Munchausen syndrome masquerading as bleeding disorder in a group of pediatric patients.

This short communication is about Munchausen's syndrome in a group of pediatric patients and co morbid Munchausen's syndrome by proxy. A 7-year-old girl presented with spontaneous bleeding from forehead, eyes and scalp. The girl was investigated thoroughly by pediatricians at a tertiary care hospital in western India for all possible bleeding disorders, but there was no conclusive diagnosis. After two days, cases with similar complaints were reported among children residing in the same locality and with similar socioeconomic background. All of them were investigated in detail for possible causes of bleeding but nothing came out. There was a media reporting of the cases as a mysterious bleeding disorder. At this point of time, an expert opinion from the psychiatrist was demanded. Covert video surveillance and series of interviews revealed Munchausen's syndrome and possible Munchausen's syndrome by proxy. An in-depth literature review with special reference to Munchausen's syndrome was carried out to come to a final conclusive diagnosis.

INTRODUCTION

Feigned illness with the goal of receiving medical treatment for its own sake is known as Munchausen's syndrome. The syndrome is named after Baron Von Munchausen (1720-1791) by Asher in 1951. Munchausen's syndrome is characterized by a self-inflicted lesion.[12] These patients have dramatic, but nonexistent symptoms and demand radical treatment. A similar entity of symptoms is often referred to as Munchausen's syndrome by proxy in which caretaker of the child (most commonly mother) creates symptoms in the child or makes the physician believe it.[3]

CASE REPORT

Index case was a 7-year-old female child who presented to the pediatric OPD of SMIMER Hospital, Surat, with a history of spontaneous bleeding from face, forehead, cheek, and scalp for last 20 days. As per history, bleeding was sudden, intermittent, not related to any time and was 1 to 2 cc in amount. The blood was red in color, not associated with any bruise, abrasion or petechiae on the skin. Index case had no history of trauma, bleeding diathesis, pain, joint swelling, itching, fever, drug ingestion, chemical ingestion or insect bite.

Her history and family history was not significant. Her clinical examination was completely normal and laboratory investigations which included complete blood count, bleeding time, clotting time, prothombin time, aPTT, platelet counts, sickling test, test for dengue and leptospirosis were found negative. It was decided to treat her symptomatically. She was discharged with a request to make a follow-up if the episode of bleeding reoccurred.

After 2 days, she presented to the OPD again with similar complaints along with 4 other children. Three females and one male came with their parents with history of bleeding episodes. All were of different age groups (ranging from 3 to 10 years), different families but of the same locality and sociocultural background.

All of them were admitted in pediatric ward for observation. Many of them had spontaneous bleeding during their stay in the hospital ward itself. All the investigations like CBC, bleeding time, clotting time, PT, aPTT, platelet counts, sickling, dengue and leptospirosis were negative. Various differential diagnoses like viral hemorrhagic fever, hemarthrosis, functional platelet defects and toxic irritant material were put under discussion. Most common site of the bleeding was scalp.

Blood samples from the bleeding sites were collected and were sent to the pathology lab for further investigations. It was confirmed that the sample collected was human blood. Later, the blood grouping of the blood from bleeding sites and vein of the index child was carried and it matched.

On close microscopic examination of the blood, it was found that there were plenty of mucus strands and epithelial cells in the blood [Figure 1]. At this stage, patients were referred for psychiatric consultation.

Figure 1

Microscopic view of blood

During the psychiatric evaluation, three of the mothers appeared indifferent to the manner of occurrence of the whole episode. They did not believe that it could be a psychiatric illness and many a times showed their discontent in the form of anger to even simplest of the questions asked. Mothers were apprehensive about the cause of the bleeding, but at the same time were seemingly not very serious regarding the illness of their children.

On insisting for cooperation from parents to have a detailed psychiatric evaluation of both children and parents, they left the hospital against medical advice. There was considerable media hype regarding this in the community because the news was out in a leading local paper as a mysterious illness.

Two days after leaving the hospital, three patients returned back to wards to collect reports where they were again counseled for a detailed history and were admitted in psychiatry ward. Two fresh cases of bleeding were reported from the city but were from different locality where the index case visited recently. The significant thing that emerged was that index case was present when bleeding occurred in those new cases.

It was observed that whenever children were given suggestions in playful manner, bleeding occurred. It was also noticed that every time when there was a fresh bleeding from forehead, it was accompanied with a transient visit to some other room or in a place of isolation by the child. To gain an insight into the entire clustering of cases and to avert a possible panic in population about this mysterious disease, it was decided to put two children under video surveillance (including index case) while interviewing them.

The findings of the recording revealed some interesting facts. The 7-year-old index child was found biting her buccal mucosa with her teeth and then spitting the blood on her hand and applying it on her forehead. It was done briskly and smartly when nobody was noticing her. On examining her oral cavity, multiple small ulcerations on her buccal mucosa [Figures 2 and 3] were found. Index child was shown the recorded video and was again asked about the whole act. She accepted that she did it herself and confessed that she did it to get attention. When the films were shown to the mothers, the reaction was unusual, it could not be ascertained from the reaction if the mothers had either been assisting them or were aware of her behavior.

Figure 2

Ulcers in buccal mucosa

Figure 3

Blood in oral cavity

Keeping in view of new evidences, an in-depth interview of the mothers and other children was planned again, but could not be completed as parents were not cooperative. All the patients were discharged after there was no reported episode of bleeding. The cases were followed telephonically after 5 days and no such episodes were reported. No new cases were found or reported in the locality after the discharge of all the cases.

DISCUSSION

Munchausen's syndrome alone or Munchausen's by proxy with similar type of presenting symptoms in a group is rarely reported in the literature. Although we were able to prove Munchausen's only in the index case, we suspected it by proxy in other children as they had bleeding only in scalp not on the face and few of them were too young to do it by themselves (3 patients were just 3 years old).

Second, in-depth interview of index case suggested possible involvement of the mother; however, we were not able to prove it as all took discharge and were not cooperative. Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness.[4] Most of the time, evidence of unresolved trauma or loss reactions in mothers is seen.[5] It was suspected that index case might be responsible for causing bleeding in other patients but the purpose for the same was not clear. This was suggested by the fact that when the index case made a visit to one of their relatives for few days, a 20-year-old lady had bleeding from her scalp but she did not take medical advice.

In factitious disorders, the patients inflict lesions to satisfy an internal psychological need to gain attention and sympathy. A review of their background can reveal childhood neglect or abuse.[25] Unlike malingerers, there is no apparent secondary gain. Many a times, even the patient is not able to clearly give reasons for this behavior.[2] In this case probably, she (Index child) did it to gain attention from her mother.

Media hype and its effect on the community was one of the most important issues that led to an immediate confrontation, following which they fled away and hence time to go for structured in-depth interview could not be borrowed. Primary aim for this rapid response from investigators was to prevent occurrence of fresh new cases.

Lastly, the importance of covert video surveillance in these types of cases was once again highlighted.[6] Number of experts from different fields were suspecting some mysterious bleeding disorder or hemorrhagic fever in this group, and it was covert surveillance which proved out to be diagnostic.

Certain questions are still unanswered and unclear and are left open.

Were the other older children taught by the index child or did they learn it to gain attention as well?

Who applied blood to the younger cases?

Was there any involvement of mothers and, if yes, why?

SUMMARY

Munchausen's syndrome in a group is not so common. Psychiatrist approach to such syndrome is to limit investigations and harmful procedures on the suspected cases. A therapeutic approach should always be used but support to the patient is must. After diagnosis and confrontation, symptoms usually resolve significantly but cases deny their role in the production of symptoms and refuse psychiatric treatment and like in the present communication where all went for a premature discharge. When this syndrome presents with community-level effect, we should act really fast to prevent further consequences.