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   Introduction
   Case Report
   Discussion
    References

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 Table of Contents    
CASE REPORT  
Year : 2020  |  Volume : 62  |  Issue : 4  |  Page : 435-436
A rare case report of Lilliputian and Brobdingnagian hallucinations in a case of pemphigus vulgaris


1 Department of Psychiatry, AIIMS, Bhopal, Madhya Pradesh, India
2 Department of Dermatology, AIIMS, Bhopal, Madhya Pradesh, India

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Date of Submission19-Jun-2019
Date of Decision06-Oct-2019
Date of Acceptance09-Feb-2020
Date of Web Publication27-Jul-2020
 

   Abstract 


Pemphigus vulgaris is an autoimmune disorder characterized by intraepithelial, blistering lesions affecting the skin and mucous membrane. Psychiatric manifestations of pemphigus vulgaris are generally described secondary to steroid and immunosuppressant therapy though recent studies highlight independent association of pemphigus with psychotic disorders. We describe a unique development of Lilliputian hallucinations, their transformation into Brobdingnagian hallucinations on treatment with steroids and gradual resolution back to Lilliputian status on treatment with risperidone. Earlier Lilliputian hallucinations have been described in a case of Charles Bonnet syndrome, Balint syndrome, alcohol withdrawal delirium, head injury and dementia. This unique phenomenon carries it significance in the literature from psychopathological perspective.

Keywords: Brobdingnagian, hallucinations, Lilliputian, pemphigus, steroid

How to cite this article:
Sutar R, Patra S, Siddiqui F, Diwan S, Rajan A. A rare case report of Lilliputian and Brobdingnagian hallucinations in a case of pemphigus vulgaris. Indian J Psychiatry 2020;62:435-6

How to cite this URL:
Sutar R, Patra S, Siddiqui F, Diwan S, Rajan A. A rare case report of Lilliputian and Brobdingnagian hallucinations in a case of pemphigus vulgaris. Indian J Psychiatry [serial online] 2020 [cited 2020 Aug 9];62:435-6. Available from: http://www.indianjpsychiatry.org/text.asp?2020/62/4/435/290988





   Introduction Top


Pemphigus vulgaris is an autoimmune dermatological condition associated with various systemic manifestations. Psychiatric manifestations are generally secondary to treatment with steroid and immunosuppressant therapy.[1] We describe a unique resizing of Lilliputian and Brobdingnagian hallucinations in a case of pemphigus vulgaris.[2]


   Case Report Top


A 44-year-old gentleman, married and unemployed, had a history of bullous lesions over the tongue, buccal mucosa, and palate. Dermatological evaluation revealed bullae and crusted erosions over the forehead spreading toward the chest, abdomen, and ventral aspects of thighs. He responded poorly to dapsone (100 mg/day), azathioprine (100 mg/day), and prednisolone (20 mg/day) for 10 weeks. In view of large areas of erosions with significant pain, he was hospitalized and was started on intravenous (IV) dexamethasone 8 mg once daily, tablet cyclophosphamide 50 mg once daily, and IV immunoglobulin 2 g/kg of total dose for 5 days. Meanwhile, he developed significant dysphoria, pessimistic ideas, death wishes, and fear against two unknown persons that he could see in their absence. Detailed psychiatric evaluation revealed depressed mood, easy fatigability, and crying spells with Lilliputian hallucinations of seeing two small individuals (size of 2 feet) threatening to kill him. On mental status examination (MSE), an interesting phenomenon noted was the evolution of tiny Lilliputian hallucinations into gigantic Brobdingnagian hallucinations (size of 10 feet) on treatment with steroids. The description of the visuals could not fit dysmegalopsia or visual imagery. There was nothing suggestive of delirium or seizures. Neurological and ophthalmic evaluation was normal. His routine blood investigations and computed tomography of the brain were within the normal limits. A diagnosis of organic depression with psychotic symptoms was made by consultation–liaison psychiatry team and started on oral escitalopram up to 20 mg and risperidone up to 4 mg/day. Within a week of treatment, the size of hallucinations reduced back to tiny people (from 10 feet to 2 feet) while preserving the shape of them and completely resolved by the end of 2 weeks. His depression improved at the time of discharge backed by MSE and drop in the Hamilton Depression Rating Scale scores from 18 to 6.


   Discussion Top


Lilliputian hallucinations are characterized by the smaller appearance of things or people than their actual size, while Brobdingnagian hallucinations are described in the context of a gigantic appearance of them. They are rare but commonly seen in neurological and ophthalmic conditions and rarely in psychiatric syndromes.[3] Pemphigus vulgaris is an autoimmune disorder, and the recent study shows an association of psychotic disorders independently with pemphigus which was not established in our case.[1],[4] Depressive psychosis is described in a case of pemphigus similar to our case with evolving depressive symptoms accompanied by Lilliputian hallucinations. Steroids are well known to cause psychosis,[5] but there is no literature on unique change in the size of visual hallucinations in pemphigus. A single case report demonstrating both Lilliputian and Brobdingnagian hallucinations in senile patients exists;[6] however, this is the first time that interplay of Lilliputian and Brobdingnagian hallucinations is described in association with steroid dosage. Eventual resolution of Brobdingnagian hallucinations to Lilliputian status is a unique phenomenon from a psychopathological perspective.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kridin K, Zelber-Sagi S, Comaneshter D, Cohen AD. Association between schizophrenia and an autoimmune bullous skin disease-pemphigus: A population-based large-scale study. Epidemiol Psychiatr Sci 2019;28:191-8.  Back to cited text no. 1
    
2.
Chand PK, Murthy P. Understanding a strange phenomenon: Lilliputian hallucinations. Ger J Psychiatry 2007;10:21-4.  Back to cited text no. 2
    
3.
Chen YJ, Wu CY, Lin MW, Chen TJ, Liao KK, Chen YC, et al. Comorbidity profiles among patients with bullous pemphigoid: A nationwide population-based study. Br J Dermatol 2011;165:593-9.  Back to cited text no. 3
    
4.
Försti AK, Jokelainen J, Ansakorpi H, Seppänen A, Majamaa K, Timonen M, et al. Psychiatric and neurological disorders are associated with bullous pemphigoid-A nationwide Finnish care register study. Sci Rep 2016;6: 37125.  Back to cited text no. 4
    
5.
Cohen MA, Alfonso CA, Haque MM. Lilliputian hallucinations and medical illness. Gen Hosp Psychiatry 1994;16:141-3.  Back to cited text no. 5
    
6.
Thomas C, Fleming G. Lilliputian and brobdingnagian hallucinations occurring simultaneously in a senile patient. J Ment Sci 1934;80:94-102.  Back to cited text no. 6
    

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Correspondence Address:
Dr. Roshan Sutar
Department of Psychiatry, AIIMS, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_340_19

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