A Case of Delusional Parasitosis Secondary to Severe Iron Deficiency Anaemia in a Tertiary Care Hospital: An Area for Clinical Vigilance

INTRODUCTION Delusional parasitosis has had many terminologies assigned to it historically, the earliest literature citing the term "Acarophobia" in 1894, given by Thieberge. Thereafter, in 1938, it came to be known as "Ekbom Syndrome" or "Presenile Dermatological Delusion,"[1] and continues to be held in literature as "Ekbom Syndrome."[2] Delusional disorders can be categorized into primary and secondary (functional vs. organic). Our case report features the occurrence of delusional parasitosis secondary to organicity, more specifically, anemia. CASE REPORT A 62-year-old widow, Mrs. X, an illiterate, homemaker, hailing from low socioeconomic status with comorbid diabetes mellitus, presented to the psychiatry outpatients with a crawling sensation over the scalp, face, and whole body for the past 9 months. She had a belief that worms had been infesting her scalp and body for 9 months, with associated easy fatigability, poor sleep, and appetite from the past 6 months was noted. The onset was insidious and gradually progressive. Crawling sensation began in the scalp and spread to the head, face, upper body, limbs, and even genitals. The associated biting sensation was noted, with itching and burning sensation in areas where she believed worms were residing. The patient picked at her scalp and eyebrows to remove the worms, resulting in hair loss. A history of exacerbation of the above symptoms from the past 6 months with irritability, restlessness, and anger outbursts when the family confronted her was revealed. Mrs. X frequently used foul language with family members and began spending most of her time standing outside her house in an attempt to remove the worms. She avoided going inside the house, fearing worms from her body would contaminate the house. She refused to allow anyone to sit/sleep next to her, as she believed she could spread the infestation. In attempts to rid herself of the worms, the patient increased her frequency of handwashing each time she did even trivial household work. The patient reports feeling sad as a consequence, with thoughts that her life is ruined and wishes to die. On examination, vitals were normal, pallor present (moderate grade), hyperpigmentation over the face, and abrasions over the back were noted. Patchy loss of hair over the scalp and eyebrows was observed. Psychomotor activity was increased, and speech was relevant and coherent but minimal and with a low tone. The mood was dull, appeared fatigued/distressed with a delusion of infestation, ideas of helplessness, and tactile and visual hallucinations present; insight was Grade 1. Blood investigation showed low hemoglobin (6.8 mg/dL), high postprandial and fasting glucose (127 mg/dL and 228 mg/dL, respectively), and raised creatinine (1.29 mg/dL). Peripheral smear showed microcytic hypochromic anemia with leukopenia and thrombocytopenia. Ultrasound abdomen showed splenomegaly, small-sized left kidney with Grade IV renal parenchymal changes, Grade II renal parenchymal changes in the right kidney, and bilateral mild hydronephrosis. Computed tomography brain showed no significant abnormality. The final diagnosis of iron deficiency anemia with organic delusional (Schizophrenia-like) disorder (F.06.2) was made as per the International Classification of Diseases 10th edition.[3] Mrs. X was admitted under general medicine with comanagement from psychiatry with advice for packed red blood cells (PRBC) transfusion of 2 pints, with re-titration of oral hypoglycemic. The postprandial blood sugar read as 124 mg/dL and fasting blood sugar as 162 mg/dL by day 3 of adjusted oral hypoglycemic. Psychiatric treatment was initiated with tablet haloperidol 2.5 mg 0-0-1 and increased to 5 mg 0-0-1. Marked improvement was noted in beliefs of infestation, crawling sensation, and mood, with a rise in hemoglobin to 10.5 mg/dL. Brown Assessment of Beliefs scale,[4] The Massachusetts General Hospital Hair Pulling Scale,[5] and Positive and Negative Symptoms Scale[6] rating scale were applied. Complete resolution of symptoms was observed by Day 20 post 2nd blood transfusion [Table 1].Table 1: Psychometric scales applied, treatment, and timeline of therapeutic progressDISCUSSION Delusional parasitosis has been categorized into primary and secondary. Primary disorders occur de novo, whereas secondary occur as a consequence of an underlying pathology. Secondary delusional parasitosis occurs due to psychiatric disorders, substance use, side effects of medications, and finally, secondary to medical conditions.[7] Medical conditions likely to result in delusional parasitosis (DP) include neurological disorders such as cerebral vascular accident, dementia, Huntington's disease, and multiple sclerosis. Diseases presenting with pruritus include hepatic disease, renal disease, and lymphoma.[7,8] In addition, DP has also been attributed to nutritional deficiencies, primarily B12 deficiency, folate deficiency, and pellagra caused by niacin deficiency.[7,8] Our case report remains the second to report DP secondary to severe anemia that then resolved following the restoration of anemic status.[7] The specific etiology of this syndrome remains indeterminate. A common initial presentation is itching, and a plausible explanation could be a false interpretation of the itching sensation. An in-depth examination is mandated to sift out any other diseases that may present with itching. Other co-existing symptoms include formication, tingling, sensation of movement under the skin, or even pain, which invariably exists with subjective certainty that the symptoms are caused by the presence of worms, insects, or other parasites in the body.[9] Thereby, tactile hallucinations or paresthesia form the primary symptoms. Thereupon, self-inflicted wounds in the form of cuts, excoriation, small bruises, and excoriated lesions are common in an attempt to eliminate parasites. Furthermore, secondary skin damage is witnessed wherein the individual, in an attempt to rid self of the parasite, resorts to repeated cleansing/makes use of aggressive measures like caustic substances.[9] Our case presented with beliefs of infestation and florid tactile hallucination and consequently having pulling of hair, patches of alopecia, and some excoriation marks on the face and back. Unlike known literature, the patient did not collect "the worms" and there was no matchbox sign.[10] Treatment choices, when reviewed, revealed that cases responded to antipsychotic treatment such as haloperidol, pimozide, trifluoperazine, and risperidone.[11] Given the risk of extrapyramidal and cardiovascular side effects of typical antipsychotics, treatment preferences have shifted to atypical antipsychotics.[12] The duration of treatment is debatable, but a norm of 1–4 weeks for treatment response is considered. Recommendations for treatment to continue for a couple of months more after symptoms abate, gradual taper, and in case of resurfacing symptoms, then treatment should be re-initiated from the general rule.[13] Evaluation into our case found severe anemic status, thereby swift correction formed the mainstay of treatment. Haloperidol was chosen at a low dose of 2.5 mg with a hike up to 5 mg, which was continued for a week, with simultaneous PRBC transfusions. We found a marked change after the second PRBC transfusion with a reduction in crawling sensation, sleep disturbance, itching, and severity of belief of infestation. Almost complete resolution of all symptoms was noted after 20 days of tablet haloperidol 2.5 mg and tablet ferrous sulfate 1-1-1, and hemoglobin (Hb) levels at 10.5 mg/dL. Tablet haloperidol 2.5 mg was stopped in the next 7 days, with a continuation of tablet ferrous sulfate transient ischemic dilatation (TID), and the patient continued to be symptom-free in the next follow-up visit. We found only a single anecdotal report of DP secondary to iron deficiency anemia and complete resolution after restoration of anemic status.[7] Although the haloperidol dosage was maintained at 5 mg from day 3 for a week, and the only variation in treatment remained the 2nd PRBC transfusion on day 5, with continuing ferrous tablets TID, the marked improvement in Mrs. X's belief and hallucination was consistent. This improvement remained despite a reduction in haloperidol dosage to 2.5 mg, thereby pointing toward the reason for improvement being Hb level restoration to normal. A multidisciplinary team approach with timely collaboration brings forth the best outcome in patients with delusional parasitosis. CONCLUSION This case alludes to the need for clinical vigilance and frequent checks for nutritional deficiencies presenting as reversible psychiatric manifestations, particularly in the elderly population. Clinical significance Awareness of secondary reversible causes for delusional parasitosis as a clinical presentation to enhance earlier detection and better patient outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.