Ekbom's syndrome followed by self-mutilation

Abstracts

O delírio parasitário (ou síndrome de Ekbom) é uma condição rara, onde o paciente apresenta uma forte convicção de que está infestado por pequenos parasitas ou organismos. Muitas vezes, os delírios são tão intensos que levam esses pacientes à automutilação. Relatamos aqui um caso de um senhor de 67 anos, isolado socialmente, solteiro, apresentando delírio parasitário em região perineal, culminando em lesões por automutilação.

Transtornos paranóides; delusões; automutilação; síndrome de Ekbom

CASE REPORT

Ekbom's syndrome followed by self–mutilation^*

Pedro Domingues Goi^I; Caroline Thimmig Scharlau^II

^IPhysician, Family Health Program, Municipal Department of Health, Faxinal do Soturno, RS, Brazil

^IIPsychiatrist, Universidade Federal de Santa Maria, RS, Brazil. Specialist in Psychiatry, Brazilian Psychiatric Association. Head, Psychiatric Ward, Municipal Department of Health in Faxinal do Soturno, RS, Brazil

^{Correspondence}

ABSTRACT

Delusional parasitosis (or Ekbom's syndrome) is a rare condition, in which the patient has a strong conviction that he or she is infested by small parasites or organisms. These delusions are often so intense that they lead the patient to self–mutilation. We report a case of a 67–year–old man, socially isolated, single, with delusional parasitosis in the perineal area, culminating in self–mutilation lesions.

Keywords: Paranoid disorders, delusions, self–mutilation, Ekbom's syndrome.

Introduction

Ekbom's syndrome – delusional parasitosis, parasitophobic neurodermatitis, acarophobia or, as Ekbom himself named it, dermatozoenwahn (dermatozoic delusion) – has been reported and studied since the 19^th century.^1–4 However, it was only in 1938 that this Austrian physician reported a series of cases of a psychiatric disease, mainly affecting senile and pre–senile women. His patients presented a delirious and persistent idea that worms and microbes were infesting them and coming out of their skin.^1–7 Such delusion leads patients to self–mutilation, scratching, cutting and injuring their skin, with the aim of eliminating those parasites.^8,9 These lesions are usually called dermatitis artefacta.⁴ Other authors consider this phenomenon as being a fear that insects infest patients' bodies, classifying this syndrome as monosymptomatic hypochondriacal psychosis.^1,4 Therefore, the range of symptoms involved in this pathology may vary from psychotic symptoms and delusions to phobic and obsessive symptoms; 42% of patients can also manifest variable levels of organic disorders, such as peripheral neuritis, diabetes mellitus, dementia, among others.^1,9 Substance abuse can also generate hallucinations related to insects, such as cocaine bugs, a phenomenon related to use of cocaine.⁴

Some patients even collect debris, desquamative tissue, hair, back and other substances that adhere to the lesions (dust, vegetal rests, parts of insects, clothing debris, etc.) and take them in boxes and plastic bags to their physicians, claiming that the parasites are there and usually asking them to have that material analyzed in a laboratory. This is known as the "matchbox sign."^1,3,4,8–11

Patients' ability to see parasites is part of the delusion, besides describing and even drawing them in the most varied shapes and sizes. The most common images are of tiny arthropods with legs and head and whitish cylindrical worms of variable length.^1,6

When these patients do not live alone, they are often able to generate induced psychotic disorder in neighbors and relatives (folie à deux, folie à famille), corresponding to around 5–25% of cases, depending on the literature.^1,2,7 It is also known that women are more able to induce this disorder than men.¹

The prototype of a patient with delusional parasitosis is a woman, mean age of 58 years, socially isolated, divorced or widow and with low schooling level, which makes these characteristic risk factors for developing this disease.^1–5

Case Description

A 67–year–old, Caucasian, male patient, retired rural worker, single, no children. The patient agreed with and authorized the publication of this case and respective images.

He reported that, approximately 25 years ago, he started having pruritus and self–mutilation in the scrotum, which was increasing in extension and reaching other perineal areas and perianal region.

The patient reported that pruritus and self–mutilation, which he performed through skin incisions using a razor blade, aimed at removing and killing the parasites. The patient described parasites as being small cylindrical worms of reduced diameter, externally reddish and internally whitish, ranging from 5 to 20 cm in length, with a small head at the end. When requested, he drew sketches of them, such as the one shown in figure 1.

He reported that such worms cause an "infection in his organism" and that they "mainly affect the liver." He claimed that, to eliminate them, he had to remove them from the perianal region with a razor blade and put them in the sun to dry, which makes them melt and die. He stated that this is the only form of killing the parasites and that any other medication used by physicians could extinguish them.

The patients did not present depressed mood neither phobic–anxious symptoms. He had an organized and coherent thought, with a slightly accelerated speech. Despite delusions concerning delusion parasitosis, he never had any other psychotic symptoms. He denied substance abuse. He did not present memory deficit, was oriented to time, space and self–psychically, reaching 29 points out of 30 in Folstein Mini–Mental Status Exam (Mini–Mental). He did not present insight as to his condition, despite presenting adequacy to the reality test.

He lives in a rural area, isolated, with few resources and no help from close relatives.

Disease onset was at 43 years, when he was hospitalized at a clinical hospital due to self–mutilation lesions, and was later transferred to a psychiatric hospital due to his delusional status. Before that, the patient presented psychic functioning with no significant changes. He denied family history of psychiatric disease. Since he started receiving care from the health center team, in mid–February 2005, he already presented a certain degree of iron deficiency anemia, due to constant blood loss triggered by self–mutilation lesions. He frequently presented organic symptoms, such as exhaustion, fatigue, muscle pains and dyspnea to efforts, when he was invariably hospitalized at a clinical hospital for blood transfusion. In March 2005, during a home visit, the patient was found with xerostomia, pale, dyspneic, tachycardic, presenting lesions in the perianal region with serosanguineous secretion. At that time, diagnostic hypothesis of somatic delusional disorder was proposed.

Besides iron deficiency anemia caused by blood loss and skin infection where self–mutilations were performed, the patient did not have any other organic disease. He was assessed by clinicians and dermatologists while he was hospitalized at a reference tertiary care hospital to undergo treatment for anemia and lesions.

The patient was initially submitted to pharmacotherapy with pimozide 4 mg/day and promethazine 50 mg/day, and relatives were advised that the patient should be constantly monitored by a caretaker. He progressed with good response and good treatment adherence while his caretaker remained at the patient's house. He was never asymptomatic in relation to delusional symptoms, but caused less self–mutilation. After disagreements with his relatives, he lost treatment adherence, with worsening of delusional status and resuming self–mutilations.

Discussion

This case reveals a patient with Ekbom's syndrome who, apart from gender, is very close to the standard found in the literature of a person between the fourth and fifth generation of life, socially and geographically isolated, single, divorced or widow, with low schooling level. Symptoms, with some peculiarities for each case, also have little variation.^1–6 Self–mutilation found in the present patient was also reported in some other cases,^6,8,10,12 but with lower intensity.

Such patients, when they do not present other diseases, usually reach high Mini–Mental scores, even the elderly.⁹ Similarly, our patient had a good score, excluding a possible case of dementia. Absence of productive psychotic symptoms and patient's adequate functioning, even without treatment, dismiss the hypothesis of schizophrenia.

The patient was referred to the Dermatology Service at Hospital Universitário de Santa Maria during one of his hospitalizations, where other purely dermatological pathologies were excluded. Laboratory tests at that time were unspecific. Besides hypochromic microcytic anemia developed after self–mutilation onset, any other organic disease was observed.

Concerning the treatment, the patient initially responded well to pimozide, which is in agreement with the literature.^{1,3–5,9,10–14} However, as we could also conclude based on our case, poor adherence is the main factor leading to few results.^3,10

References

Received September 25, 2006.

Accepted March 21, 2007.

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*

This study was carried out at the Municipal Department of Health in Faxinal do Soturno, RS, Brazil.

Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Accepted
  21 Mar 2007
• Received
  25 Sept 2006