Medical Case: Allodynia? tactile alodynia?
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Allodynia? tactile alodynia? (Dermatology)

Dr. Rishu Sharma., MBBS, DIPLOMA (CARDIOLOGY)

 

Medical Case Details:

29 year old male, started to have a feeling of increased sensation all over the body. He can feel even the touch of his clothes, even air is causing mild pain and increased sensations. Patient says that he can feel a pain in every part of his skin (all over the body), and he can feel even the slightest touch. Patient says that he feels as if bees are stinging on his back (100 bees at a time stinging). Initially treated with methyl prednisolone 4mg tds and hydroxizine 25 mg bd along with allegra 120mg once daily. Not relieved. After that started on with methyl cobalamine 1500mcg once, pregabalin 75mg twice daily along with nortyptalline 10 mg twice daily. A bit relieved for some times but again the symptoms are full blown.

What is your opinion about the diagnosis?
What tests are indicated?
Cbc, KFT, all basic tests are normal.

Non smoker
Non alcoholic
Was perfectly fine few days back.
History of same thing 3 years back but was relieved at that time.

 


    Discussions


    Dr. Amiya Kumar Chattopadhyay
    Cardiologist

    Hi Dr Rishu
    I think it is a case of "Delusion of parasitosis".
    Orap(pimozide)-2mg 1 daily.
    This I know but I have never used it & no experience as I have heard it is toxic.
    I suggest treatment by Psychiatrist.
    Regards
    Dr Amiya Kumar Chattopadhyay

    28.Jan, 04:30pm

    Dr. J. Mariano Anto Bruno Mascarenhas
    Neuro Surgeon

    This condition requires Psychiatric Evaluation

    28.Jan, 05:43pm

    Dr. Alok Vinod Kulkarni
    Psychiatrist

    1. Rule out delusion of parasitosis as has been rightly suggested. 12 RCTs recommend the usage of Pimozide for persistent delusional disorder. However, it is not frequently used in clinical practice.
    2. Rule out Persistent Somatoform Pain Disorder. SNRIs like duloxetine and Venlafaxine address pain symptoms.
    3. May try a course of TENS (transelectric nerve stimulation).
    4. Also needs Reattribution therapy and JPMR.

    ▲ 1
    28.Jan, 07:20pm

    Dr. Manjunadh M
    Psychiatrist

    Well..
    There are a few possibilities
    If he is describing it as a belief that actually bees exist in his body and biting him,its more like a delusion.Then he can be treated with a small dose of antipsychotic like olanzapine or risperidone or even classical pimozide.
    Second possibility is of exaggerated pain response because of defective functioning of pain pathways,like what is seen in chronic pain syndromes or somatoform disorder,again acute onset and episodicity is bit atypical, since he responded to dosage of pregabalin,,its worth a try a combination of 150 to 300 mg of pregaba with 40 to 60 mg of duloxetine or 50 to 100 mg Milnacipran.
    Regards

    ▲ 1
    28.Jan, 08:33pm

    Dr. Rishu Sharma
    Cardiologist

    Hey dr thanks for suggestion,but just for query why do every one thinks its delusion?
    As said by dr majumdar why cant it be hyperalgesia or tactile hypalgesia?if they were delusions then how come they settled by themselves 3 years back?Patient is fully functional ,the word bees were used by patient as he can not easily explain his problem ..so he told me as a example as if many bees are stinging at a time !
    Any more suggestions friends?

    Best comment
    28.Jan, 09:59pm

    Dr. Udaya Nath Sahoo
    General Practitioner

    Hi,
    Please check whether you have done PCR[ Polymerase chain reaction] test of blood to ruled out shingles .
    Thanks

    29.Jan, 02:34pm

    Hayat Ali
    Psychologist Counselor


    There are a few possibilities
    If he is describing it as a belief that actually bees exist in his body and biting him,its more like a delusion.Then he can be treated with a small dose of antipsychotic like olanzapine or risperidone or even classical pimozide.
    Second possibility is of exaggerated pain response because of defective functioning of pain pathways,like what is seen in chronic pain syndromes or somtoform disorder,again acute onset and episodic is bit atypical, since he responded to dosage of pregabalin,,its worth a try a combination of 150 to 300 mg of pregaba with 40 to 60 mg of duloxetine or 50 to 100 mg Milnacipran. with all these should take a CBT session for remove his false belifes

    29.Jan, 08:32pm

    Dr. Hitesh Kumar
    Neurologist

    Nice discussion going on above.
    Here patient is not complaining for bees inside his skin, instead complaining of pain.
    possibility of delusion seems little low.
    I suggest to think about possibility of Complex Regional Pain syndrome (though here pain is not regional).
    Also can try to do autonomic function tests.
    If all other medical management fails, " sympathetectomy" may be considered as an option.

    29.Jan, 09:11pm

    Dr. Rishu Sharma
    Cardiologist

    Patient was on pregabalin 150 and notryplatllinr 20 for 20 days not relieved a single dose duloxetine 40 was given 90% relieved

    ▲ 2
    29.Jan, 10:44pm



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