CE Credit Article Clinical & Refractive Optometry is pleased to present this continuing education (CE) article by Rebecca A. Schuller and Dr. Leonid Skorin Jr. entitled Floppy Eyelid Syndrome Conjunctivitis in a Patient with Delusional Parasitosis. In order to obtain 1-hour of COPE-approved CE credit, please refer to page 444 for complete instructions.
Floppy Eyelid Syndrome Conjunctivitis in a Patient with Delusional Parasitosis Rebecca A. Schuller, BA; Leonid Skorin Jr., OD, DO, FAAO, FAOCO
ABSTRACT A patient was referred for ophthalmologic assessment due to chronic conjunctivitis. Examination revealed floppy, easily evertible eyelids as well as unusual lesions on the forehead, temple and jaw line that the patient reported as a chronic problem due to parasites. Laboratory testing of specimens showed no evidence of parasites. The patient was diagnosed with floppy eyelid syndrome and secondary chronic conjunctivitis. He was also diagnosed with delusional parasitosis. Delusional parasitosis is a diagnosis of exclusion. Management with psychotherapy and antipsychotic medications can be beneficial.
CASE REPORT Initial Presentation An 80-year-old white male presented to our clinic on referral by his primary care provider for an ophthalmology consultation. His recent ocular history included treatment for chronic bacterial conjunctivitis with Zymar (gatifloxacin ophthalmic solution 0.3%, Allergan). After prolonged use of the Zymar and because his chronic conjunctivitis did not appear to resolve, he was treated with Polytrim (trimethoprim sulfate 0.1% with polymyxin B, Allergan) and oral Duricef (cefadroxil monohydrate, Bristol-Myers Squibb). Currently, he was using Patanol (olopatadine hydrochloride ophthalmic solution 0.1%,
R.A. Schuller — 4th Year Optometry Intern, Pacific University College of Optometry, Forest Grove, OR; L. Skorin, Jr. — Staff Ophthalmic Surgeon, Albert Lea Eye Clinic, Mayo Health System, Albert Lea, MN Correspondence to: Dr. Leonid Skorin, Jr., Albert Lea Eye Clinic, Mayo Health System, 1206 West Front Street, Albert Lea, MN 56007; E-mail:
[email protected]
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Alcon) for allergic conjunctivitis secondary to medicamentosa. He stated that discharge from the eye was still present, although the itch was gone with the use of Patanol. Upon questioning, he noted that the discharge was mostly noted in the mornings upon waking. The patient did sleep on his stomach. Visual acuity with his current glasses was 6/18 (20/60) in the right eye and 6/12 (20/40) in the left eye. Anterior segment exam revealed significant dermatochalasis and easily evertible floppy eyelids on both upper lids (Fig. 1). Mild diffuse superficial punctate keratopathy was noted on the right eye only. Mucus discharge was noted in the conjunctiva of both eyes. Other findings were unremarkable. It was also noted that the patient had multiple round and linear lesions along the jaw and hairline on the right side of his face, which were covered by makeup. He stated that these were due to parasites infecting his skin after a Chihuahua dog had shaken itself on him ten years earlier. He felt that fleas and other parasites jumped onto him during that episode. He took a hot shower immediately afterwards, but this did not remove the parasites as they had already become embedded under his skin. Despite seeing many doctors, including dermatologists, no one had been able to discover exactly what was infecting him or treat the condition successfully. However, he stated that none had ever tested any of the parasites that he removed and collected. He was currently self-treating the parasites by removing as many as he could by hand, and cleaning the areas with hydrogen peroxide and iodine. He had also used undiluted vinegar in the past. Although the lesions were near his eyes, he denied using any of the chemicals in his eyes and instead preferred the oral antibiotics for his chronic conjunctivitis. We diagnosed the patient with floppy eyelid syndrome and secondary chronic conjunctivitis. He was prescribed doxycycline 50 mg twice a day for one month and asked to continue Patanol twice a day. As he felt he was not ready to consider blepharoplasty for his floppy eyelids, it was suggested he try swimming goggles while sleeping to prevent the eyelids from everting and rubbing on his pillow casing. In addition, he was asked to collect samples of the parasites that he removed for further evaluation and testing.
Fig. 1 Left eye, showing upper lid laxity and easy eversion
Fig. 2 Circular lesion on patient’s right temple
Recent attempts at psychiatric consultation were refused by the patient as he had tried this previously with no success.
Fig. 3 Linear lesions on patient’s right mandible. Also note uneven skin tone as a result of scarring from previous self-induced trauma.
Pertinent Past Medical History The patient’s previous medical records were obtained and reviewed following the initial ophthalmology consultation. They indicated at least three previous biopsies or skin samples from the shins, forehead and left forearm for parasite identification. Multiple courses of Keflex (cephalexin, Lilly) and occasionally other antibiotics had been prescribed by other clinicians for low-grade cellulitis and localized skin infections in the areas of the excoriations. At a dermatology consultation eighteen months previously, the patient reported he had a supply of 2 mg Risperdal (risperidone, Janssen Pharmaceutica), which had been prescribed some years previously as an “antiparasitic” medication. However, he was modifying the dosage to a half pill once or twice weekly as it upset his gastrointestinal system. He also reported at that time that he felt the parasites were causing his frequent eye infections, but that the ophthalmologist he had seen “Didn’t know what to do”.
One Month Follow-Up The patient reported decreased mattering since use of the oral antibiotic. His itching remained under control with the continued use of Patanol. He had not yet tried the swim goggles while sleeping. Visual acuity was 6/18 (20/60) in each eye with his current glasses. Anterior segment examination revealed trace crusting on the lashes of both eyes, and persistent mucus of the left eye conjunctiva. The corneas of both eyes had diffuse grade 2-3 superficial punctate keratopathy. Other findings were unremarkable. Evaluation of the lesions on the patient’s face and head without makeup showed a large circular scab on the right temple (Fig. 2), and linear lesions on the right mandible (Fig. 3). In addition, a smaller lesion was present on the left side of the nose. The pathology report from the patient’s collected specimens revealed only keratinic debris, with no evidence of parasites. A secondary diagnosis of delusional parasitosis was now also made. This was discussed with the patient, but he was skeptical in believing the diagnosis. The patient was instructed to decrease the oral antibiotic to once a day, and to continue the Patanol once a day. In addition, Systane (Alcon) lubricant eye drops were added for the superficial punctate keratopathy. The patient was still not interested in pursuing any surgical correction for his floppy eyelids. He was also not interested in seeing a psychiatrist as the last one he had seen told him, “There is nothing he can do for him”.
DELUSIONAL PARASITOSIS Delusional parasitosis is a rare disorder in which patients mistakenly but firmly believe they are infested by parasites.1,2 These presumed parasites may be ectoparasites such
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as mites, fleas, lice, or spiders, or internal parasites such as worms, bacteria, or other organisms.2 Patients with primary psychotic delusional parasitosis typically are not afraid of insects, and are behaviorally and rationally normal aside from the belief of infestation. Delusional parasitosis may be secondary to functional conditions, such as schizophrenia, paranoia, or depression; it may also be secondary to organic conditions, such as drug abuse, vitamin B12 deficiency, cerebrovascular disease, hypothyroidism, or diabetes mellitus.1 According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the disorder is a somatic type delusional disorder, in which delusions are nonbizarre and persist for at least 1 month. In addition, the delusions cannot be due to the effects of a substance or a general medical condition, and patients must not meet criterion A for schizophrenia.3 (Criterion A states that at least two of the following are present: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms [such as avolition or alogia]. These symptoms must be present for a significant portion of at least one month. Only one symptom needs to be present if delusions are bizarre or hallucinations include running commentary or multiple voices conversing with each other). Patients with delusional parasitosis will have made numerous visits to dermatologists, emergency room physicians, primary care physicians, and occasionally exterminators and others; however, these professionals are often viewed as incompetent by the patient.1,2 Some of the visits may have resulted in treatments of infections caused by the excoriation of the skin due to excessive itching or injuries due to the patients’ attempts to rid themselves of the parasites.1 The patients often bring “proof” with them to exams, which is referred to as the “matchbox sign”. The samples typically contain skin cells or other human tissue, lint, dust, hair, scabs, and other objects.1,2,4 Patients with delusional parasitosis are more commonly female with a female-to-male ratio of 1.5:1, and the mean age of onset is 56.9 years.4 However, this data is variable, as younger patients are more likely to be males who are often abusing illegal drugs such as cocaine or methamphetamine.1 The mean duration of the delusion is 3.0 +/4.6 years (median of 1 year).5 The presumed infestation can occur anywhere on the body, but is generally in a location which the patient can easily access.2 Linear excoriations caused by a patient’s fingernails are common. Patients describe the infestation as being on or just under the skin, in or around body openings, or located internally (particularly in the stomach or intestine.)1,2 As patients are generally resistant
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to psychiatric consultation, dermatologists are more often involved in their treatment.4 However, since ocular and periorbital areas may be sites of suspected infestation as well, optometrists and ophthalmologists may be involved in the care of these patients. Reported ocular injuries have included conjunctival lacerations by tweezers, corneal epithelial defects from cotton swabs, and instillation of antilice medication into the eyes.6 The standard treatment of delusional parasitosis is psychotherapy with the possible use of the antipsychotic drug pimozide (multiple trade names and manufacturers).2,4,6 A literature review by Trabert in 1995 found that use of antipsychotic medications increased the rate of full remissions from 33.9% without use of antipsychotics to 51.9% with the medication.5 However, the dosage of pimozide must be carefully managed due to its extrapyramidal effects and the patient needs to be monitored with repeat electrocardiograms.4,7 Recent attempts at treatment with atypical antipsychotics such as Risperdal and Zyprexa (olanzapine, Lilly) appear to have at least equally successful rates of treatment of delusional parasitosis while avoiding the side effects seen with pimozide.7-9 o
REFERENCES 1.
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University of California, Davis. Bohart Museum of Entomology. Human skin parasites and delusional parasitosis. Available at: http://delusion.ucdavis.edu/ delusional.html. Accessed September 11, 2006. Minnesota Department of Health. Delusional parasitosis. Disease Control Newsletter. 2005; 33(5): 61. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Text revision. Washington, DC: American Psychiatric Association; 2000. Zomer SF, De Wit RF, Van Bronswijk JE, Nabarro G, Van Vloten WA. Delusions of parasitosis: a psychiatric disorder to be treated by dermatologists? An analysis of 33 patients. Br J Derm 1998; 138: 1030-1032. Trabert W. 100 years of delusional parasitosis. Metaanalysis of 1,223 case reports. Psychopathology 1995; 28(5): 238-246. Sherman MD, Holland GN, Holsclaw DS, Weisz JM, Omar OHM, Sherman RA. Delusions of ocular parasitosis. Am J Ophthalmol 1998; 125(6): 852-856. Meehan WJ, Badreshia S, Mackley CL. Successful treatment of delusions of parasitosis with olanzapine. Arch Derm 2006; 142: 352-355. Elmer KB, George RM, Peterson K. Therapeutic update: Use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis. J Am Acad Derm 2000; 43(4): 683-686. Safer DL, Wenegrat B, Roth WT. Risperidone in the treatment of delusional parasitosis: a case report [letter]. J Clin Psychopharm 1997; 17: 131-132.
