Vasant P. Dhopesh, MD, Pilar Cristancho, MD, and Stanley N. Caroff, MD, University of Pennsylvania School of Medicine
Published Online: May 17, 2007 - 11:48:22 PM (CDT)
Vasant P. Dhopesh, MD Attending Psychiatrist VA Medical Center Clinical Associate Professor, Department of Psychiatry
Pilar Cristancho, MD Resident, Department of Psychiatry
Stanley N. Caroff, MD Chief, Inpatient Psychiatry VA Medical Center Professor, Department of Psychiatry
University of Pennsylvania School of Medicine Philadelphia, Pa
In 1889, Magnan and Saury described 3 patients (including 1 physician) who had visual and tactile hallucinations induced by chronic injections of cocaine.1 These hallucinations involving animals or insects crawling under the skin, with resulting self-inflicted excoriations, is so typical of patients with cocaine toxicity that it became known as Magnan?s sign or ?cocaine bugs.?
The presence of telltale skin excoriations is an important clue to covert cocaine dependence. We report a patient with classic cocaine-induced tactile and visual hallucinations as a reminder to clinicians in the primary care setting of this condition, which should be called Magnan-Saury?s sign, since the behavior was originally described by both Magnan and Saury.
Case Presentation A 35-year-old man with a history of chronic cocaine dependence went on an intravenous cocaine binge. Twelve hours after his last cocaine use, he presented to the clinic and was admitted to the psychiatry ward, because he believed he saw dirt particles in his skin and, occasionally, also felt as if small bugs were crawling under his skin. He tried to pick these particles and bugs with tweezers, thereby producing excoriations all over his body. Since he was right-handed, the excoriations were most marked on his left forearm (Figure). He had no history or signs of schizophrenia or mood disorder, and his sensorium was clear, suggesting absence of delirium. The physical examination was unremarkable, except for the skin lesions. The dermatology consultant agreed with the diagnosis of self-inflicted excoriations that were prompted by cocaine-induced tactile and visual hallucinations. The patient understood that cocaine caused his hallucinations. His skin lesions were treated with liniments and softening creams and healed in a few days. His tactile and visual hallucinations rapidly resolved 12 hours after his admission to the hospital.
Discussion Our case is identical to the cases reported by Magnan and Saury more than a century ago.1 Magnan and Saury noted that their patients? hallucinations were characteristic of chronic cocaine abuse, and that such hallucinations were often the first sign of neurotoxicity but resolved rapidly after drug discontinuation.
Magnan-Saury?s sign consists of a combination of tactile and visual hallucinations associated with a secondary delusion of parasitosis, often leading to self-mutilation. The remarkable preservation across time and cultures of the striking phenomenology and skin lesions of Magnan-Saury?s sign indicates that it is a direct neurobehavioral effect of the drug itself, regardless of sociocultural or psychological factors.
Usually, tactile and visual hallucinations are part of a broader cocaine-induced psychosis, of which paranoia is a prominent feature. For example, investigators of one study administered a questionnaire to 55 cocaine-dependent inpatients.2 They found that 29 of the patients exhibited symptoms of transient cocaine-induced psychosis. Of these 29 patients, 26 (90%) had paranoid delusions, 24 (83%) had auditory hallucinations, 11 (38%) had visual hallucinations, and 6 (21%) had tactile hallucinations of bugs or foreign objects under the skin. An earlier study of 85 cocaine abusers showed that 15 (18%) of them experienced different sensory hallucinations; of these, 11 (13%) reported tactile hallucinations occurring specifically after cocaine binges.3
Although limited information is available about the risk factors for Magnan-Saury?s sign, accumulating data suggest that the severity of dependence, as well as the dose, duration, and route of administration of cocaine, may correlate with the risk of psychotic symptoms in general.2 Our patient was unique in demonstrating Magnan-Saury?s sign in the absence of any other delusions, hallucinations, or delirium, and with intact insight regarding the cause of his hallucinations.
Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,4 our patient?s clinical picture is consistent with a diagnosis of cocaine intoxication with perceptual disturbances. The differential diagnosis of Magnan-Saury?s sign includes other substance-induced psychotic disorders with somatic symptomatology (Table). In delirium tremens, similar tactile and visual hallucinations occur in the setting of altered sensorium.
The cocaine-induced perceptual disorder seen in our patient should also be differentiated from the somatic type of delusional disorder, which is usually chronic and involves bodily functions or sensations as the central theme of delusion. The most common scenario in the somatic type of delusional disorder (also called delusional parasitosis) is that the patients are convinced that their bodies are infested with parasites or that they are emitting a foul odor from their bodies. These symptoms occur in the absence of an identifiable pathology.
In a classic study, 11 of 25 (44%) patients with amphetamine addiction presented with tactile hallucinations.5 A more recent study reported 3 children with attention-deficit/hyperactivity disorder who developed tactile and visual hallucinations, characterized by the sensation of bugs or snakes crawling over them after several months of treatment with therapeutic doses of methylphenidate.6 Because several stimulants (eg, amphetamines, methylphenidate, cocaine) can produce these hallucinations, it is postulated that this phenomenon is mediated via dopaminergic pathways, although the exact mechanism is unclear.6
Conclusion Magnan-Saury?s sign remains remarkably constant as a characteristic sign associated with cocaine toxicity. Although similar somatic features are found in other substance-induced and psychotic disorders, we suggest that physicians should be aware of and consider dermatologic evidence of Magnan-Saury?s sign, with secondary excoriations of the skin, as a valuable clue to cocaine addiction, so that patients can be appropriately diagnosed and effectively treated to prevent relapse.
References 1. Magnan V, Saury M. Trois cas de cocainisme chronique [in French]. C Rend Soc de Biol(Paris). 1889;41:60-63.
3. Siegel RK. Cocaine hallucinations. Am J Psychiatry. 1978;135:309-314.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:244-245.
5. Ellinwood EH Jr. Amphetamine psychosis: a description of the individuals and process. J Nerv Ment Dis. 1967;144:273-283.
6. Gross-Tsur V, Joseph A, Shalev RS. Hallucinations during methylphenidate therapy. Neurology. 2004;63:753-754.
