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| CASE REPORT |
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| Year : 2023 | Volume
: 43
| Issue : 2 | Page : 79-83 |
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Lurasidone treatment for delusional infestation in a patient with dementia
Yu-Ning Her1, Hsin-An Chang2, Fan-Jung Wan1, Nian-Sheng Tzeng2
1 Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Department of Psychiatry, School of Medicine, Tri-Service General Hospital, National Defense Medical Center; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| Date of Submission | 10-Dec-2020 |
| Date of Decision | 15-Nov-2021 |
| Date of Acceptance | 11-Feb-2022 |
| Date of Web Publication | 25-May-2022 |
Correspondence Address:
Dr. Nian-Sheng Tzeng
Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist., Taipei 114
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmedsci.jmedsci_410_20
Delusional infestation has been described since 1894. The variety of treatments of delusional infestation has been administered in different atypical antipsychotic agents. Here, we present a case of first treatment with lurasidone on the delusional infestation in a 68-year-old female with vascular dementia, and the literature reviews of the related delusion infestation management.
Keywords: Lurasidone, delusional infestation, dementia
How to cite this article:
Her YN, Chang HA, Wan FJ, Tzeng NS. Lurasidone treatment for delusional infestation in a patient with dementia. J Med Sci 2023;43:79-83 |
| Introduction | |  |
Psychotic symptoms such as delusions and hallucinations are frequently found in dementia.[1] The delusional infestation, which is also known as delusional parasitosis, has been described in medical literature since 1894, which was defined as a syndrome in which there is a fixed, false belief that one is infested with pathogens despite the absence of medical evidence.[2] Lurasidone is widely used in the treatment of psychotic and mood disorders.[3] However, there are no available studies for the effects of lurasidone in delusional infestations or other psychotic symptoms of patients with dementia.[4] Here, we report a case of a dementia-related delusional infestation of a snake that was successfully treated by lurasidone.
| Case Report | | |
A 68-year-old female patient, without medical, personal, or family history of mental illness, except vascular dementia, was sent to the geropsychiatric outpatient department for her fixed delusional belief about “a snake that lives in my body,” and psychomotor agitation. Her first episode of the delusion of snake infestation can be traced back to 3 years ago, when she received a major operation of the left jaw osteonecrosis under general anesthesia, and experienced spontaneous remission after 3 weeks. In this case, her mood symptoms are just secondary to delusional infestation, such as worry and anxiety. There is no significant impairment in attention and not fluctuated throughout the day. In addition, physical examinations, imaging examinations, and laboratory examinations were also arranged, which revealed the case has no other active medical and surgical diseases.
Then, the delusion of snake infestation, on and off over 2 years, and which was spontaneously resolved within 2 weeks. Besides, she presented a series of episodes of declining recent memory and was diagnosed with vascular dementia 14 months before this visit in a neurology department. A structural brain computerized tomogram revealed senile changes with cortical atrophy over the bilateral frontotemporal regions and chronic periventricular white matter ischemic change. The laboratory workup, including the glucose level, renal and liver function tests, serologic tests for syphilis, vitamin B-12 and red blood cell folate levels, and thyroid function tests, only found low-level folic acid (4.2 ng/mL). At first, she was receiving treatment with piracetam 1200 mg/day and folic acid 5 mg/day for disturbance behaviors and subjective distress due to the persistent delusional infestation for 1 month in the neurology department. For the cognitive function tests, the score of Mini-Mental Status Examination (MMSE) was 16 and the Clinical Dementia Rating (CDR) scale was 1.0, which showed recently cognitive function rapid deterioration (the MMSE score decreased from 20 points to 16 points compared with 1 month ago).
She had no obvious response to persistent management among cognitive enhancer such as piracetam and folic acid supplement for 2 months. Then, she was sent to the geropsychiatric outpatient department under the circumstance of marked subjective distress due to the delusional infestation for 3 months, and additionally, she also suffered from auditory hallucinations with a voice discussing “about the snake,” persecutory delusion, and delusional of being under surveillance. Among contemporary antipsychotic drugs, lurasidone has a relatively well-tolerated side effect profile, with low propensity for sedation, cardiac arrhythmia, weight gain, and lipid-related adverse effects.[5],[6] The patient had a history of constipation for long time and had falling down several times, so we chose this lurasidone for its low side effect profile. Lurasidone 20 mg/day was initiated for the patient and titrates to 40 mg/day after 2 weeks. After 4 weeks of treatment, the delusion of the snake infestation subsided, and we increased the lurasidone dosage to 80 mg/day for the persistent auditory hallucinations. After 1 month of lurasidone treatment with 80 mg/day, the psychotic, including the auditory hallucinations symptoms of delusional infestation, became fairly controlled, but the extrapyramidal side effects (EPSE) such as rigidity was found. Therefore, we gradually tapered the lurasidone dosage to 40 mg/day, and then 20 mg/day in the following 3 months for maintenance treatment, and then the delusion of snake infestation and EPSE disappeared. The patient's drug compliance was assured by her son, the major caregiver. The follow-up outpatient clinics in the following 3 years found that although the test scores (MMSE and CDR) did not change, the patient and her family reported that the memory of the patient had slightly improved. Perhaps the improvement was not large, so the test scores did not change.
| Discussion | | |
There were several researches about the delusions in the cultural or subculture milieu related to snakes.[7] However, in previous studies, patients with delusional infestation often falsely believed that they were “infested” by parasites or insects.[8] This is a rare case of the patient falsely believing that there was a snake, instead of parasites or insects, in her body. Some previous reports have shown that the patients with delusional parasitosis are concomitant with tactile hallucinations,[9],[10] but in this case, there were no tactile hallucinations, and the underlying reasons are not clear. In addition, delusional infestations are rarely seen in patients with dementia and prior studies are limited.[11],[12],[13],[14],[15] Furthermore, the patients with delusional infections might injure themselves in attempts to be rid of the “parasites,” resulting skin damages, as well as damage caused from using chemical substances and obsessive cleaning routines.[16],[17] However, there was no self-harmful behavior in this case.
In this case, we presumed that the effects of lurasidone on the delusional infestation by the temporal relationship. Previously, several case reports have suggested that delusional infestation best responds to atypical antipsychotics, such as olanzapine,[18],[19],[20] risperidone,[21] aripiprazole,[11],[16],[22],[23],[24 quetiapine,[21] blonanserin,[25] or ziprasidone,[24] as listed in [Table 1]. However, it has also been successfully treated by haloperidol, pimozide, and lurasidone may also have such an effect. | Table 1: Summary of previous studies investigating the use of atypical antipsychotics for the treatment of delusional infestations
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Lurasidone, as a second-generation, serotonin-dopamine antagonist, has a favorable safety profile for the young patients with psychotic or mood disorders.[3] One review pointed out that lurasidone is both of reasonable safety and efficacious in the acute and maintenance treatment for the elderly patients with bipolar disorders.[26] In addition, a study found that lurasidone, in the treatment for a patient with schizophrenia, showed improvement in the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery.[27] This finding hints that lurasidone demonstrates the potential to improve cognition, and hence, could be beneficial for the elderly patients with dementia. As in this case, 3 years of follow-up showed that her cognitive function did not decline anymore, and the memory has improved a little. The prompt relief of EPSE by the decrease of the daily dosage in our case also supports the safety of the usage of lurasidone in the elderly patients with dementia. As with other atypical neuroleptics, lurasidone should be used with caution in the elderly due to an increased risk for a stroke, transient ischemic attack, and mortality compared to placebo,[28],[29],[30] which was caused by atypical antipsychotics that are likely to cause metabolic syndrome. Recent studies on safety and tolerability have shown older adult treatment with lurasidone was associated with minimal effects on weight, lipids, and measures of glycemic control.[31],[32] Most geriatric patients used 60–80 mg/day of lurasidone, which appeared to be efficacious, well-tolerated.[33] Nonetheless, a further study is necessary for the safety profile in these older patients with dementia.
| Conclusion | | |
To the best of our knowledge, this is the first case of lurasidone as a successful treatment for delusional infestation. This therapeutic experience should serve as a reminder for the clinicians who are responsible for the care of patients with delusional infestation.
Ethical approval
The Institutional Review Board of the Tri-Service General Hospital, Taipei, Taiwan, as TSGH-IRB No.: C202005108.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was supported by the Taoyuan Armed Forces General Hospital (TYAFGH-A-110020). The sponsor had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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