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(143) Case Report: Delusional Parasitosis in Von Hippel Lindau Syndrome


Andrew Malanga, DO – PGY4 Psychiatry, The Ohio State University Wexner Medical Center

Katherine Brownlowe, MD – Assistant Professor, The Ohio State Wexner Medical Center


Presenting Author: Andrew Malanga, DO, The Ohio State University Wexner Medical Center
Co-Author: Katherine Brownlowe, MD, The Ohio State Wexner Medical Center


Background: Delusional Parasitosis is a rare syndrome characterized by fixed and false delusions of parasitic infestation despite lack of findings on exam. This syndrome has not been previously reported in Von Hippel-Lindau Syndrome (VHL). This syndrome results in central nervous system hemangioblastomas, peripheral hemangiomas and subsequent tumorectomy, any of which may induce aberrant sensory signaling lending towards induction of the typically endorsed formications (tactile hallucination). Additionally, the variable locations of tumor occurrence may cause vulnerability to circuit disruption and subsequent neuropsychiatric phenomena.

Case History: Patient is a 47 year old female with a history of Von Hippel-Lindau Syndrome (multifocal hemangioblastomas including eyes, cerebellum, brainstem, and upper spinal cord; multiple surgeries including left posterior cerebellar tumor removal), blindness (spontaneous retinal detachment at age 16), neuropathy (associated with dysesthesia, hyperalgesia and allodynia), and multiple other general medical conditions. Initially she was diagnosed with MDD and PTSD. At follow-up, the patient described a sensation of (insect?) hooks being inserted into her skin by an undetermined infestation. She stated she contracted this from a trash can within the previous years. She described an ability to “pull out the legs” from her skin and a sensation of string-like fibers between her fingers and the site of removal. She noted showering 2.5 hours daily to address this as well as excessive excoriation. Her caregiver, although reportedly initially concerned for psychiatric etiology, had also become convinced of the likelihood of infestation. She reported previous dermatological intervention including negative biopsies and ivermectin treatment. She remained convinced that her dermatologist should be able to identify microscopic organisms under magnification. Upon review of outside records, concerns were raised for delusional parasitosis months earlier by dermatology. Interestingly, concerns for skin sensations/discomfort had been raised by the patient years earlier; at that time she had insight into this likely being of neurological and/or iatropic etiology secondary to opioid pain medication.

Conclusion: Delusional parasitosis in VHL is a previously undescribed phenomenon in the literature. In our patient, etiology may be multifactorial, with contribution from CNS hemangioblastomas, partial cerebellectomy, opioid pain Rx, B12 deficiency, and hypothyroidism. The role of the cerebellum in psychosis is also relatively newly described, and the burden of cerebellar pathology due to VHL and its treatment at least have led to the patient’s vulnerability for this syndrome. Treatment is challenging and requires tactful psychoeducation discussing the complexity of the condition. Given the multifactorial nature of the condition and its treatment, collaboration between all providers in various specialities (dermatology, neurology, neurosurgery, pain management, primary care) is paramount for successful treatment. Consult-Liaison psychiatrists are ideal to provide coordination diagnosis and of treatment for those patients with complex, rare, and multifactorial conditions.

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