Academic journal article Hong Kong Journal of Psychiatry

Delusion of Parasitosis: An Atypical Initial Presentation of Multiple Sclerosis

Academic journal article Hong Kong Journal of Psychiatry

Delusion of Parasitosis: An Atypical Initial Presentation of Multiple Sclerosis

Article excerpt


Multiple sclerosis (MS), a common demyelinating disorder, has been associated with mood symptoms for years. Its association with psychosis has been described in the literature (1-4) but not many cases have been reported. "Psychosis" as a first presentation of MS has always been a hot topic of debate (5) but there are very few reports (6-8) in which the psychiatric symptoms are either the presenting signs of MS or present simultaneously with the neurological symptoms. We report a case of an individual with MS presenting with a delusion of parasitosis as the first manifestation. There were no neurological signs and symptoms pertaining to MS in this case.

Case report

Ms B, a 49-year-old African American female with a lifelong history of eczema presented to Psychiatry Emergency (CRISIS) in September 2007 with a 6-month history of seeing and feeling bugs crawling on her skin and on her clothes. These bugs had not been seen by anyone else in her family. The patient reported that the bugs are a species of gnat that came from the everglades. She described different species of gnats, "angel gnats", which she described as small and less aggravating and not coming near her if she kept her body clean, "nasty gnats" which were bigger and looked like creatures from outer space and were always present, and "misty gnats", aggravating gnats which were the worst ones that the patient could not see but which she could feel, saying they itch, sting and bite. She reported their presence all over her body except the genital areas "because she used powder there and the gnats don't like the powder". She self medicated with creams and insecticide sprays without any benefit and reported using alcohol, tylenol and benadryl for 3 weeks to "numb" the sensation of the bugs. She also reported hearing "whispers" in her house, when alone at home. These gradually disappeared and she has not heard them since.

Her history included 3 episodes of depression. The first episode occurred after her first pregnancy, which ended in a miscarriage in 1983. The other 2 episodes were postpartum, occurring after the births of her 2 children (1985 and 1989). She denied being given any treatment for depression. She also gave a history of chronic eczema treated by many doctors with poor results.

She said she drank alcohol occasionally at parties (1-2 glasses of wine twice a year) except for recently when she had tried to use alcohol to numb the skin sensation, reporting drinking 3 bottles of wine daily for 3 weeks. She denied any illicit substance use. Her family history was significant for a sister with seizures, a daughter with attention-deficit hyperactivity disorder, and the death of an elder sister 1 year earlier due to colon carcinoma.

A mental status examination revealed a physically healthy woman who was calm and cooperative and totally preoccupied with her alleged "bugs". Her thought form was well organised, but the content was replete with firmly held delusions. She was alert and oriented on admission, with a Folstein score of 30/30. Along with the bug delusions and generalised pruritus that the dermatologists did not believe was caused by an infestation, visual hallucinations were also present. The patient reported that she could see these bugs and even taste them as they sometimes entered her mouth. There were no other abnormalities at the time of her mental status examination. She satisfied the DSM-III criteria for atypical psychosis. She was stable and did not show any signs of alcohol withdrawal.

She was diagnosed as having delusions of parasitosis, was admitted to the psychiatry inpatient unit and treated with chlorpromazine 25 mg orally twice a day, thiamine 100 mg orally daily, folic acid 1 mg orally daily, aquaphor topical 3 times a day, and alcohol taper, to target any withdrawal symptoms. On day 5 of her admission, triamcinolone 0.1% topical (twice a day) and hydrocortisone 2. …

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