Cutaneous Munchausen Syndrome by Proxy: A Diagnostic Challenge for Dermatologist.

Munchausen syndrome by proxy (MSBP) is a rare psychiatric disorder of a caregiver (commonly mother) who induces injury or symptoms on victim because of his or her psychiatry illness. The victims are usually under 6 years of age who cannot complain regarding inflicted injury. Diagnosis is challenging to the physician. We came across a 15-month-old girl child, who had consulted various specialists for episodes of blister followed by erosions on body since 6 months of age. Dermatological examination revealed blisters and healed leaf-shaped scars of different sizes which were suggestive of scalds. Smell of different varieties of oils, dribbling of hot oil from body at various intervals, and mother being the first to notice appearance of new skin lesions in all past episodes lead to suspicion of cutaneous MSBP with mother being the culprit. The family members were counselled regarding nature and course of the condition, mother was started on psychotropics, and the child was rescued from mother along with symptomatic treatment of the skin lesions.

Introduction

Munchausen syndrome by proxy (MSBP) or factitious disorder by proxy is a psychiatric disorder in which a caregiver induces a disease mimicking symptoms on a baby.[1] Diagnosis is difficult and requires high index of suspicion and confirmation by a detailed corroborating history with clinical feature and a multidisciplinary approach. We are reporting cutaneous MSBP in a 15-month-old female child who was misdiagnosed by various physicians as epidermolysis bullosa since 7 months.

Case Report

A 15-month-old female child presented with history of recurrent blisters and ulcers over body since 6 months of age. Parents gave history of sudden appearance of blisters at 3–4 days intervals, which ruptured to form ulcers that healed in 1–2 weeks. The ulcers were healing on its own within 1–2 weeks. The child had been seen by several physicians, diagnosed to have epidermolysis bullosa, and given conservative treatment. On examination, there were two linear ulcers on scalp and right cheek of the child with mild oozing from surface. There were multiple hypopigmented, hyperpigmented, hypertrophic, and atrophic scars at various stages [Figure 1a and b]. There was patchy cicatricial alopecia on scalp and ectropion of left upper eyelid [Figure 1c and d]. The child was suspected to be a case of epidermolysis bullosa at first instant. However, careful examination of abdomen, genitalia, back, and thighs (both on trauma and non trauma-prone sites) of the child revealed bizarre-shaped scars with majority having imprint of leaves [Figure 2a–c]. The morphology of lesions leads to suspicion of some inflicted injuries. On cross-questioning, the father told every time there was a smell of different kinds of oils such as mustard oil, kerosene oils, coconut oils, and sometimes hot oil trickling from the scalp of child, which was more frequent for last 4 months. The new lesions were appearing at day time during sleep in absence of father and when the child used to be in deep sleep. The mother was always the first person to notice the lesions. From the above history, mother was being suspected as the culprit of such injuries to the child. The psychiatry consultation was done and the child was confirmed to be of MSBP. The child was hospitalized with strict separation from the mother. During 20 days of hospital, no new blisters developed. Both parents were counselled separately by psychiatrist. Father was convinced to keep the child at paternal uncle's house away from mother and the mother was started on Escitalopram 20 mg/day. Family therapy was advocated. Now the child is doing well and not developing any skin lesions.

Figure 1

(a) Linear ulcers on scalp and cheek. (b) Bizarre-shaped hypopigmented and hyperpigmented scars on various parts of body. (c) Patchy cicatricial alopecia on scalp. (d) Ectropion of left upper eyelid

Figure 2

(a-c) Scars with imprint of leaves on trunk, abdomen, and thighs

Discussion

MSBP has been defined as “the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role.”[1]

In 85% of cases mother is the culprit and less often the father or other caregivers.[234] American classification of mental disorders, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), states that the aim of the perpetrator is to maintain a sick role by means of a proxy, i.e. the child.[5]

DSM-IV diagnostic criteria include:

Intentional fabricating or replicating somatic or psychological symptoms in other people who are directly cared for by the perpetrator;

The aim of such behavior is to cause the symptoms of the disease in that person (the proxy);

There are no external motives (such as pecuniary benefits);

The aforementioned behavior cannot be qualified as other mental disorders.

However, the above criteria are not specific to diagnose MSBP. Cutaneous MSBP has been rarely described in the literature. Most of the time, the clinical presentation mimics other disease condition leading to misdiagnosis and treatment. There have been reports of cutaneous MSBP presenting as granuloma annulare, cicatricial pemphigoid, recurrent nail avulsion, purpura, and coagulopathy.[1678]

The diagnosis of MSBP is challenging as victims are usually under 6 years of age who cannot tell the nature of occurrence or cause of their injuries.[9] It requires high index of suspicion and corroborating clinical features with detailed history obtained from family members to arrive at the diagnosis of MSBP. These cases more often remain undiagnosed, resulting in frequent unnecessary investigations and hospitalizations leading to considerable morbidity and even mortality.[10] Most of the time, participation of many physicians with different areas of expertise is needed for both diagnosis and treatment.[235] In our case the child presented with recurrent blisters rupturing to form ulcers healing with postinflammatory hyperpigmentation, hypopigmentation, atrophic, and hypertrophic scars along with patchy cicatricial alopecia and ectropion of left eye. Because of the above presentation, she was misdiagnosed as a case of epidermolysis bullosa. However, the bizarre-shaped scars with imprint of leaves, history of smell of different kinds of oils from body of child, appearance of new skin lesions during deep sleep day time in absence of father, and mother being always the first person to notice the lesions lead to suspicion of cutaneous MSBP and mother being the culprit in our case.

Treatment is multipronged and complex. The child should be immediately rescued from the culprit caregiver. After ensuring safety of child, psychiatric and psychological treatment should be started for the culprit.[5] In the present case the child was hospitalized, mother was separated, and the family members were counselled regarding the course and nature of disease. The culprit mother was sent to psychiatric department where she was counselled and started on psychotherapy. After discharge from hospital, the child was sent to stay at her paternal uncle's house away from mother.

Diagnosis of cutaneous MSBP is challenging for dermatologist. We are reporting the present case for rarity and rare clinical presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.