International Journal of Emergency Mental Health and Human Resilience, Vol. 17, No.3, pp. 624-625, ISSN 1522-4821 IJEMHHR • Vol. 17, No. 3 • 2015 624 INTRODUCTION Delusional parasitosis can present as a unique symptom or as a component of a full blown psychotic episode. The typical picture is of a patient who seeks medical attention for an infestation of the skin by small, usually infectious pathogens. There may be somatic symptoms such as formication, sensation of insects crawling under the skin (Freudenmann & Lepping, 2009). Rarely, these delusions have taken the form of larger parasites, such as rats or snakes, infesting various internal cavities and organs (Tenyi & Trixler, 1993). Delusions of larger parasites are generally termed delusional infestations. Here we present two very similar cases of atypical delusional infestation, one in a patient with schizophrenia and the other in a patient with bipolar disorder. Both cases are unusual due to the size and nature of the parasite, as well as the sites of infestation. CASES PRESENTATION CASE 1 Patient with a history of schizophrenia as well as alcohol, cocaine, and cannabis use disorder that was brought to the emergency room by police because of disorganized behavior. She was found in possession of an eight-inch steak knife with which she planned to remove a snake from her stomach through her abdominal wall. She reported that the snake had been moving around in her stomach for two months, and she also reported attempting to remove the snake through her vagina. She had been noncompliant with oral haloperidol. Her psychiatric history included numerous hospitalizations for disorganized behavior, two suicide attempts, and sexual assault as an adult. She was college-educated and had a physical therapist license. She had two children: one died at birth, and the other passed away four months after birth. She reported a history of gastritis characterized by epigastric pain that preceded and was relieved by meals. She further reported skipping meals frequently for several months. On evaluation, the patient was disheveled and malodorous with fattened affect. She denied auditory hallucinations, and her thought process was somewhat tangential. She was disorganized, paranoid, and perseverant about somatic delusions regarding snakes. She was hospitalized voluntarily and started on haloperidol and esomeprazole. She also received metronidazole for vaginosis and doxycycline for a urinary tract infection. During hospitalization the patient reported having had nonconsensual sex with a man who introduced a snake into her body through intercourse. She believed that the snake had made a nest and laid eggs inside her gallbladder and that these eggs could hatch at any moment, and was very disturbed by the notion of having even more snakes in her body. The patient requested an abdominal x-ray to confrm her beliefs. Additionally, the patient reported persecutory delusions of prostitutes that put a pin on her anus. She was very suspicious of her roommate, and believed that prostitutes would come to her room to harm her at night. During the following days, the character of the patient’s delusions evolved. At one point she complained of nausea and said that the snake had teeth and was eating her abdominal organs. Later, she said the snake broke muscular and bony structures to move inside her thorax and insisted on a chest x-ray despite denial of breathing problems. She could not explain how her vital signs and physical condition were stable despite the snake eating some of her internal organs. She believed that surgery was the only way to remove the snake from her body and asked for such intervention. Nearing the end of her hospitalization, she complained of back pain and said 'the snakes are doing it'. After fve days of inpatient care, the patient’s delusions decreased in intensity and frequency. She no longer felt the snake moving inside her body, and she appeared much less disturbed by this idea. She also denied persecutory delusions or delusions of harm. Her thought process became goal-directed. Haldol decanoate was given prior to discharge. At the time of discharge, her delusional infestation had attenuated to the point that she did not complain of somatic symptoms or sensations of internal movement. CASE 2 Patient with a history of marijuana and alcohol use disorder *Correspondence regarding this article should be directed to: Ddurand@med.miami.edu Delusion of Snake Infestation Following Sexual Intercourse: Report of Two Cases Sidney Winford 1 , Dante M. Durand 2 *, Andrew Klise 2 , Ricardo Cáceda 1 1 Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 West Markham St., Slot #554, Little Rock, AR, USA 2 Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine 1695 NW 9th Avenue, Suite 1517-B, Miami, FL, USA ABSTRACT: Delusional infestation, a condition wherein a person believes his or her body to be infested with living organisms, has been observed in patients with primary psychotic disorders, as well as those with psychotic episodes secondary to mood disorders. Here we describe two similar cases of delusional snake infestation following sexual intercourse in female patients, one with schizophrenia and the other with new diagnosis of bipolar disorder. During the course of hospitalization, both patients misinterpreted abdominal pain/abnormal sensation following sexual intercourse as snakes infesting various parts of the abdomen and genital tract. In both cases, symptoms rapidly resolved after antipsychotic and appropriate medical treatment. Key words: Delusional parasitosis, delusional infestation, somatic delusion, snake delusion.