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.
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.
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
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?
28.Jan, 09:59pm
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