pimozide. However, newer antipsychotics are equally appropriate, such as the 2nd generation olanzapine and risperidone and the 3rd generation aripripazol.4 ...
“Cabbage lice infestation” - How psychiatrists solved this in the past 1500 days Cátia Martins1; Fábio da Silva1; Mariana Pinto da Costa1; Serafim Carvalho2 1 – Psychiatric Trainee, Hospital de Magalhães Lemos; 2 – Senior Psychiatrist, Hospital de Magalhães Lemos
Introduction: Delusion of parasitosis, also known as Ekbom’s syndrome, is a form of psychosis defined by an irrefutable false belief of being infested with parasites. Patients affected by this psychiatric condition usually go to several doctors, as dermatologists, in the expectation to have their supposed infection confirmed and treated. Patients may present skin lesions created by rubbing, scratching and picking or by skin treatments, for example by using abrasive products. A very characteristic sign is the matchbox sign, which occurs when the patient brings a “bug” in a small box to the doctor. Usually, the bug is actually a fiber or skin debris. Interestingly, a folie à deux develops in approximately 12% of cases, including internet-induced and patient-doctor shared delusions.1,2,3 Methods: We present a case-study of a 65 years old female patient followed at our Psychiatry Department during the past four years, after being discharged by several doctors and finally referred to us by her family doctor.
Results: See figure below Discussion: Therapeutic alliance remains the main factor for treatment outcome, as many patients are initially very reluctant about consulting a psychiatrist, do not comply with antipsychotic treatment or are lost during follow-up. Apart from this challenge, the prognosis for patients who accept psychiatric treatment is good. Our patient was treated with haloperidol and indeed typical antipsychotics are historically used in this disorder, specially pimozide. However, newer antipsychotics are equally appropriate, such as the 2nd generation olanzapine and risperidone and the 3rd generation aripripazol.4,5 Some patients may believe that it was the psychiatric medication that killed the bugs. However, when doctors say this to their patients, should be aware of the risk of reinforcing the belief in a real infestation. Conclusions: This case illustrates the importance of the observation,
Now 65 years-old caucasian woman Housekeeper
Skin lesions and “sting sensation” in both hands since
No previous psychiatry history Medical conditions: - Diabetes; - Osteoporosis Medicated with Metformin 1000 mg No history of toxics No relevant family history
- 2 negative skin biopsies - Diagnosed allergic dermatitis (allergy to thimerosal and colophony – present in many medical supplies and everyday use products) - Medicated with topic zinc oxid
2005
Since 2007 skin lesions in both lower limbs: - “I saw the lice jumping from my legs… I am infested with cabbage lice” – Illusions/Visual Hallucinations? + Delusion of parasitosis - “I can only get rid of the cabbage lice with pliers “ – Self inflicted skin lesions - “I caught some and kept them in a box to show to my previous doctors I was not lying, but they said it was old skin… probably because the lice were already dead” Matchbox sign
diagnosis and treatment by psychiatrists, and in this case the administration of antipsychotics as the proper treatment to disorders that have been first observed by other medical specialties, combined with a solid therapeutic alliance with patients and proper referrals between colleagues. This brings attention to the consequences of working closely with other medical specialties, as psychiatry and dermatology or any other medical specialty according to how the body is involved in the delusion, raising awareness to the importance of Liaison Psychiatry at the General Hospitals and in Primary Care. References: 1. 2. 3. 4. 5.
Edison KE, Slaughter JR, Hall RD. Psychogenic parasitosis: a therapeutic challenge. Mo Med. Mar-Apr 2007;104(2):132-7; quiz 137-8. Bury JE, Bostwick JM. Iatrogenic delusional parasitosis: a case of physician-patient folie a deux. Gen Hosp Psychiatry. Mar-Apr 2010;32(2):210-2. Patel V, Koo JY. Delusions of Parasitosis; Suggested Dialogue between Dermatologist and Patient. J Dermatolog Treat. Dec 9 2014;1-15. Freudenmann RW, Schönfeldt-Lecuona C. Delusional parasitosis: treatment with atypical antipsychotics. Ann Acad Med Singapore. Jan 2005;34(1):141-2 Ladizinski B, Busse KL, Bhutani T, Koo JY. Aripiprazole as a viable alternative for treating delusions of parasitosis. J Drugs Dermatol. Dec 2010;9:1531-2
From 2005 to 2011: Observed in many departments -Internal Medicine -Dermatology - 2 doctors - Vascular Surgery
Bedrriden for 5 months Uncapable of working - Job quitting Isolated from people Confined to her house Uncapable of stitching (main hobbie) Feeling misunderstood by family and doctors
Always discharged . No resolution of symptoms
Submitted to intravenous corticosteroid
6 months later… Medicated with Venlafaxine 75 mg +Hidroxizin 100 mg and refered to our Psychiatry Department in
2011 by her Family Doctor presenting like this…
Our therapeutic strategy - Haloperidol 5 mg - Clonazepam 5 mg - Increased Venlafaxine to 150 mg - Advised to keep the topic zinc oxid and Hidroxizin
2015… Followed by us initially monthly and then every 6 months
Medication was gradually tappered since 2011 to - Haloperidol 0,5 mg - Clonazepam 0,5 mg - Venlafaxine 75mg - Keeps the topic zinc oxid and Hidroxizin
No symptoms of delusional parasitosis “I am cured from the infestation. Now I only have the allergy in my hands” Back to her usual daily activities and her responsibilities at work
