Dear Sir,
Alcohol use is a major problem in most of the countries which is taking an increasing toll on people and indirectly on their family members as well. Alcohol withdrawal has a broad range of symptoms which varies from mild tremors to a serious condition known as delirium tremens (DT), and seizures. It could progress to death if not recognized early and treated promptly, commonly encountered in general hospital settings.[1]
Selfinjurious behavior, though rare, is a severe form of behavior usually seen in psychotic disorders. Self-mutilation represents voluntary intentional injury focused on the person’s own body, without suicidal intent.[2] Genital selfmutilation (GSM) refers to selfaggressive behavior on the genitals, with aggressivity of varying degrees, ranging from the smallest mutilations to the most serious ones, which constitute urological emergencies (penile or testicular amputation).[3]
A 40-year-old male farmer, with no known co-morbidities, was admitted -to the surgery ward presenting with a self-inflicted penile injury in the background of being a known case of chronic alcohol use. He had been consuming about three-quarters of country alcohol daily, used to develop tremors of hands, severe anxiety, palpitations, sweating, restlessness, and even seizure episodes on stopping alcohol which used to subside upon taking alcohol again. He had stopped alcohol about 10 days back, then had a seizure episode and was hearing voices of unknown people inaudible to others, threatening to kill him if he did not cut his genitals. He had been seeing shadows like ghosts with some sharp objects in hand trying to attack him.
While he was alone at home, the patient cut off his penis from the base with a knife. He did not mention it to anyone, but the pool of blood was observed by family members later, who then rushed him to the hospital. After initial surgical management, he was referred for psychiatric evaluation. [Figure 1] He was managed with benzodiazepines, thiamine, and other supportive measures. On stabilization, he underwent penile injury wound repair with urethrostomy. On improvement and during reviews in the following months, he was found to be partially abstinent.
Figure 1.
Penile stump under surgical care
Severe self-injuries have been mostly reported in Schizophrenia and other psychotic episodes and are rarely associated with alcohol withdrawal delirium. In a systematic review of GSM, psychiatric illness was reported in about 91% of patients, with schizophrenia spectrum disorders implicated in 49% of these patients while substance use disorders were only 19% of the cases. Among cases with substance use disorders, the most implicated substances were cannabis, cocaine, and amphetamines.[4]
S. V. Sathish Kumar and Roopesh Gopal[1] described in a case series of self-injurious behaviors during alcohol withdrawal, including a case of a 35-year-old male self-amputating his right foot after having visual hallucinations of a snake biting the foot. Patra et al.[5] reported a case in which a patient inflicted multiple stab injuries to his own abdomen during complicated alcohol withdrawal in response to alcoholic hallucinosis. Management of GSM requires collaborative effort between medical and psychiatric care providers. It is crucial for all team members to exhibit professionalism and respect to avoid exacerbating the patient’s feeling of shame or embarrassment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity.
Author contributions
All authors contributed substantially to the write-up of the article, and all take responsibility for the content of the publication.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
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