Intoxicants
Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg, Praveen V. Mummaneni in Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health Professionals, 2017
Cocaine blocks reuptake of dopamine, norepinephrine, and serotonin from the synaptic cleft, therefore prolonging their activity on the postsynaptic membrane. Patients under cocaine intoxication present with euphoria, psychomotor agitation, grandiosity, hallucinations (tactile type is formication), and paranoid ideation (Lukas and Renshaw, 1998). The sympathetic system is overstimulated, and as a result pupils dilate, appetite decreases, and heart rate with blood pressure rises. Systemic vasospasm may have end-organ effect causing myocardial infarction, stroke, or placental infarction. Chronic cocaine users may present with nasal septum perforation (Kiesselbach plexus vasospasm) (Businco et al., 2008). Treatment of cocaine overdose is symptomatic with antipsychotics, benzodiazepines, and antihypertensives. Vitamin C promotes excretion of the drug.
Neurotoxicology
Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw in Hankey's Clinical Neurology, 2020
Arsenic has a long history of being a poison used to facilitate homicide. Inorganic arsenic produces essentially all cases of human toxicity. Organic arsenic compounds serve a physiologic function in marine organisms and are ingested with seafood consumption but do not cause clinically significant toxicity. Most laboratory tests for arsenic do not speciate inorganic from organic arsenic compounds leading to a high risk of false-positive tests. Toxicity will typically manifest with GI symptoms including vomiting and diarrhea and can progress to multiorgan system failure and shock. Arsenic poisoning causes characteristic skin changes consisting of a hyperpigmented macular rash, which tends to be most prominent of the hands and feet, and patchy alopecia. Neurologic manifestations can include peripheral neuropathy, formication, and encephalopathy (progressing from headache and irritability to delirium, hallucinations, and seizures). The peripheral neuropathy of arsenic poisoning can present within 24 hours of exposure but is most commonly seen 1–3 weeks after an acute exposure. The earliest signs of this neuropathy are sensory—loss of light touch and vibratory sense—and can progress to a flaccid paralysis mimicking Guillain–Barré syndrome. Peripheral neuropathy without GI symptoms occurring concurrently or within 1 month of onset is unlikely related to arsenic toxicity. Treatment involves removal from exposure and intensive supportive care with chelation in appropriate cases.
Licit and illicit drugs
Jason Payne-James, Richard Jones in Simpson's Forensic Medicine, 2019
Physical effects of stimulant use generally include dilation of pupils, increased heart rates and raised blood pressure. The problem for a clinician involved in attempting to assess or determine the type of drug used in an intoxicated individual is that few users (either dependent on, or using drugs recreationally) use a single drug, and thus drugs from different groups may produce a wide variety of clinical states. Heavy cocaine users often manifest some paranoid symptoms. If psychosis does occur, it can include formication (the sensation of having insects crawling on or under the skin), and self-injury. Extreme forms of this syndrome are manifest by self-injury. Methamphetamine abusers not infrequently manifest symptoms of florid paranoid psychosis. The unique feature of methamphetamine psychosis is that it may reoccur years after drug usage has been discontinued. Its occurrence seems to be related to methamphetamine-induced damage to cortical white matter. These pathological changes can be visualised with magnetic resonance imaging (MRI) scanning. This ability is not shared by cocaine or other stimulants.
The Koo-Brownstone staging system as a tool to assist in the management of patients with a possible diagnosis of dermatological delusions: an experts suggestion
Published in Journal of Dermatological Treatment, 2022
The first stage is ‘Formication Only’, which means that there is no ideation of parasitosis and the patient only complains of crawling, biting, stinging sensations. The second stage is ‘Overvalued Ideation’ where these patients become more worried about the erroneous ideation of a parasitic infestation but still have enough insight to be often apologetic that they are so preoccupied with these symptoms. The third stage is ‘Pre-Delusional’, which is defined as a patient who initially appears delusional but, after developing a strong rapport with the provider, proves able to consider alternative explanations for their symptoms. The fourth stage is ‘Delusional’ which is where the patient is not open-minded at all and cannot tolerate alternative explanations. Many delusional patients are still willing to consider pharmacotherapy, if it is presented as a ‘trial and error’ approach and is deliberately not linked to any psychiatric terminology. The fifth stage is ‘Terminal Delusion’. These patients are only interested in the validation of their parasitic ideations and is also almost impossible to get them to accept pharmacotherapy unless the medication kills their ‘parasites’.
Radiotherapy for Melanoma with Perineural Invasion: University of Florida Experience
Published in Cancer Investigation, 2018
Simeng Zhu, William M. Mendenhall
Perineural invasion (PNI) is an uncommon histologic finding in skin cancers. It is defined as tumor growth in or around a nerve (6, 7) and is associated with a worse prognosis compared with lesions without PNI since the nerve facilitates the tumor spread (7–9). PNI is often discovered incidentally as most patients with skin cancers with PNI are asymptomatic (2). In symptomatic patients, formication may be noted and slowly progress to numbness, pain, or weakness (10). Due to the increased risk of local-regional recurrence associated with PNI, adjuvant RT is often used after surgical resection, and several reports have demonstrated improved disease control (10–13). Patients with incompletely resectable skin cancers with PNI, such as those extending to the cavernous sinus, are treated with definitive RT (14). However, very few studies have reported the outcomes of patients with melanoma with PNI treated with postoperative or definitive RT (15). The purpose of this study is to report our institutional experience with these patients.
Choosing the appropriate pharmacotherapy for Morgellons disease: an expert perspective
Published in Expert Opinion on Pharmacotherapy, 2022
Esther A. Balogh, Katherine G. Beuerlein, Steven R. Feldman
Because many prescription drugs and illicit substances, such as stimulants used in ADHD management and cocaine, can cause or worsen feelings of formication, physicians should consider screening for and encourage reduction of stimulants and other psychoactive substances in their MD patients. In a study of 147 patients with DI by the Mayo Clinic, 24% of the patients had a history of illicit drug use, while 8 patients were taking prescribed medications that may bring about delusional states such as amphetamine and dextroamphetamine, methylphenidate, ciprofloxacin, and levodopa [21]. In the CDC’s pivotal 2012 study on MD’s etiology, in a case series of 41 patients, 24% had a past history of drug or alcohol abuse, and 50% of the patients had at least one drug (amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, or propoxyphene) detected through hair sampling. High rates of drug abuse in this patient population have also been our clinical experience [2]. Because discussion of the use of illicit substances with patients and its potential contribution to their delusional disorder can be a sensitive topic, one potential route for discussion could emphasize that certain drugs make some patients a ‘petri dish’ for infestation and that reducing the use of these drugs may be necessary to ‘get the infestation under control.’ The complexity of managing patients who are on multiple drugs with psychoactive effects may be another reason to involve a psychiatrist in the management of these patients and their treatment regimens.
Related Knowledge Centers
- Delusional Parasitosis
- Diabetic Neuropathy
- Mercury Poisoning
- Paresthesia
- Pesticide
- Skin Cancer
- Menopause
- Itch
- Scratch Reflex
- Particulates