distress and harmful polypharmacy.
Author Biography — Dr Ellapen V. Rapiti, MBBS, FCFP, DCH, DMH, MBA, is a senior family physician with nearly fifty years of continuous clinical practice in Cape Town. His academic work focuses on diagnostic reasoning, mental health, addiction medicine, and atypical presentations in primary care. During the COVID‑19 pandemic, he contributed to community‑based management through an early‑intervention approach that informed practical care for patients outside hospital settings. His current interests include complex diagnostic challenges and reducing misdiagnosis and unnecessary polypharmacy in frontline medicine.
References
1. Havlickova B, Czaika VA, Friedrich M. Epidemiological trends in skin mycoses worldwide. Mycoses. 2008;51(Suppl 4):2–15.
2. Bonifaz A, et al. Majocchi’s granuloma: clinical and mycological experience of 22 cases. Int J Dermatol. 2014;53(3):e199–e203.
3. Elewski BE. Majocchi’s granuloma: deep dermatophyte infection. J Am Acad Dermatol. 1995;32(2 Pt 2):S42–S46.
4. Gupta AK, Cooper EA. Update in antifungal therapy of dermatophytosis. Mycopathologia. 2008;166(5–6):353–367.
5. Korting HC, et al. Fluconazole in dermatophyte infections: a review. Clin Exp Dermatol. 1992;17(6):397–400.
6. Hay RJ. Superficial fungal infections. Medicine. 2009;37(12):649–653.
7. Verma SB, Madhu R. The great imitator: dermatophytosis mimicking other dermatoses. Clin Dermatol Rev. 2017;1(1):41–45.
8. Koo J, Lebwohl A. Psychodermatology: the mind and skin connection. Am Fam Physician. 2001;64(11):1873–1878.
9. Gaebel W, et al. The dangers of misdiagnosis and inappropriate psychiatric treatment. World Psychiatry. 2016;15(1):3–4.
Dr Ellapen V. Rapiti
MBBS, FCFP, DCH, DMH, MBA
Cape Town, South Africa
20 July 2026
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| 2 | By the first day she felt immediate improvement. By the fourth day the symptoms had completely disappeared. Her urinary frequency settled, her nocturia resolved, and she regained normal sleep. The daytime drowsiness vanished. Her depression was replaced with joy and elation. She felt relieved that her sexual life had returned to its former state.
I shared her sense of joy because it bothered me immensely that I could not find a cause for her problem. It was a first for me.
Discussion
Deep dermatophyte infection as the underlying cause
The patient’s unusual presentation—perineal dryness, burning on urination, urinary frequency, nocturia, sleep disturbance, daytime drowsiness, and formication without any visible rash—is characteristic of a deep dermatophyte infection, most commonly caused by Trichophyton rubrum. Unlike superficial tinea, deep dermatophyte infections invade the hair follicles and dermis, producing granulomatous inflammation and irritation of cutaneous nerves, which explains the crawling sensation.
Majocchi’s granuloma, the deep form of dermatophyte infection, is well known for its resistance to topical antifungals and poor response to fluconazole. This is because the organism resides below the epidermis, where superficial agents cannot reach. The patient’s lack of response to barrier creams, steroid–antifungal combinations, castor oil, and increased topical oestrogen is consistent with this deeper pathology.
Itraconazole is the preferred systemic agent for deep dermatophyte infections due to its excellent penetration into keratin, hair follicles, and subcutaneous tissue. The patient’s rapid improvement within 24 hours and complete resolution by day four strongly supports the diagnosis of a deep T. rubrum infection.
Psychological consequences of undiagnosed medical conditions
Undiagnosed, debilitating medical conditions often exert profound psychological effects on patients. Persistent symptoms without an identifiable cause can lead to anxiety, hopelessness, and depression. In this case, the patient feared she would suffer indefinitely, and her distress escalated as multiple treatments failed. The nocturia and sleep deprivation worsened her emotional state, creating a vicious cycle of fatigue, despair, and fear.
Such scenarios create fertile ground for misdiagnosis, particularly when clinicians become desperate for an explanation. When symptoms are atypical or invisible, patients may be labelled as having psychiatric disorders, opening the floodgates to useless and often harmful polypharmacy. This includes sedatives, antidepressants, antipsychotics, and neuropathic agents—none of which address the underlying pathology and many of which carry significant metabolic and cognitive risks. This case underscores the importance of maintaining diagnostic humility and considering less common medical causes before attributing symptoms to psychiatric disease.
Conclusion
This case highlights the importance of recognising deep fungal infections in patients with perineal sensory disturbances, dysuria without urinary tract infection, urinary frequency, nocturia, sleep disturbance, and formication in the absence of visible rash. Deep dermatophyte infections, particularly those caused by Trichophyton rubrum, may present atypically and be easily overlooked. Failure to identify such conditions may lead to psychiatric misdiagnosis and harmful polypharmacy. Clinicians should remain vigilant and consider deep fungal disease when confronted with unexplained perineal dysesthesia.
Learning Points
Not all fungal infections present with a rash.
Deep dermatophyte infections can cause formication, burning, dysuria, urinary frequency, and nocturia.
Sleep deprivation and daytime drowsiness may result from nocturia caused by deep fungal disease.
Trichophyton rubrum can invade the dermis and hair follicles, producing symptoms without visible skin changes.
Itraconazole is highly effective for deep fungal infections when topical agents fail. | 6 |
| 3 | Skin Condition Without a Rash: A Deep Dermatophyte Infection Presenting as Perineal Dysesthesia and Formication
Dr EV Rapiti — MBBS, FCFP, DCH, DMH, MBA
July 20, 2026
Abstract
Deep dermatophyte infections are uncommon and often misdiagnosed, particularly when they present without visible skin changes. This case describes a woman in her sixties with perineal dryness, burning on urination, urinary frequency, nocturia, sleep deprivation, daytime drowsiness, and formication in the absence of rash. Multiple topical therapies failed, and the unusual symptom constellation led to significant psychological distress. Empirical treatment with itraconazole resulted in rapid and complete resolution, including restoration of normal sleep and elimination of daytime somnolence. The case highlights the importance of considering deep fungal infections, particularly Trichophyton rubrum–associated Majocchi’s granuloma, in patients with unexplained perineal sensory symptoms. Failure to recognise such conditions may lead to psychiatric misdiagnosis and harmful polypharmacy. This report underscores the need for clinical vigilance in atypical presentations of fungal disease.
Keywords
Deep dermatophyte infection; Majocchi’s granuloma; Trichophyton rubrum; formication; perineal dysesthesia; nocturia; misdiagnosis; polypharmacy; itraconazole.
Introduction
Dermatophyte infections typically present with characteristic rashes, scaling, or erythema. However, deep dermatophyte infections—particularly Majocchi’s granuloma caused by Trichophyton rubrum—may invade hair follicles and dermis, producing sensory disturbances without visible skin changes. These atypical presentations pose diagnostic challenges and may be mistaken for neuropathic, psychogenic, or genitourinary conditions. Misdiagnosis can lead to unnecessary investigations, inappropriate psychiatric labelling, and harmful polypharmacy. This case illustrates the importance of recognising deep fungal infections in patients with unexplained perineal symptoms.
Case Presentation
A female in her sixties, who had been my patient for over forty years, presented with a most unusual constellation of symptoms arising from the skin around the perineum—without any rash.
She complained of dryness in the skin between the vagina and anal area. In addition to the dryness, she experienced a burning sensation over that part of the skin when she went to urinate. She dreaded passing urine because of the pain. She also developed a sudden increase in urinary frequency, despite her diabetes being well controlled.
Her urinary frequency progressed to nocturia, waking her several times at night. This led to sleep deprivation, and she became excessively drowsy during the day, struggling to stay awake and function normally. The nocturia and daytime somnolence added significantly to her distress.
We tried a wide range of topical creams to relieve her symptoms, but nothing worked. Barrier creams, mild steroids mixed with antifungal creams, and even castor oil patches offered no relief. Increasing her topical oestrogen cream was attempted, suspecting an oestrogen deficiency might explain the dryness, but that did not work either.
The symptoms worsened. She complained of a sense of formication—as if something was crawling under her skin. There was no pruritus to suggest an allergy.
This went on for two whole months. It made her depressed, not knowing the cause and fearing she might suffer with this condition for the rest of her life.
Had she seen a psychiatrist, she would likely have been diagnosed with a psychotic disorder and placed on a metabolically dangerous atypical antipsychotic, worsening her diabetes through weight gain.
Based on past clinical experience, I decided to treat her empirically for a resistant fungal infection with itraconazole 100 mg daily for two weeks. | 7 |
| 4 | https://open.substack.com/pub/drevrapiti/p/skin-condition-without-a-rash-a-deep?r=z9ikb&utm_campaign=post&utm_medium=web&showWelcomeOnShare=true | 8 |
| 5 |  Нет текста... | 57 |
| 6 | https://www.instagram.com/reel/DX1eQjFz56J/?igsh=MXA2a3h5c3Z0cGJvcA== | 59 |
| 7 |  Нет текста... | 58 |
| 8 | https://substack.com/@romanbystrianyk/note/c-283298494?r=z9ikb | 56 |
| 9 |  Нет текста... | 58 |
| 10 | https://open.substack.com/pub/drevrapiti/p/when-bureaucracy-breaks-people-the?r=z9ikb&utm_campaign=post&utm_medium=web&showWelcomeOnShare=true | 60 |
| 11 |  Нет текста... | 95 |
| 12 |  Нет текста... | 91 |
| 13 |  Нет текста... | 118 |
| 14 |  Нет текста... | 142 |
| 15 |  Shedding: The Truth About MMR 💉
If there is an outbreak of any “vaccine preventable disease,” the blame is always placed on the unvaccinated. We can see this on full display in the media’s reporting of the Texas measles outbreak. However, according to Dr. Larry Palvesky, the MMR vaccine can shed and infect others, which could create an “outbreak.”
“The vaccine is what's called alive attenuated vaccine, meaning there's live replicating
virus in there that can spread.”
Join 👉 https://t.me/RogerHodkinson | 137 |
| 16 |  Dr. Charles Hoffe: "I knew they wanted to reduce the population; they've been very clear about that...[And the COVID-jab mandates] made no sense...So...clearly...they wanted to reduce fertility—there's no other logical reason...[to] vaccinate all these university students..."
Hoffe is a practicing family physician in BC, Canada. This clip is taken from a recent episode of the @ ChildrensHD series Financial Rebellion.
Join 👉 https://t.me/RogerHodkinson | 95 |
| 17 | https://open.substack.com/pub/drevrapiti/p/when-truth-is-twisted-a-reflection?utm_source=share&utm_medium=android&r=z9ikb | 86 |
| 18 | When Truth Is Twisted: A Reflection on Accountability and the Wisdom of Maturity
By Dr E.V. Rapiti
11 July 2026
www.drrapiti.com
Some behaviours only reveal themselves when people are confronted with uncomfortable truths. It is in these moments — when accountability knocks at the door — that character is exposed. Some respond with honesty and introspection. Others retreat into a private bubble where facts are bent, events are rewritten, and responsibility is denied.
As I have often observed:
“Narcissists live in their own bubble.
When they are exposed, they twist the truth with fabricated lies, confidently believing that the world is gullible enough to believe them.”
This is not a diagnosis. It is a description of a pattern that repeats itself across human relationships, organisations, and public life. It is the behaviour of individuals who cannot tolerate being wrong, and who will reshape reality rather than confront their own actions.
The Art of Twisting Truth
When such individuals are challenged, they do not engage with the facts. Instead, they:
deny what is plainly documented
reinterpret events to cast themselves as victims or heroes
shift blame onto others
present alternative narratives with unwavering confidence
assume that those around them will accept their version without question
This twisting of truth is not accidental. It is a defence mechanism — a way of protecting a fragile self‑image from the discomfort of accountability.
The Sudden Softening
What is even more revealing is how quickly the tone can change. A person who has made serious accusations may, days later, send a casual message as though nothing happened, hoping to “discuss things” informally.
This behaviour shows a profound disconnect between their actions and the consequences of those actions. It reflects an inability — or unwillingness — to recognise the harm caused or the seriousness of their own words.
When Lies Fail, Taunts Begin
There is another pattern worth noting:
When they fail with their lies, they will provoke you with more taunts to invite you into a fight.
Ignoring them leaves them desperate and destitute for more taunts.
This escalation is not about truth. It is about control. When manipulation fails, provocation becomes the next tool. And when provocation is ignored, they are left without the fuel they need to sustain the conflict.
Why the Wisdom of Maturity Calls for Silence
When someone has demonstrated a willingness to distort the truth, further engagement often serves no purpose. Responding only invites more manipulation, more rewriting of events, and more attempts to pull you into their bubble.
Silence, in such cases, is not avoidance.
It is the wisdom of maturity — the understanding that not every battle deserves your energy, and not every distortion deserves a reply.
Integrity as a Measure of Character
Integrity is not tested when life is easy. It is tested when we are confronted with our own mistakes, when we must face uncomfortable truths, and when we must choose between honesty and self‑preservation.
Those who choose honesty strengthen the communities they belong to.
Those who choose distortion weaken them.
In every organisation — whether a body corporate, a workplace, or a public institution — truth matters. Accountability matters. And the courage to face one’s own actions matters most of all.
About the Author
Dr E.V. Rapiti is a family physician with over four decades of clinical experience. He has a keen interest in mental health and has spent many years observing how human behaviour shapes relationships, conflict, and personal wellbeing. This article arises from a personal experience of dealing with a difficult personality type, and his reflections are intended to help others facing similar situations. His simple advice: “Calm silence starves the narcissist of all ammunition.” | 97 |
| 19 | https://youtube.com/shorts/FnznOfzNTLg?si=2s-WEfRFfi52IwM5
Mood disorders are an important side effect of glp1 agonists like ozempic which are denied by many doctors and drug companies. They suppress appetite, starve the neurological system of essential nutrients that improve moods.
When people get depressed after taking Glp1 to reduce weight they end up being put on antidepressants and end up becoming addicted or dependent on them. | 133 |
| 20 |  Нет текста... | 136 |
