Ophthalmic Delusional Parasitosis
Disease Entity
Disease
Delusional parasitosis (DP) is a monothematic, somatic delusional disorder [1]. Ophthalmic delusional parasitosis is a subtype of DP in which patients have a fixed belief that parasites are infesting their eyes. These beliefs persist even without evidence to support them. Patients with DP can have fixed beliefs involving any organ, skin being the most common organ involved [2]. Ophthalmic DP presents as a cutaneous delusion such as insects crawling in the eyelids [3,4] and less commonly as parasites invading the eye itself [5]. In a broader sense, DP can be classified as primary, secondary (functional), or organic [6]. Primary DP patients present with delusions, but they have no underlying psychiatric or organic condition. Patients with secondary DP have an underlying psychiatric cause for their delusion. Delusions in patients with organic DP, are secondary to other sources such as medical conditions, infectious diseases, or drug abuse.
Epidemiology
The incidence of DP is between 1.9 to 27.3 cases per year per 100,000 people [7]. Although DP can present in any age, it most often presents in patients between 50 to 70 years old. Caucasians are more likely to present with these somatic delusions [2]. Women and men present with delusional parasitosis in a ratio of 1:1 under the age of 50, however over the age of 50 women are more likely to present with this condition than men at a ratio of 3:1 [2].
Etiology
The inciting cause of delusional parasitosis is not always discovered. However, some patients report a preceding stressful life event. [2].
General Pathology
When samples are taken from patient’s skin lesions or excoriations, no true parasites are found [6].
Pathophysiology
The pathophysiology of ophthalmic DP and DP is not well understood. However, Huber et al. proposed that deterioration of striatal dopamine transporter (DAT) receptors may play a role [7,8]. As DAT levels in the striatum diminish, extracellular dopamine levels increase. Some other conditions that diminish the functionality of DAT include cocaine use, alcohol use, schizophrenia, Parkinson’s disease, and Huntington’s disease. All these conditions have been linked as secondary causes of DP with associated decreased DAT function. Atypical antipsychotics, which are dopamine receptor inhibitors, have been utilized as an effective treatment in patients with primary delusional parasitosis [9]. This provides further credence to the theory proposed by Huber et al.
Diagnosis
Delusional Parasitosis is a diagnosis of exclusion. Therefore, when clinicians are evaluating a patient complaining of parasitic infection, a thorough work up is advised to rule out other causes for the patient’s symptoms.
History
Patient history may include exposure to various potential vectors such as other people infected with parasites, house pets, or recent travel to developing countries. Patients can also develop DP after successful treatment for a real parasitic infection in the past [2].
Physical examination
Patients suffering from tactile hallucinations involving the skin may present with skin excoriations, ulcers, or corneal abrasions from attempting to remove the perceived parasites [10]. They may also have chemical dermatitis from attempts to cleanse the infected skin with home remedies [7]. Slit lamp exam and dilated fundus exam can assess for an inflammatory response or other signs which might indicate real parasitosis or organic DP. Fluorescein is useful for detecting corneal abrasions.
Symptoms
Ophthalmic DP will present primarily in patients as a complaint of parasitic eye infection. Associated symptoms may include pruritis or tactile hallucinations such as a sensation of bugs crawling or biting through the patient’s eyelids. However, clinicians should be aware that the clinical presentation can vary as broadly as the patient’s imagination allows.
Clinical diagnosis
Delusional Parasitosis is a somatic subtype of delusional disorder. According to the DSM-5, patients with delusional disorder must:
1. Have the persistent delusion for at least 1 month
2. Not meet criteria for schizophrenia
3. Not have markedly impaired function, odd or bizarre behavior
4. Not have prolonged episodes of mania or depression. If episodes exist, they must be brief in comparison to the length of the delusion
5. Not have another underlying cause for delusions such as substance use, a medical condition, or other mental illness [1]
Diagnostic procedures
An MRI brain and orbits with and without contrast can help assess for abnormal brain lesions or other secondary causes that may lead to the patient’s delusions. Sometimes, physicians may decide to perform mineral oil skin scrapings or biopsy to assess for parasites [6,9].
Laboratory test
A large part of the work up for patients with delusional parasitosis includes ruling out true microbial infection, and organic causes of delusional parasitosis. Providers can consider ordering: complete blood count with eosinophils, urine drug screen, IgE level, vitamin levels such as B12 and folate, thyroid labs, and testing for microbial organisms such as syphilis, tuberculosis, HIV, or other endemic organisms [6,7].
Differential diagnosis
The differential diagnosis includes real parasitosis, psychiatric illness, substance use, and organic ophthalmic or medical pathology. Patient’s may present with ocular symptoms other than their parasitic delusion such as vision loss or eye pain. Therefore, a full work up is recommended to rule out life or vision threatening causes before diagnosing a patient with ophthalmic delusional parasitosis.
Conditions that can present as organic DP include:
Medical: hypothyroidism, diabetes, anemia, folate deficiency, and vitamin B12 deficiency.
Infectious organisms: syphilis, tuberculosis, HIV, leprosy, other endemic organisms
Substance abuse: cocaine, amphetamines, methylphenidate, pemoline, alcohol [6]
Associated Conditions
Patients with DP often have other coexisting psychiatric conditions. The Department of Psychiatry at the Mayo Clinic found that out of 54 patients with DP, 74% received additional psychiatric diagnosis and only the remaining 26% had DP alone [11]. Thus, it is advisable to exclude secondary psychiatric causes for patients with ophthalmic DP.
Management
General treatment
Pavlovsky et al. found only 8% of patients with DP accept referral to psychiatry [12]. Therefore, building trust is a vital component for successful treatment. A multi-disciplinary approach is encouraged for patients with DP involving primary care, psychiatry, infectious disease, dermatology, or ophthalmology in the case of ophthalmic DP. For mild cases of DP, some patients may experience resolution with a strong therapeutic relationship, and symptomatic management for pruritis, pain, or otherwise [2]. For more severe cases of DP, often atypical antipsychotics such as risperidone, olanzapine, and quetiapine are used for psychopharmacological management [13]. Patients often refuse treatment with antipsychotics. Medication adherence is more likely when physicians explain to the patient that they are not prescribing antipsychotics for schizophrenia. Rather, psychiatrists and dermatologists frequently use them to treat distress and the antihistamine component of antipsychotics can help reduce itching [6].
Medical follow up
Consistent multidisciplinary follow up bolster the patient physician relationship and is advised for successful patient treatment.
Complications
Skin excoriations and corneal abrasions have been reported in cases of ophthalmic delusional parasitosis [10]. There is a reported case by Ma et al. of Morgellons disease, a subtype of DP, where enucleation was required after corneal perforation and endophthalmitis [14].
Prognosis
Patients with DP typically are not markedly impaired. However, the delusions and associated symptoms such as pruritis may prove a persistent nuisance decreasing quality of life [6]. Secondary complications of ophthalmic DP may result such as infected skin excoriations, corneal abrasions, corneal perforation, or endophthalmitis [10,14]. Patients generally respond well to atypical antipsychotics with studies showing partial or full remission in 60-100% of patients [9].
References
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.
2. Mumcuoglu KY, Leibovici V, Reuveni I, Bonne O. Delusional Parasitosis: Diagnosis and Treatment. Isr Med Assoc J. 2018 Jul;20(7):456-460. PMID: 30109800.
3. Whitfield NT, Krasniak AE, Nguyen HT. Concurrent Delusions of Ocular Parasitosis and Complex Visual Hallucinations from Charles Bonnet Syndrome Treated Successfully with Aripiprazole in an Elderly Male: A Case Report. Perm J. 2020 Dec;25:1-3. doi: 10.7812/TPP/20.132. PMID: 33635770; PMCID: PMC8817919.
4. Sandhu RK, Steele EA. Morgellons Disease Presenting As an Eyelid Lesion. Ophthalmic Plast Reconstr Surg. 2016 Jul-Aug;32(4):e85-7. doi: 10.1097/IOP.0000000000000258. PMID: 25192328.
5. Sherman MD, Holland GN, Holsclaw DS, Weisz JM, Omar OH, Sherman RA. Delusions of ocular parasitosis. Am J Ophthalmol. 1998 Jun;125(6):852-6. doi: 10.1016/s0002-9394(98)00048-8. PMID: 9645723.
6. Reich A, Kwiatkowska D, Pacan P. Delusions of Parasitosis: An Update. Dermatol Ther (Heidelb). 2019 Dec;9(4):631-638. doi: 10.1007/s13555-019-00324-3. Epub 2019 Sep 13. PMID: 31520344; PMCID: PMC6828902.
7. Ansari MN, Bragg BN. Delusions Of Parasitosis. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541021/.
8. Huber M, Kirchler E, Karner M, Pycha R. Delusional parasitosis and the dopamine transporter. A new insight of etiology? Med Hypotheses. 2007;68(6):1351-8.
9. Lepping P, Russell I, Freudenmann RW. Antipsychotic treatment of primary delusional parasitosis: systematic review. Br J Psychiatry. 2007 Sep;191:198-205. doi: 10.1192/bjp.bp.106.029660. PMID: 17766758.
10. Meraj A, Din AU, Larsen L, Liskow BI. Self inflicted corneal abrasions due to delusional parasitosis. BMJ Case Rep. 2011 Jul 28;2011:bcr0420114106. doi: 10.1136/bcr.04.2011.4106. PMID: 22689836; PMCID: PMC3149412.
11. Hylwa SA, Foster AA, Bury JE, Davis MD, Pittelkow MR, Bostwick JM. Delusional infestation is typically comorbid with other psychiatric diagnoses: review of 54 patients receiving psychiatric evaluation at Mayo Clinic. Psychosomatics 2012; 53: 258-65.
12. Pavlovsky F, Peskin V, Di Noto L, Stagnaro JC. Delusion of parasitosis: report of twelve cases. Vertex 2008; 19: 99-111.
13. Freudenmann RW, Lepping P. Delusional infestation. Clin Microbiol Rev. 2009 Oct;22(4):690-732. doi: 10.1128/CMR.00018-09. PMID: 19822895; PMCID: PMC2772366.
14. Ma, J., Roelofs, K. A., & Badilla, J. (2019, May 30). Morgellons disease leading to corneal perforation and enucleation. Canadian Journal of Ophthalmology. Retrieved August 14, 2022, from https://www.canadianjournalofophthalmology.ca/article/S0008-4182(19)30212-1/fulltext.
