Delusions of ocular parasitosis

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  • Delusions of Ocular Parasitosis


    c PURPOSE: To describe four cases of delusions ofparasitosis in which self-inflicted ocular traumaoccurred. Delusions of parasitosis is a somaticdelusional disorder in which patients have theirrational belief that their bodies are infested byparasites or other infectious organisms. Self-in-flicted trauma can result from attempts to elimi-nate the supposed infestation.c METHODS: We reviewed the case histories offour patients (one male, three females, 35 to 45years of age) who presented with complaints ofocular infestation but had no evidence of infec-tious ocular disease. The characteristics of thesecases were compared with the features of delusionsof parasitosis.c RESULTS: All patients maintained their beliefsregarding infestation, despite extensive clinical andlaboratory investigations that found no evidence ofinfectious diseases. Self-inflicted eye injury, asso-ciated with attempts to eliminate the infestation,occurred in each case.c CONCLUSIONS: The cases presented in this re-port are consistent with a diagnosis of delusions ofparasitosis. The eye can be a principal focus ofattention in this disorder, which may lead to visionloss caused by self-inflicted injury. (Am J Oph-

    thalmol 1998;125:852856. 1998 by ElsevierScience Inc. All rights reserved.)

    D ELUSIONS OF PARASITOSIS IS DEFINED AS ANerroneous but unshakable belief that thebody is infested by parasites or other infec-tious organisms.13 It is a well-characterized disorderseen most commonly by dermatologists and infec-tious disease specialists.47 Delusions of parasitosishas been described as the most difficult problem ofmanagement in dermatology.1 We present fourpatients with delusions of parasitosis in which theprincipal focus of attention was their eyes.


    c CASE 1: A 40-year-old woman presented to theemergency room for evaluation of periorbital ery-thema. She reported that her home was infestedwith insects and that her eyes were infested as well.She demonstrated how she would remove the insectparticles from her eyes with a cotton-tip swab.There was no known history of psychiatric disor-ders. There was no history of recent substanceabuse. Visual acuity (contact lens correction in theright eye only) was RE, 20/30 and LE, countingfingers. Intraocular pressure was normal in botheyes. External examination demonstrated moderateleft eyelid erythema. The left bulbar conjunctivahad marked chemosis and the left cornea demon-strated punctate epithelial keratopathy. There wereno other signs of local or systemic infestation. Eyelidcultures demonstrated rare colonies of coagulase-negative Staphylococcus species. The patient wastreated with topical erythromycin ointment andfollow-up at the outpatient ophthalmology clinicwas arranged. An emergency room psychiatry con-

    Accepted for publication Oct 22, 1997.From the Southern California Permanente Medical Group, Cornea/

    External Disease Service (Dr Sherman) and UCLA Ocular Inflamma-tory Disease Center, The Jules Stein Eye Institute, and Department ofOphthalmology, UCLA School of Medicine, and OphthalmologySection, Surgical Service, West Los Angeles Department of VeteransAffairs Medical Center (Drs Holland, Weisz, and Omar), Los Angeles,California; University of California, San Francisco, School of Medicine,Department of Ophthalmology and The Francis I. Proctor Foundation,San Francisco, California (Dr Holsclaw); and University of California,Irvine, School of Medicine, Division of Infectious Disease, Departmentof Medicine, Irvine, California (Dr Sherman).

    Reprint requests to Mark D. Sherman, MD, Department of Ophthal-mology, 411 N Lakeview Ave, Anaheim, CA 92807-3028; fax: (714)279-6204; e-mail:

    1998 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.852 0002-9394/98/$19.00PII S0002-9394(98)00048-8

  • sultant determined that she was not holdable andarranged an outpatient psychiatric evaluation. Shedid not keep her follow-up appointments. Sixmonths later, she returned complaining of fungalinfestation of both eyes. She described removingmaterial from her left eye with a cotton-tip swaband brought samples of objects she had removedfrom her eyes, ears, mouth, and rectum. Examina-tion did not reveal a substantial change from herprevious emergency room visit. The patient did notreturn for further follow-up.

    c CASE 2: A 45-year-old woman was seen with achief complaint of tiny white worms and yellowtube-bugs shooting out of my skin into my eyes.She denied any history of ocular, medical, or psy-chiatric disorders. There was no history of previoussubstance abuse. The patient had given away onedog and two cats because of her belief that theycarried worms. She terminated her friendship with aneighbor, believing the neighbor to be a source ofworms. The patient reported a 14-month history ofitching, scratching, and a wiggling sensation be-neath her skin, scalp, eyebrows, and ears. She hadbeen evaluated by more than 10 dermatologists, allof whom she described as being completely incom-petent. She had been previously referred for psy-chiatric evaluation but did not keep her appoint-ments. On examination, visual acuity withoutcorrection was measured at BE, 20/20. Externalexamination was notable for three discrete patchesof alopecia on her scalp. There was mild inspissationof the meibomian glands in the eyelids of both eyes.The tarsal conjunctiva showed a mild papillaryreaction in both eyes. The corneas were clear, andthe remainder of the anterior and posterior segmentexamination was unremarkable in both eyes. Eyelidcultures grew coagulase-negative staphylococci.Conjunctival cultures were negative. The patientwas treated for blepharitis with eyelid hygiene andpreservative-free artificial tears. She returned forfollow-up with her eyebrows shaved off, which sheexplained as an attempt to get rid of the worms. Onthree subsequent visits, she brought specimenswhich she had removed with her fingernails andtaped onto a piece of wax paper. On one occasion,the patient presented with a 3-mm conjunctival

    laceration in the right eye, which she had causedwhile trying to dig out worms with tweezers.

    c CASE 3: A 35-year-old home health care nursewas seen with a nonresolving corneal ulcer in herleft eye. She had been using an assortment ofprescribed, as well as over-the-counter, topical med-ications. Her ocular, medical, and family historieswere unremarkable. There was no known history ofpsychiatric disorders. The patient complained thatlittle crawlies had infested her left eye. On exam-ination, her visual acuity without spectacle correc-tion was RE, 20/20 and LE, hand motions. Externalexamination was unremarkable. The right eye wasnormal. On the left, there was a mild papillaryreaction of the lower tarsal conjunctiva. The corneashowed a dense midstromal focal infiltrate in theupper nasal quadrant and multiple small satelliteinfiltrates in the midperiphery. A 6-mm epithelialdefect was present. The anterior chamber was quietand posterior pole was normal. Cultures were ob-tained and she was started on topical fortifiedantibiotics. The cultures showed no growth andsmears showed inflammatory cells but no organisms.There was no other sign of local or systemic infes-tation. After 2 weeks without improvement, acorneal biopsy was performed and demonstratedCandida albicans. She was started on topical ampho-tericin B 0.15% every hour and oral ketoconazole(200 mg twice a day). The cornea became progres-sively necrotic and a therapeutic penetrating kera-toplasty was performed. The patient did well for 6weeks, obtaining 20/80 vision in that eye. Despite asuccessful graft, she was not convinced that theinfection had been eradicated. Eight weeks aftersurgery, she presented to the office complaining ofbugs crawling out of her eye, nostrils, and rectum.She said they were on her furniture, in her cats eye,and was concerned that her children may carrythem as well. As evidence, she brought a culturettewith which she cultured her cats eye and collectedspecimens that she taped to a sheet of paper. Onexamination, she was found to have a dense cornealinfiltrate that involved the donor cornea as well asthe recipient bed and sclera. She underwent urgentlimbus-to-limbus penetrating keratoplasty. Culturesobtained in the office and intraoperatively grewLactobacillus species. Her postoperative course was


  • complicated by repeated episodes of epithelialbreakdown that healed with patching. Ultimatelythe graft failed and a conjunctival flap was per-formed. She was treated during this period withfluoxetine (Prozac) on the recommendation of theinpatient psychiatry consultant, who felt she suf-fered from an obsessive-compulsive disorder. Shewas referred for continued outpatient psychiatrycare but did not keep her appointments because shefelt that hers was not a psychiatric disorder. Oncethe conjunctival flap was performed, the patient wasconvinced that the infestation was gone and she hasdone well, despite her decreased vision.

    c CASE 4: A 40-year-old man presented to the emer-gency room complaining of 3 weeks of severe burning,tearing, and light sensitivity of both eyes. The patientreported that he was infested with lice and had beenbathing in, and applying to both eyes, antilice medi-cation. He was homeless. There was no history ofrecent substance abuse. Visual acuity without correc-tion was BE, counting fingers at 10 feet. Externalexamination revealed multiple periocular superficialexcoriations. The eyelids were moderately erythema-tous. The bulbar conjunctiva was injected and mildlychemotic bilaterally. No signs of lice were visible inthe periocular region or along the eyelids. Both cor-neas had epithelial defects involving over 90% of thecorneal surface, moderate stromal haze, and mildedema without infiltrate. He was treated with eryth-romycin ointment and unilateral patching, which thepatient promptly removed in order to get at the lice.Dermatologic evaluation revealed no objective signs oflocal or systemic parasitic infection. Psychiatric con-sultation resulted in a diagnosis of bipolar disorder, andthe patient was admitted for inpatient psychiatricstabilization. The patient was followed for approxi-mately 13 days, during which time there was nore-epithelialization of the corneas, and he persistentlyclaimed his eyes were infested with lice. After 2 weeksof hospitalization, the patient left the hospital againstmedical advice and was lost to follow-up.



    ocular involvement are described. The patients

    included three women and one man. The averageage was 40 years (range, 35 to 45 years). Eachpatient maintained the belief that his or her eyeswere infested despite exhaustive clinical and labo-ratory evidence to the contrary. Three patientssubmitted specimens of their supposed infectiousagents. Patients attributed their conditions to avariety of organisms, including fungi (Case 1),worms (Case 2), parasites (Case 3), and lice (Case4). Three patients presented to the ophthalmologistwith a complaint of concomitant nonocular infes-tation. One patient, who initially presented with anisolated ocular complaint, later developed systemiccomplaints. Three patients underwent at least aninitial psychiatric evaluation. One of these patientswas diagnosed with bipolar affective disorder, andanother was diagnosed with obsessive-compulsivedisorder. None of the patients continued with theirformal psychiatric evaluation.

    Self-inflicted eye injury occurred in each case.Three patients sustained bilateral ocular injury, andthe other had unilateral injury. Injuries were me-chanical in two patients, chemical in one patient,and combined chemical and mechanical in onepatient. Visual acuity ranged from 20/20 to handmotions in the involved eyes. The spectrum of tissuedamage included periocular excoriation, papillaryconjunctivitis and chemosis, conjunctival lacera-tion, corneal epithelial toxicity, and corneal stromalulceration. One patient required surgical interven-tion.



    the French dermatologist Thibierge in 1894.8 Before1946, the condition was known by a variety ofnames, including acarophobia, dermatophobia, andparasitophobia. Wilson and Miller coined the namedelusions of parasitosis to distinguish the unshak-able conviction that the skin is infested from thefear of infestation.9,10 Patients with delusions ofparasitosis characteristically come to the physiciancomplaining of itching, biting, and crawling sensa-tions. They may point to tracks on their skin anddescribe the life-cycle of the parasite. Frequentlythey have had multiple encounters with physicians


  • and may describe with hostility the ineptitude of thephysicians at recognizing or curing the disease.6 Thepatients may report multiple changes in domicile,extensive use of pesticides at home, and evenelimination of family pets thought to be possibleintermediate hosts for the parasites.4,6,7 Consulta-tion with a psychiatrist is unusual because thepatients are not easily convinced that psychiatricevaluation is indicated and they are resistant tothorough psychiatric evaluation.1113

    The most extensive survey of patients with delu-sions of parasitosis was reported by Lyell.1 In hisseries of cases, he found a 1:1 male to female ratiofor patients under 50 years of age and 3:1 ratio forpatients over 50 years of age. Lyell described pa-tients with a variety of personality types, includingthose with paranoid and aggressive personalities.Two theories have been proposed to explain thebehavior manifested in patients with delusions ofparasitosis.6,1417 The first theory suggests that themajor problem is a primary somatic delusional stateknown as formication, in which the patient displaysmonosymptomatic hypochondriacal psychosis. Thesecond theory suggests that the delusion is anelaboration of another pathologic state, such astactile hallucinations, pruritus, or paresthesias. Pa-tients may remain functional in other areas of theirlives.6

    The skin lesions manifested in patients withdelusions of parasitosis can be classified into thefollowing categories: psychosomatic dermatoses(neurodermatitis); physical trauma resulting fromattempts to remove the parasites with fingernailsor other instruments; and chemical trauma causedby solvents and soaps used to kill or remove theparasites. In some cases, however, no abnormalityof the skin may be discernible. Patients frequentlybring samples of the parasites wrapped in tissue,enclosed in small containers (the matchbox sign),or sealed in envelopes.1,3 Careful examination ofthese specimens is imperative. In cases of delusionsof parasitosis, these specimens generally turn out tobe bits of dirt, mucus, or keratotic skin debris.

    The differential diagnosis of sel...