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Pimozide in delusions of parasitosis
Journal of thc
312 Brief communications
American Academy of
Dermatology
REFERENCES l. Schweckcndiek W. Heilung von Psoriasis vulgaris. Mcd Monatsschr 1959;13:103-4. 2. Schafer GN. Fumarsaurc lindcrt die Schuppenflechte. Selecta 1984;15:1260-1. 3. Glantz SA. Primer of biostatistics. New York: McGrawHill, 1981 ;269-31l.
Pimo7Jde in delusions of parasitosis J. Timothy Damiani, MD,a Franklin P. Flowers, MD,b and Douglas K. Pierce, MDb Cross City and Gainesville. Florida Delusions of parasitosis is a type of monosymptomatic hypochondriac psychosis (MHP). In MHP the patient's sole complaint focuses on a single delusion. For some, the delusion may be their beliefin the abnormal shape of their face; for others it may take the form of a fantasized odor emitted from their body. Dermatologists frequently deal with patients who bring a jar full of debris and claim that these are creatures that infest their scalp, limbs, or orifices (Fig. 1). What seems to set these patients apart is that beyond their delusion they are normal, or at least within acceptable bounds. Case report. A 71-year-old white woman had an 8-month history of burning and itching of the scalp. She had been treated without success with antibiotics and shampoos. Physical examination revealed keratotic papules and a few areas of patchy alopecia. Results of laboratory studies revealed no significant abnormality. Prurigo nodularis was diagnosed and the patient was treated with oral doxepin, 25 mg, taken at bedtime. Shortly thereafter, she reported "something crawling under my scalp" and was convinced thatsome bugs were either "dead" or "moving around" on her scalp. The doxepin was discontinued and she was treated with oral pimoride, 1 mg, twice a day. Inone month the patient was much improved although she still had a burning sensation of the scalp. The dosage of pimozide was increased to 2 mg twice a day and the complaints subsided. She discontinued her medication at 6 months and the delusions returned. Pimozide, 2 mg, twice a day was given again and the patient's symptoms were under control for an additional year.
Discussion. Pimozide is approved for the treatment of chronic schizophrenia and Gilles de la Tourette syndrome but has also been found effective in the treatment of MHP.1- 6 In addition, Duke5 found that patients who had postherpetic neuralgia with neurotic excoriations, symptoms of delusions of parasitosis, or both also benefited From the U.S. Public Health Service, Cross City,' and the Division of Dermatology & Cutaneous Surgery, University of Florida College of Medicine, Gainesville.b Reprint requests: Franklin P. Flowers, MD, Division of Dermatology, University of Florida, Box J-277, ,IHMHC, Gainesville, FL 32610.
16/1/13805
Fig. 1. Patients with delusions of parasitosis may bring in assorted scale and debris to "prove that they are infested." from pimozide. Only patients with severe pain and no other complaint did not benefit from the drug. 4 However, Hamann? observed pimozide to be effective in a case of onychotillomania. Contraindications to pimozide include vascular insufficiency of the central nervous system, blood dyscrasias, Parkinson's disease, prolonged congenital QT syndrome, cardiac dysrhythmias, or drugs that prolong the QT interval. Pimozide also reduces the convulsive threshold and should be used with caution in persons with epilepsy. Its safety has not been established in children or pregnant women. Acute and transient adverse effects include extrapyramidal reactions (restlessness, dystonia, parkinsonism). Tardive dyskinesia is a serious reaction; elderly patients receiving high-dose therapy are at greatest risk. This may be irreversible after long-term use of the drug. However, fine vermicular movements of the tongue may be an early sign of tardive dyskinesia; if the medication is stopped at that time, the syndrome may disappear. Electrocardiographic changes have been reported with prolongation of QT interval, T-wave changes, and the appearance of U waves. Sudden unexpected deaths and grand mal seizures have occurred at doses greater than 20 mg/day. Dosage, after a baseline electrocardiogram, should be begun at 1 to 2 mg/day in divided doses. Dosage may be increased every other day; however, doses greater than 0.2 mg/kg/dayor 10 mg/day arc not recommended. In no case should the dose exceed 0.3 mg/kg/day or 20 mg/day.8 Gould and Gragg9 recommended that, in a patient who has delusions of parasitosis, the role of the dermatologist should be to rule out other causes of pruritus that may contribute in some way to the delusion. Any attempt at referral to a psychiatrist will be often resisted. In fact, it may even alienate a patient who has already chosen the type of treatment he or she wants or will accept. Munr02 recommends that all patients with diagnoses
Volume 22 Number 2, Part I February 1990
confirmed as delusions of parasitosis be given a trial course of pimozide. If the delusions remain and are still interfering with the patient's life, then referral to a psychiatrist is appropriate. The duration of treatment required has been disputed. Munro lO initially believed that pimozide did not effect a cure but only a remission. However, Lenskov and Baadsgaard6 found that a large proportion of patients with delusion of parasitosis could discontinue the medication after 3 to 5 months of treatment. REFERENCES 1. Lyell A. Delusions of parasitosis. Br J Dermatol 1983; 108:485-99. 2. Munro A. Monosymptomatic hypochondriacal psychosis manifesting as delusions of parasitosis. Arch Dermatol 1978;114:940-3. 3. Reilly TM, Jopling WH, Beard A W. Successful treatment with pimozide of delusional parasitosis. Br J Dermatol 1978;98:457-9. 4. Hamann K, Avnstorp C. Delusions of infestation treated by pimozidc: a double-blind crossover clinical study. Acta Derm Venereol (Stockh) 1982;62:55-58. 5. Duke E. Clinical experience with pimozide: emphasis on its usc in postherpetic neuralgia. J Am Acad Dermatol 1983; 8:845-50. 6. Lindskov R, BaadsgaardO. Delusions of infestation treated with pimozidc, a follow-up study. Acta Derm Venereol 1985;65:267-70. 7. Hamann K. Onychotillomania treated with pimozide. Acta Derm Venereol 1982;62:364. 8. Physicians' desk reference. 42nd ed. Oradell, N.J.: Medical Economics Company, 1988. 9. Gould W, Gragg T. Delusions of parasitosis. Arch Dermatol 1976; 112: 1745-8. 10. Munro A. Monosymptomatic hypochondriacal psychosis. Br J Hosp Med 1980;24:34-8.
Acquired secondary syphilis in a child Sandra K. Echols, BS, David L. Shupp, MD, and Arnold L. Schroeter, MD Dayton, Ohio Recent statistics released by the Centers for Disease Control indicate that the incidence of both primary and secondary syphilis in men and women has been steadily increasing during the past 2 years. In 1987, the nationwide rate of 14.6 syphilis cases per 100,000 people was the highest since 1950 and the largest increase within a single year since 1960. This also represents a 25% increase over the 1986 incidence.! As more adull~ are infected, so the likelihood of children contracting syphilis increases. From the Departmentof Dermatology, Wright Slate Univcrsity School of Medicinc. . Reprint requests: David L. Shupp, MD. Wright Slate Univcrsity, Dcpartment of Dermatology, School of Medicine, Dayton, OH 45401.
16/4/13900
Brief communications 313 Case report. A 4-year-old girl had a "rash," hair loss, cough, and sore throat. When examined, the patient had a low-grade fever and a few enlarged cervical lymph nodes. There were scattered white patches on the buccal, palatal, and gingival mucosa and erythematous, denuded areas of the tongue. Patchy areas of alopecia were noted that gave the child's hair a "motheaten" appearance. Numerous hyperpigmented macules with peripheral scales were present on the palms and soles. Results of a genital examination were normal without any signs of trauma but a I X 1.5 em, hypopigmented, moist verrucous plaque was noted in the perianal area. A scraping examined under a darkfield microscope demonstrated multiple spirochetes. A VDRL test was positive at a dilution of ] :64. The fluorescent treponemal antibody absorption (}
Discussion. Syphilis is probably not as well recognized as it was in the preantibiotic era. 2,3 The disease follows the same clinical course in children as it does in adults. Tn all cases of acquired syphilis in children, the mode of transmission is of as much concern as the treatment. The child must be protected from further harm and infection. Detection of the route of infection is often difficult but if the primary lesion is found in a genital or anal site, it is generally clear-cut evidence ofsexual abuse. Difficulties arise in cases of extragenital chancres or in cases of secondary stage disease, without evidence of another sexually transmitted disease. In these cases nonsexual transmission may have occurred (e.g., via breast-feeding, kissing, handling, and sharing eating utensils).4-6 In a 1939 report of 125 cases of acquired syphilis in patients aged 10 years or younger, 34% were due to sexual abuse whereas 23% reportedly were due to innocent kissing or household contact. 3 However, more recently it has been reported that more than 95% of all cases of syphilis are acquired by sexual contact.7, 8 Therefore it is essential that nonvenereal transmission be considered only after all investigations into a possible source of sexual abuse have been made. 9 1n most states, as in Ohio, it is legally mandatory to report any suspicion ofsexual abuse to local Child Protective Services. Although acquired syphilis in children is rare, it is important to realize that it does still exist. As long as there is a continued increase in the total incidence of syphilis in this country, there will most likely be a concomitant increase in pediatric syphilis, both congenital and acquired.
312 Brief communications
American Academy of
Dermatology
REFERENCES l. Schweckcndiek W. Heilung von Psoriasis vulgaris. Mcd Monatsschr 1959;13:103-4. 2. Schafer GN. Fumarsaurc lindcrt die Schuppenflechte. Selecta 1984;15:1260-1. 3. Glantz SA. Primer of biostatistics. New York: McGrawHill, 1981 ;269-31l.
Pimo7Jde in delusions of parasitosis J. Timothy Damiani, MD,a Franklin P. Flowers, MD,b and Douglas K. Pierce, MDb Cross City and Gainesville. Florida Delusions of parasitosis is a type of monosymptomatic hypochondriac psychosis (MHP). In MHP the patient's sole complaint focuses on a single delusion. For some, the delusion may be their beliefin the abnormal shape of their face; for others it may take the form of a fantasized odor emitted from their body. Dermatologists frequently deal with patients who bring a jar full of debris and claim that these are creatures that infest their scalp, limbs, or orifices (Fig. 1). What seems to set these patients apart is that beyond their delusion they are normal, or at least within acceptable bounds. Case report. A 71-year-old white woman had an 8-month history of burning and itching of the scalp. She had been treated without success with antibiotics and shampoos. Physical examination revealed keratotic papules and a few areas of patchy alopecia. Results of laboratory studies revealed no significant abnormality. Prurigo nodularis was diagnosed and the patient was treated with oral doxepin, 25 mg, taken at bedtime. Shortly thereafter, she reported "something crawling under my scalp" and was convinced thatsome bugs were either "dead" or "moving around" on her scalp. The doxepin was discontinued and she was treated with oral pimoride, 1 mg, twice a day. Inone month the patient was much improved although she still had a burning sensation of the scalp. The dosage of pimozide was increased to 2 mg twice a day and the complaints subsided. She discontinued her medication at 6 months and the delusions returned. Pimozide, 2 mg, twice a day was given again and the patient's symptoms were under control for an additional year.
Discussion. Pimozide is approved for the treatment of chronic schizophrenia and Gilles de la Tourette syndrome but has also been found effective in the treatment of MHP.1- 6 In addition, Duke5 found that patients who had postherpetic neuralgia with neurotic excoriations, symptoms of delusions of parasitosis, or both also benefited From the U.S. Public Health Service, Cross City,' and the Division of Dermatology & Cutaneous Surgery, University of Florida College of Medicine, Gainesville.b Reprint requests: Franklin P. Flowers, MD, Division of Dermatology, University of Florida, Box J-277, ,IHMHC, Gainesville, FL 32610.
16/1/13805
Fig. 1. Patients with delusions of parasitosis may bring in assorted scale and debris to "prove that they are infested." from pimozide. Only patients with severe pain and no other complaint did not benefit from the drug. 4 However, Hamann? observed pimozide to be effective in a case of onychotillomania. Contraindications to pimozide include vascular insufficiency of the central nervous system, blood dyscrasias, Parkinson's disease, prolonged congenital QT syndrome, cardiac dysrhythmias, or drugs that prolong the QT interval. Pimozide also reduces the convulsive threshold and should be used with caution in persons with epilepsy. Its safety has not been established in children or pregnant women. Acute and transient adverse effects include extrapyramidal reactions (restlessness, dystonia, parkinsonism). Tardive dyskinesia is a serious reaction; elderly patients receiving high-dose therapy are at greatest risk. This may be irreversible after long-term use of the drug. However, fine vermicular movements of the tongue may be an early sign of tardive dyskinesia; if the medication is stopped at that time, the syndrome may disappear. Electrocardiographic changes have been reported with prolongation of QT interval, T-wave changes, and the appearance of U waves. Sudden unexpected deaths and grand mal seizures have occurred at doses greater than 20 mg/day. Dosage, after a baseline electrocardiogram, should be begun at 1 to 2 mg/day in divided doses. Dosage may be increased every other day; however, doses greater than 0.2 mg/kg/dayor 10 mg/day arc not recommended. In no case should the dose exceed 0.3 mg/kg/day or 20 mg/day.8 Gould and Gragg9 recommended that, in a patient who has delusions of parasitosis, the role of the dermatologist should be to rule out other causes of pruritus that may contribute in some way to the delusion. Any attempt at referral to a psychiatrist will be often resisted. In fact, it may even alienate a patient who has already chosen the type of treatment he or she wants or will accept. Munr02 recommends that all patients with diagnoses
Volume 22 Number 2, Part I February 1990
confirmed as delusions of parasitosis be given a trial course of pimozide. If the delusions remain and are still interfering with the patient's life, then referral to a psychiatrist is appropriate. The duration of treatment required has been disputed. Munro lO initially believed that pimozide did not effect a cure but only a remission. However, Lenskov and Baadsgaard6 found that a large proportion of patients with delusion of parasitosis could discontinue the medication after 3 to 5 months of treatment. REFERENCES 1. Lyell A. Delusions of parasitosis. Br J Dermatol 1983; 108:485-99. 2. Munro A. Monosymptomatic hypochondriacal psychosis manifesting as delusions of parasitosis. Arch Dermatol 1978;114:940-3. 3. Reilly TM, Jopling WH, Beard A W. Successful treatment with pimozide of delusional parasitosis. Br J Dermatol 1978;98:457-9. 4. Hamann K, Avnstorp C. Delusions of infestation treated by pimozidc: a double-blind crossover clinical study. Acta Derm Venereol (Stockh) 1982;62:55-58. 5. Duke E. Clinical experience with pimozide: emphasis on its usc in postherpetic neuralgia. J Am Acad Dermatol 1983; 8:845-50. 6. Lindskov R, BaadsgaardO. Delusions of infestation treated with pimozidc, a follow-up study. Acta Derm Venereol 1985;65:267-70. 7. Hamann K. Onychotillomania treated with pimozide. Acta Derm Venereol 1982;62:364. 8. Physicians' desk reference. 42nd ed. Oradell, N.J.: Medical Economics Company, 1988. 9. Gould W, Gragg T. Delusions of parasitosis. Arch Dermatol 1976; 112: 1745-8. 10. Munro A. Monosymptomatic hypochondriacal psychosis. Br J Hosp Med 1980;24:34-8.
Acquired secondary syphilis in a child Sandra K. Echols, BS, David L. Shupp, MD, and Arnold L. Schroeter, MD Dayton, Ohio Recent statistics released by the Centers for Disease Control indicate that the incidence of both primary and secondary syphilis in men and women has been steadily increasing during the past 2 years. In 1987, the nationwide rate of 14.6 syphilis cases per 100,000 people was the highest since 1950 and the largest increase within a single year since 1960. This also represents a 25% increase over the 1986 incidence.! As more adull~ are infected, so the likelihood of children contracting syphilis increases. From the Departmentof Dermatology, Wright Slate Univcrsity School of Medicinc. . Reprint requests: David L. Shupp, MD. Wright Slate Univcrsity, Dcpartment of Dermatology, School of Medicine, Dayton, OH 45401.
16/4/13900
Brief communications 313 Case report. A 4-year-old girl had a "rash," hair loss, cough, and sore throat. When examined, the patient had a low-grade fever and a few enlarged cervical lymph nodes. There were scattered white patches on the buccal, palatal, and gingival mucosa and erythematous, denuded areas of the tongue. Patchy areas of alopecia were noted that gave the child's hair a "motheaten" appearance. Numerous hyperpigmented macules with peripheral scales were present on the palms and soles. Results of a genital examination were normal without any signs of trauma but a I X 1.5 em, hypopigmented, moist verrucous plaque was noted in the perianal area. A scraping examined under a darkfield microscope demonstrated multiple spirochetes. A VDRL test was positive at a dilution of ] :64. The fluorescent treponemal antibody absorption (}
Discussion. Syphilis is probably not as well recognized as it was in the preantibiotic era. 2,3 The disease follows the same clinical course in children as it does in adults. Tn all cases of acquired syphilis in children, the mode of transmission is of as much concern as the treatment. The child must be protected from further harm and infection. Detection of the route of infection is often difficult but if the primary lesion is found in a genital or anal site, it is generally clear-cut evidence ofsexual abuse. Difficulties arise in cases of extragenital chancres or in cases of secondary stage disease, without evidence of another sexually transmitted disease. In these cases nonsexual transmission may have occurred (e.g., via breast-feeding, kissing, handling, and sharing eating utensils).4-6 In a 1939 report of 125 cases of acquired syphilis in patients aged 10 years or younger, 34% were due to sexual abuse whereas 23% reportedly were due to innocent kissing or household contact. 3 However, more recently it has been reported that more than 95% of all cases of syphilis are acquired by sexual contact.7, 8 Therefore it is essential that nonvenereal transmission be considered only after all investigations into a possible source of sexual abuse have been made. 9 1n most states, as in Ohio, it is legally mandatory to report any suspicion ofsexual abuse to local Child Protective Services. Although acquired syphilis in children is rare, it is important to realize that it does still exist. As long as there is a continued increase in the total incidence of syphilis in this country, there will most likely be a concomitant increase in pediatric syphilis, both congenital and acquired.