Delusional parasitosis, yclept Ekbom’s Syndrome, was originally described in 1938 and has an incidence of up to 4.2 per 100,000 people (Olivera, 2017; Orsolini, 2020). While the average duration of this delusion is three years, it can last decades (Al-Imam, 2019). Ekbom’s Syndrome of ultra-short duration, only one hour, has not heretofore been described.

A 36-year-old woman with a past history of schizoaffective disorder, bipolar subtype, generalized anxiety disorder, and alcohol use disorder with a history of seizures and delirium tremens presented with a one- hour duration of the delusion of being infested with bugs. She believed that microscopic bugs flew up her nose, stayed there for one hour, and flew out. This had never happened to her before nor since. She admitted to sadness, crying spells, hopelessness, lack of social interaction, anhedonia, fatigue, irritability, anger, insomnia, anorexia, low interest, amotivation, lack of sexuality, racing thoughts, and anxiety. She denied déjà vu and jamais vu, or any other hallucinations—tactile, visual, or auditory.

Abnormalities in Neurologic Examination: Mental Status Examination: Oriented x2, hyperverbal, anxious mood, blunted affect. Memory Testing: Immediate Recall: 6 digits forwards and 4 backwards. Recent Recall: 2 of 4 objects in three minutes without reinforcement, 4 of 4 objects with reinforcement. Remote Recall: Unable to name the presidents. Able to spell the word “world” forwards, but not backwards.

Oral Calculations: 75%. Written Calculations: 50%. Ideomotor Apraxia: Absent. Ideational Apraxia: 66%. Vocabulary Testing: 19/24. Drawing to Commands: 1/3. Higher Cognitive Function Test: 66%. Proverbs: 60%. Similarities: 80%. Judgement: 40%. Cranial Nerve (CN) Examination abnormalities. Cranial Nerve (CN) Examination: CN I: Alcohol Sniff Test: 2 (anosmia). CN III, IV, VI: Bilateral ptosis. Reflexes: 3+ throughout. Other: Blood Alcohol: 0.03.

Delusional Parasitosis, in Diagnostic and Statistical Manual V (DSM V), is categorized as delusional disorder, somatic type, and requires persistence of symptoms for at least one month (American Psychiatric Association, 2013). Ekbom’s Syndrome is generally years in duration, ranging from months to decades, with over 20% of individuals suffering for more than five years (Hinkle,2010). Others have found that mean duration is 2.6 years and suggested that a shorter duration reflected a better prognosis (Boggild, 2010). In a meta-analysis of 1,223 cases, mean duration was found to be three years with no correlation between age of onset and duration of delusions (Trabert, 1995). In a study with 365 patients with delusional parasitosis, 39% had symptoms for less than 1 year, 61% were of greater than a year, and 20% had Ekbom Syndrome for five years or longer (Reilly, 1986). A short duration of 3 months has also been noted but delusional parasitosis is more typically seen to last more than twenty years (Martins, 2016; Colbeaux,2020; Dridi, 2015; Olari, 2011; Alves, 2010; Nicolato, 2006; Mahler, 2008; Bellanger, 2009).The one-hour duration in our patient suggests either that this delusional disorder diagnosis must remain provisional or the criteria should be reduced to substantially less than one-month duration. In those with symptoms of delusional parasitosis, the transient nature of symptoms should not preclude the diagnosis and query as to this disorder in those with acute delusions may be revealing.

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The pandemic of coronavirus disease 2019 (COVID-19) has been associated with widespread myriad chemosensory dysfunction with smell loss as high as 99% and taste loss in 89% of those studied (Kim 2021, Paderno 2020, Renaud 2020). Other chemosensory problems, occur often in combination, including dysgeusia and hyposmia (3.2%), dysgeusia and anosmia (3.4%), ageusia and hyposmia (3.4%) and, ageusia and anosmia (8.5%) (Giacomelli, 2020). Hyperosmia has also been reported to be precipitated by COVID-19 infection (Di Stadio 2022, Kamali 2021). COVID-19 induced persistent hyposmia with resolution of smell and taste dysfunction with COVID-19 reinfection has not heretofore been described. Such a case is presented.

Two years prior to the presentation, a 26-year-old right-handed single male developed COVID-19 at which time his sense of smell and taste were totally eliminated. His smell gradually returned to 40-50% of normal whereby he was able to smell everything, but less intensively than he normally did. Furthermore, some odors he experienced in a hyperosmic fashion, such as smoke which was 200% more intense than normal. Prior to COVID-19 exposure, he experienced frequent flavorful eructations which were eliminated after COVID-19 exposure. His taste was initially absent after the COVID-19 exposure, but gradually returned to 60-70% of normal whereby he would taste everything but less intensively. Two years and one month after the initial COVID-19 infection despite being fully vaccinated, he contracted a recurrent COVID-19 infection. Prior to the infection, his smell and taste were 60% of normal. Acutely with the reinfection, his smell and taste ability abruptly dropped to 0% for 16 hours, after which his smell returned to 90% of normal and his taste returned to 100% of normal. During this time period, his other chemosensory problems including dysosmia, dysgeusia, cacogeusia, hyperosmia, and phantosmia all resolved, and his flavorful eructations returned. His sense of smell has remained normal for five months, but his sense of taste has gradually dropped down to 50% of normal.

Abnormalities in Physical Examination: General: Scalloped tongue. Neurological Examination: Cranial Nerve (CN) Examination: CN II: Visual acuity 20/25 OU. CN III, IV, VI: left ptosis. CN V: decreased light touch left V₁ and V₂ . CN IX and X: Uvula deviates to the right. Reflexes: Absent bilateral triceps. Neuropsychiatric Testing: Clock Drawing Test: 10/10 (normal). Animal Fluency Test: 26 (normal). Go-No-Go Test: 6/6 (normal). Center for Neurologic Study Lability Scale: 8/10 (normal). Chemosensory Testing: Olfaction: After the first infection prior to the second infection: Alcohol Sniff Test: 3 (Anosmia). Chemosensory Testing: 1 month after the recurrent COVID-19: Alcohol Sniff Test: 9 (hyposmia). Brief Smell Identification Test: 9 (normosmia). Retronasal Olfaction Test: Retronasal Index: 8 (normosmia). Gustation: Phenylthiocarbamide Taste Test: 9 (normogeusia). Waterless Empirical Taste Test: sweet: 6 (normogeusia) sour: 8 (normogeusia) salty: 6 (normogeusia) bitter: 4 (hypogeusia) brothy: 0 (ageusia) total: 37 (normogeusia).

COVID-19 induced smell loss has been observed to worsen after reinfection, improvement has not been described (Jain, Ear, Nose & Throat Journal, 2021, Lechien, Journal of Internal Medicine, 2021). Possibly the recurrent infection induced hyperosmia which superimposed upon the underlying COVID-19 induced anosmia caused an additive effect, combining together to induce normosmia as opposed to COVID-19 induced hyposmia. This may be due to persistent inflammation of the olfactory bulbs and frontal lobes, inducing excessive neuronal sprouting and associated hyperosmia (Di Stadio, European Review for Medical and Pharmacological Sciences, 2022). Alternatively, COVID-19 may have acted on not only the olfactory nerves but rather on a central basis, enhancing neuronal firings in the anterior insula and hippocampus, areas involved with the olfactory integration and which have enhanced gray matter volume in states of hyperosmia (Wabnegger, 2019). Even though COVID-19 vaccination has been noted to worsen the chemosensory function (Konstantinidis, International Forum of Allergy & Rhinology, 2021), COVID-19 immunization induced improvement in smell has also been reported (Plaza, Annals of Neurology, 2021). It is possible that such an improvement is through infection induced activation of inflammatory immune responses which then acts on the infected olfactory bulbs to reduce pathology. The current case of COVID-19 infection enhancing smell and taste strengthens such an autoimmune explanation. In those with recurrent COVID-19 infection, query and investigation as to presence of improvement of chemosensory dysfunction is warranted.

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Tinnitus not heretofore been described as the only manifestation of delusional possession in Kandinsky-Clerambault syndrome. Such a case is presented.

Case Report: A 70-year-old left handed (pathological) man, eight years prior to presentation, noted gradual onset of decreased hearing and high- pitched constant tinnitus AU made worse with stress. Initially only present in quiet, it intensified, ultimately present in all situations, even with ambient background noise. He believed that the Devil was inside of his head, had been there for many years, and was making his life unbearable by subjecting him to the tinnitus. Other than the tinnitus, the devil did not cause any other symptoms, nor did it communicate with him in any fashion. In an effort to eliminate the Devil-induced tinnitus, he twice attempted suicide through self-strangulation. The tinnitus persisted despite treatment with mirtazapine and lumateperone.

Abnormalities in physical examination: General: Decreased blink frequency. Continuous fidgeting and generalized tremulousness. Neurological examination: Mental status examination: Hypoverbal. Able to remember 5 digits forwards and 3 digits backwards. Unable to remember any of four objects in 3 minutes with and without reinforcement. Presidents as follows: Biden, Obama, ?. Animal Fluency Test: 7 (Abnormal). Cranial Nerve (CN) Examination: CN I Alcohol Sniff Test: 0 (Anosmia). CN VIII Calibrated Finger Rub Auditory Screening Test: Strong 2 AU. Motor Examination: 1+ cogwheel rigidity in the right upper extremity. Gait Examination: Unstable tandem gait. Reflexes: 1+ throughout. Other: Tinnitus Severity Questionnaire : 38/40 (Severe tinnitus). Tinnitus Handicap Inventory: 94/100 (Grade 5- Catastrophic handicap).

While Kandinsky Clerambault Syndrome, Delusion of Possession Syndrome is uncommon in the United States (Dimkov, 2020; Enoch, 2020), 46% of Italians believe in the Devil (Marra, 1990) and 0.6% of Canadians believe that they have been possessed by a demon (Ross & Joshi, 1992). Although the most common neurological presentation of Kandinsky Clerambault syndrome is glossolalia, sensory phenomenon of anosmia (Chand et al, 2000; Medeiros De Bustos et al, 2014), ageusia (Chand et al, 2000), kinaesthesia (Gedevani et al, 2022), allochiria (Medeiros De Bustos et al, 2014), synesthetic neuralgia (Medeiros De Bustos et al, 2014), cenesthesia (Medeiros De Bustos et al, 2014), pain (Medeiros De Bustos et al, 2014) and anaesthesia (Yap, 1960) have also been described. While tinnitus has not been reported with Kandinsky Clerambault, it has been noted to occur with depression, anxiety (Zöger et al, 2006; Salviati et al, 2013), and psychosis (Frankenburg & Hegarty, 1994; Jain et al, 2017). Given the widespread belief in the general population of the Devil and possession by external entities, assessment of presence of Kandinsky Clerambault Syndrome in those with intractable tinnitus may be worthwhile.

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Parkinsonian symptoms seen with B12 deficiency have been described in five cases where B12 therapy has led to their elimination. Subacute combined degeneration (SCD) presenting with parkinsonian signs of cogwheel rigidity, unresponsive to B12 supplementation, has not heretofore been described.

Case Study: This 62-year-old right-handed woman with a past medical history of hypothyroidism presented with complaints of trouble with memory. Cogwheel rigidity and pernicious anemia with low intrinsic factor and B12 levels (165 pg/ml) were found. SCD was diagnosed and treated with monthly B12 injections over the past three years, providing symptomatic relief, yet the cogwheeling persisted. She described never developing trouble with gait, movement disorders, autonomic abnormalities, olfactory dysfunction, disorders of sleep, visual hallucinations, or other parkinsonian symptoms.

Abnormalities in Neurologic Examination: Cranial Nerve (CN) Examination: CN I: Alcohol Sniff Test: 9 (hyposmia). CN III, IV, VI: Bilateral ptosis. Motor Examination: 1+ Cogwheel rigidity both upper extremities. Drift Testing: Right pronator drift with left abductor digiti minimi sign. Reflexes: 3+ throughout other than 4+ ankle jerks. Quadriceps femoris bilaterally pendular. Bilateral Hoffman and Babinski reflexes present. B12 Level: 394 pg/ml (normal).

While predominantly affecting the posterior columns and the lateral corticospinal tract, the demyelination may further extend into adjacent fibers including the reticulospinal tract and the rubrospinal tract, the tracts which, in Parkinson’s Disease, have been cited for their role in maintenance of tone and thus cogwheeling. Additionally, low B12 and elevated homocysteine levels have been noted as potential contributory factors in the pathogenesis of Parkinson’s Disease. It is also possible that this is a violation of Occam’s razor, that this individual has two separate distinct diseases — the prominent subacute combined degeneration as well as a subclinical parkinsonism which was revealed on neurologic examination. The parkinsonian signs may have been present prior to the B12 deficiency, and if not for the examination findings, could have remained undiscovered for decades. In those that present with Subacute Combined Degeneration, evaluation for parkinsonism is warranted.

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