A case of Munchausen syndrome by proxy presenting with epistaxis

Abstract

To the Editor Munchausen by Proxy syndrome MSBP was defined by Meadow in 1977 in England as a form of child abuse practiced by families or caregivers 1 2 It causes physical and emotional damage in the child because of recurrent unnecesssary medical investigations and treatments 3 The exploiters are generally women and most commonly mothers and caregivers 4 5 6 The exploiter makes up systematic information about the health of the child ascribes a disease to the child and is glad that the child gets a medical diagnosis and treatment In addition he she has an imaginary thought that the child is ill and if the child is brought to a doctor the disease will be prevented 3 Our patient was a 2 5 months old boy the third child of a 24 year old mother The patient who was born at the 36th gestational week by cesarean section had been hospitalized in the neonatal unit for 11 days because of early membrane rupture and Rh incompatibility 1 5 months after he was discharged he was brought to an otolaryngology outpatient clinic because of unilateral nasal bleeding It was told that he had a wound in the nose and topical treatment was given The patient was hospitalized in our unit with the same complaint one week later Epistaxis started one week ago drop by drop and increased gradually At hospitalization in the neontal unit there was no finding of hemorrhagic diathesis and vitamin K had been administered Systemic examination was normal Laboratory tests were as follows: Hb:10 g dL WBC: 10120 mm3 PLT: 280 000 mm3 fibrinogen: 195 mg dL PT: 12 1 s aPTT: 28 3 s INR: 1 1 s VWF level 123 IU mL FXIII level: normal Fresh frozen plasma was given when epistaxis continued Abdominal USG performed for diagnosis of possible accompanying pathologies was found to be normal The patient was discharged with recommendations Two days later he was internalized again with the complaint of nasal bleeding During the second hospitalization factor VII VIII IX XIII and thrombin time and computed tomographic scans of the head and neck were found to be normal Munchausen by proxy was considered and blood type was tested by obtaining blood sample from the patient rsquo;s nose The mother rsquo;s blood type was 0 Rh the patient rsquo;s blood type was 0 Rh and the blood type of the blood sample obtained from the patient rsquo;s nose was 0 Rh Brown black macular lesions were found on the 2 3 4 5th fingers of the mother and dermatologic examination revealed that the lesions were traumatic The mother was evaluated by the psychiatry clinic and the proposal of hospitalization with a prediagnosis of personality disorder was rejected In children presenting with unexplained persistent signs and symptoms the diagnosis of factitious disorder generated by the family caregiver should also be considered in the differential diagnosis Many conditions including bleeding fever hematuria hypoglycemia hypernatremia and skin lesions are generated intentionally by the parents and most commonly by the mother 1 7 8 It was found that our patient had no hemorrhagia during his hospitalization in our neonatal unit his nasal bleeding was always in small quantities and as blood clots in front of the nares and all tests for hemorrhagic diathesis were found to be normal The Social Service Provincial Directorate and the public Prosecution Office were given notice for the aim of helping the patient who was considered as Munchausen by Proxy and his family The person with whom the social service specialist interviewed stated that the mother was too much interested in our patient after losing her second baby and brought him frequently to the hospital because she was afraid that he would be ill During the interview made with the mother she stated that her baby had nasal bleeding she was afraid that he would be ill and therefore brought him to the hospital It was learned that they lived in the same house as 12 residents her husband had no regular work and worked on construction sites from time to time The father rsquo;s being outside most of the time the mother rsquo;s fear that her children would become ill and unneccesary investigations and treatments were found to be compatible with the literature for the diagnosis of factitious disorder MSBP is a picture which harms the economy of physicians patients and countries because of reasons including exposure of patients to many unnecessary investigations and radiation leading to administration of wrong treatment consumption of time of healthcare workers and costs of the procedures performed We think that consideration of MSBP in the differential diagnosis of patients presenting with unexplained persistent findings and evaluation of suspicious cases by psychiatric examination would be very beneficial in terms of diagnosing the condition and preventing unnecessary medical interventions Ad shy;dress for Cor shy;res shy;pon shy;den shy;ce: Suar Çakı Kılıç MD Cumhuriyet University Medical Faculty Division of Pediatric Hematology Sivas Turkey Phone: [phone] Fax: [phone] E mail: suarcaki@superonline com Re shy;cei shy;ved: 03 26 2012 Ac shy;cep shy;ted: 04 16 2012 References 1 Meadow R Munchausen syndrome by proxy Arch Dis Child 1982; 57: 92 98 2 Meadow R Different interpretations of Munchausen syndrome by proxy child abuse negl 2002; 26: 501 508 3 Polat O Dokgöz H Munchausen sendromu İçinde: Polat O yazar Tüm boyutlarıyla çocuk istismarı tanımlar Birinci baskı Seçkin Yayıncılık 2007: 275 290 4 Malatack JJ Consolini D Mann K Raab C Taking on the parent to safe a child: Munchausen syndrome by proxy Contemp Pediatr 2006; 23: 50 63 5 Schreier H Munchausen by proxy Current Probl Pediatr Adolesc Health Care 2004; 34: 126 143 6 Shaw RJ Dayal D Hartman JK DeMaso DR Factitious disorder by proxy: pediatric condition falsification Harv Rev Psychiatry 2008; 16: 215 224 7 McClure RJ Davis PM Meadow SR Sibert JR Epidemiology of Munchausen syndrome by proxy non accidental poisoning and non accidental suffocation Arch Dis Child 1996; 75: 57 61 8 Rosenberg DA Munchausen syndrome by proxy: medical diagnostic criteria Child Abuse Negl 2003; 27: 421 430

Keywords

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Burun kanaması ile başvuran “Munchausen by proxy” sendromu olgusu

Öz

“Munchausen by proxy” sendromu (MSBP); Meadow tarafından İngiltere’de 1977 yılında aileler veya çocuğa bakmakla yükümlü olan kişilerin yaptığı bir istismar şekli olarak tanımlanmıştır (1,2). Çocukta tekrarlayan gereksiz tıbbi incelemeler ve tedaviler yapılması nedeniyle fiziksel ve duygusal hasara yol açar (3). İstismarı uygulayan kişi genellikle kadınlar olup en çok anne ve bakıcılardır (4-6). Uygulayıcı, çocuğun sağlığı ile ilgili sistematik bilgiler uydurmakta ve ona bir hastalık yakıştırmakta, tıbbi tanı ve tedavi almasından mutluluk duymaktadır. Ayrıca çocuğun hasta olduğu ve onu doktora götürürse hasta olmayacağı gibi hayali bir düşünce taşımaktadır (3).

Anahtar Kelimeler

• Munchausen
• proxy
• sendromu olgusu