Childhood Factitious Disorders—A “Hot” Case of Menstruation

Abstract

Background: Factitious disorders are rarely reported in the pediatric gynecologic literature. We present a case of factitious menstruation in a ten year old prepubertal child. Case: A ten year old girl presented to her pediatrician’s office with an episode of vaginal bleeding. She reports bright red vaginal bleeding that over 4 days changed to an orange colored odorous discharge. The bleeding occured at regular intervals throughout the day. In the pediatrician’s office she was found to have a normal exam. A White Blood Cell count was 5.9 K/uL, Hemoglobin 13.3mg/dl, Hematocrit 38.8%, and the platelet count 276k. Sedimentation rate was 6 mm/hr, Thyroid Stimulating Hormone was 0.777 uIU/ml, Lutenizing Hormone 0.3 mIU/ml, Follicle Stimulating Hormone 9 mIU/ ml, Estradiol 7 pg/ml, and Free Thyroxine 1.15 ng/d. A computerized tomography (CT) scan of the abdomen and pelvis with nonionic contrast was within normal limits. There was no comment on the uterus, ovaries, or vagina. A non-contrast CT scan of the head is normal but with limited evaluation of pituitary gland. The patient was referred to an adolescent medicine specialist for further evaluation. Physical exam revealed a thin, pale prepubescent child. Breasts are prepubescent, SMR 1. Her abdomen was soft but tender to palpation in the left lower quadrant. Pubic Hair was SMR 1. Her external genitalia were normal. The hymen was annular and no discharge or erythema was present. The rectal exam was normal. A pelvic ultrasound demonstrated a prepubescent, anteverted uterus with an endometrial stripe 0.1 cm. There was no evidence of echogenic foreign body. The ovaries are normal. Gonorrhea/Chlamydia Nucleic Acid Amplification testing was negative. A genital culture grows 3+ normal flora. The patient was seen again in conjunction with a pediatric gynecologist. The vagina is irrigated with 20cc of saline. The effluent was clear. Heme testing from pad was negative. A few days later the mother found a vial of hot sauce in the child’s book bag. When confronted, the child confesses to placing the foreign liquid on the pad. A planned exam under anesthesia is thus avoided. Comments: A high index of suspicion is required in diagnosing factitious disorders. Psychosomatic illnesses have a wide spectrum of presentation and are likely more common than realized. There are three distinct mental health disorders in which a patient intentionally produces physical symptoms or illness: Malingering, Factitious Disorder, and Factitious Disorder by proxy. In Factitious Disorder the patient produces symptoms or signs to assume the sick role. Examples include induced infections and factitious fever. Malingering differs from Factitious Disorder in that in Malingering, the individual is consciously motivated by an external incentive, such as missing school or work. In Factitious Disorder the individual is usually not aware of the motivation behind the factitious behavior and external incentives are absent. Recognizing the possibility of factitious illness in patients who present with atypical clinical manifestations is imperative to reduce unnecessary risk to the patient through continued medical evaluations and to avoid long term psychopathology.