Name: Cherry Joy N. Sara Date Submitted: September 16, 2013

CLINICO PATHOLOGICAL CONFERENCE

MUNCHAUSEN SYNDROME

In our patient, it has been apparent that he suffered repeated cutaneous infections from several

trauma for 17 years i.e. gunshot wound, repeated incision and drainage, skin grafts and other

reconstructive procedures, and gas gangrene secondary to blunt trauma. It is also suspicious that these

trauma are sustained in his left arm when our patient is right-handed, thus, self-inflicted trauma can’t be

ruled out. He works on a shrimp boat which is correlated with the fact that most of the patients with

Munchausen syndrome are seafarers to evoke care and sympathy or to avoid duties (Steel 2009). Our

patient had been transferred to several facilities. This may due to complexities of the signs and

symptoms present, without correlation in his laboratory results (Zylstra et al, 2000), thus, diagnosis is

late (Steel, 2009). In some cases, patients with Munchausen syndrome presents repeatedly to different

hospitals seeking investigation and treatment for signs and symptoms that they have consciously

fabricated (Steel, 2009). Patient is also continuously self-medicating with cephalexin and cephalothin,

with clonazepam used to induce sleep. Patients suspected with psychologic illness overdose themselves

or treat with multiple medications for their feigned illnesses (Howe et al, 1983).

Four clinical clusters were identified for Munchausen syndrome: (1) self-induced infections, (2)

simulated specific illnesses with no actual disorder, (3) chronic wounds and (4) self-medication (Steel,

2009). These are already apparent in our patient.

Typical warning signs of Munchausen syndrome by proxy include (1) Persistent or recurrent

illness that cannot be explained, (2) Discrepancies between clinical findings and history, (3) Symptoms or

treatment course that is not clinically consistent, (4) a working diagnosis that is less plausible than

Munchausen syndrome by proxy (Zylstra et al, 2000).

There are several varieties of Munchausen syndrome. These include the Acute abdominal type

(laparotomaphilia migrans), Neurological type (neurologica diabolica), Hemorrhagic type (hemorrhagica

histrionica), Cutaneous type (dermatitis autogenetica), and Cardiac type. Our patient presents with the

cutaneous type which is characterized by self-inflicted skin lesions or rashes (Howe et al, 1983).

I considered Necrotizing fasciitis as my differential diagnosis as presented by the skin lesions of

the patient. Skin anesthesia was present because of the destruction of cutaneous nerves. There was also

subcutaneous emphysema or crepitation palpated indicating presence of gas-forming bacteria (Wolters

Kluwer Health, 2013). The hallmark symptom of necrotizing fasciitis is intense pain and tenderness over

the involved skin and underlying muscle. This severe pain is frequently present before the patient

develops fever, malaise, and myalgias (Edlich and Bronze, 2013). However, I ruled out Necrotizing

fasciitis since our patient presented with an underlying psychologic illness more than just the physical

findings.

References:

Richard F Edlich and Michael Stuart Bronze. 2013. Necrotizing Fasciitis Clinical Presentation

Steel, R. 2009. Factitious Disorder (Munchausen’s Syndrome). J R Call Physicians Edinb 2009; 39:343-7.

Wolters Kluwer Health. 2013. Date Seen: August 30, 2013<http://www.nursingcenter.com/lnc/journalarticle?Article_ID=482116>

Zylstra, R., Miller, K. And W. Stephens. 2000. Munchausen Syndrome by Proxy: A clinical Vignette. Primary Care Companion J Clin Psychiatry 2:2.