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LETTER TO EDITOR
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 90-91

A case of sporadic koro from Kerala


Department of Psychiatry, Jubilee Mission Medical College, Thrissur, Kerala, India

Date of Web Publication29-Mar-2018

Correspondence Address:
Dr. A P Megha
Udayanagar, Ayyanthole, Thrissur, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_105_16

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How to cite this article:
Megha A P, Antony JT, Beevi K S, Chakkalakkudy GG, Kuttichira P. A case of sporadic koro from Kerala. Indian J Soc Psychiatry 2018;34:90-1

How to cite this URL:
Megha A P, Antony JT, Beevi K S, Chakkalakkudy GG, Kuttichira P. A case of sporadic koro from Kerala. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 Jan 25];34:90-1. Available from: https://www.indjsp.org/text.asp?2018/34/1/90/228781



Dear Sir,

Koro syndrome is known as a culture-bound psychiatric disorder prevalent in the southeast Asian region. It is characterized by severe anxiety, fear of genital retraction to the abdomen, and belief of immediate death on complete retraction. It has an acute onset, has a brief duration, occurs in epidemics, and is responsive to psychoeducation. Repeated epidemics in jute workers have been reported from Kolkata.[1] Sporadic cases have been reported from India [2] and Greece.[3] An epidemic of Koro from Kerala was reported,[4] however, it was among migrant laborers mostly from the states of West Bengal and Assam. A case of sporadic Koro syndrome is reported from Jubilee Mission Medical College, Thrissur, located in the middle region of Kerala; the first case of Koro, to our knowledge, in a person born in Kerala.

A 32-year-old male manual worker working in a coconut mill from a village of Palakkad belonging to low socioeconomic status presented to the casualty department in the midnight complaining of difficulty in passing urine for previous 2 weeks and penis retracting to the abdomen of 1-week duration. The complaints started as small quantity weak stream urine without any dysuria, urgency, or frequency. After a week while he was passing urine, he experienced his penis is retracting to the abdomen. He also experienced that his abdominal muscles are getting tightened, hands and legs getting swollen, and felt dizzy. He walked briskly around his house to relieve the discomfort. It lasted for 1–1.5 hour. Since then, he had similar experiences 5–6 times a day, for which he sought medical help. The consulted physician after clinical examination and ultrasound reassured him and prescribed minor tranquilizers. However, his symptoms persisted. In the casualty department of our hospital, he was seen by a general surgeon first followed by a psychiatrist. His mother corroborated the history. There was no past history of similar symptoms or any psychiatric illnesses. His father had abandoned his mother 1 year after marriage and he was brought up by his mother. His developmental milestones were normal; he had completed matriculation after which he started working in the coconut mill. He was a steady worker. He gained information regarding sex from his school friends and had nocturnal emissions occasionally. He had never masturbated or performed intercourse, and never had any sexual fantasies. He expressed his concerns regarding his sexual potential. He was married at the age of 22, but his wife returned to her home after 2 weeks. It was a non-consummated marriage and they got divorced after 2 years. A month prior to the onset of symptoms there was a new proposal. The patient was supposed to meet the girl at the weekend when he was admitted. Premorbidly, he was a submissive person with good social interactions, albeit dependent on his mother. General examination showed all systems to be normal. His external genitalia, scrotum, cord structures, and testis appeared normal. On mental status examination, rapport was established. He firmly believed that his penis was retracting into the abdomen. His penis size was measured when he was distressed and when asymptomatic. He was shown that both the measurements were same. But he was not convinced. He was anxious. Provisional diagnosis of sporadic Koro was made. He was started on clonazepam 6 mg/day and propranolol 20 mg/day along with supportive psychotherapy. As there was no significant improvement, clonazepam dose was increased to 12 mg/day. The patient started showing improvement, however, he was still complaining of poor urine stream. Urology consultation was arranged; urine routine examination and ultrasonography (USG) of the abdomen was found to be normal. After 12 days of admission, the patient became symptomatically better and was discharged. He was symptom free when he came for follow-up. Both the patient and his mother had never heard about these symptoms previously. They never had any acquaintance with migrant laborers.

Though Koro was considered in DSM–IV, the glossary of cultural concepts of distress of DSM–V does not mention Koro syndrome. Dominant prevalence in areas of low literacy areas, epidemics falling at the times of socioeconomic turmoil, and resulting unrest have been argued to be causative factor,[1] thereby suggesting the role of psychosocial factors in the etiology. Based on computed tomography (CT) findings and brain electrical activity mapping, it was attempted to understand sporadic Koro as sexual epilepsy originating from the right temporoparietal or bitemporoparietal dysfunction.[5] Its comorbid existence with paranoid psychosis or schizophrenia were reported, highlighting the role of immigration in the pathogenesis of the clinical phenomenon.[6]

Being the southernmost state of the country, Kerala has no cultural similarity or contiguity with places from which cases were reported earlier. Globalization diffuses the boundary between cultures and is likely to carry their conflict releasing mechanisms also. The mechanism, if suited, the person in distress makes use of it. In this case, the unconscious desire of the individual (knowing his own sexual inadequacy) to keep away from remarriage proposal was made successful. Giving an explanation based on physical illness would be socially accepted and personally satisfying. The patient was over investigated and over medicated. The need for quick response and local nonpopularity of drug formularies may be contributing to over medication. However, close monitoring in the inpatient setting can be argued as a measure ensuring patient safety. Expression of discomfort can take many forms including accepted methods in a different culture. No culture is completely alien in the era of globalization and widespread migration. In this case, the patient had no previous knowledge about such a syndrome and he neither had any contact with migrant laborers. A sporadic case can spread to others in similar stressful situations if it is culturally approved. In the reported epidemic from Kerala,[4] it did not spread to Keralites because of lack of social sanction. This case study shows that Koro syndrome either is not a culture-bound syndrome alone, or in the era of globalization, it is breaking culture boundaries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chakraborty S, Sanyal D. An outbreak of Koro among 19 workers in a jute mill in south Bengal. Indust Psychiatry J 2011;20:58-60.  Back to cited text no. 1
    
2.
Kar N. Chronic Koro like symptoms - two case reports. BMC Psychiatry 2005;5:34.  Back to cited text no. 2
[PUBMED]    
3.
Ntouros E, Ntoumanis A, Bozikas VP, Donias S, Giouzepas I, Garyfalos G. Koro-like symptoms in two Greek men. BMJ Case Rep 2010;2010.  Back to cited text no. 3
    
4.
Promodu K, Nair KR, Pushparajan S. Koro Syndrome: Mass epidemic in Kerala, India. Indian J Clin Psychol 2012;39:152-6.  Back to cited text no. 4
    
5.
Joseph AB. Koro: Computed tomography and brain electrical activity mapping in two patients. J Clin Psychiatry 1986;47:430-2.  Back to cited text no. 5
[PUBMED]    
6.
Rosca-Rebaudengo P, Durst R, Minuchin-Itzigsohn S. Transculturation, psychosis and Koro symptoms. Isr J Psychiatry Relat Sci 1996;33:54-62.  Back to cited text no. 6
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