English

Abstract

This report presents the case history of a six year old child who was portrayed as having recurrent haemetemesis since two years by her mother. A detailed evaluation showed that the patient's history was inconsistent with the clinical findings and investigations, leading to a diagnosis of Factitious Disorder by Proxy (FDbp). The report highlights the rationale for under-diagnosis of FDbp in India and challenges the conventional approach ( Parentectomy ) for treating FDbp. CASE REPORT: A six year old girl born out of consanguineous marriage was admitted to the paediatric ward by her mother with the complaints of recurrent haemetemesis, associated with pain abdomen and headache since two years. There was no history of drug ingestion, food allergy, pica, foreign body ingestion contact with tuberculosis or blood transfusion. There was also no history suggestive of delayed milestones, subnormal intelligence, temper tantrums, depressive illness or any other behavioral problems. The child was an inpatient to four other hospitals in the city over the last two years and not been attending the school since then. She was thoroughly evaluated for the same problem in all the four hospitals, with no significant positive report. A detailed examination of the child was done in our hospital on admission which appeared normal. Physical examination revealed a conscious, well- oriented, non-co-operative child with an unusually loving, caring, possessive and overprotective mother always by her side. All baseline investigations - Complete blood picture, hepatic and renal functions, coagulation profile, mantoux test, chest X ray, stool for microscopy and occult blood were normal. Upper gastrointestinal endoscopy was done at another hospital, but it did not reveal any pathology. On the fourth day of the admission, the mother seemed anxious, possessive and told us that the vomiting persisted and there was no improvement in spite of the treatment. When the mother was asked to preserve the sample of vomitus, she expressed her inability to collect the sample as the child had been vomiting in the toilet. This raised the suspicion as to how a six year old child could hold back the vomiting each time until she reached the toilet. The suspicion was heightened when she said that the vomiting stopped abruptly the next day. Neither the nursing staff nor the resident doctors had witnessed the child vomiting ever since she was admitted to the ward. During the period of hospitalization, none of the other family members have visited the child. Finally when the clinical findings and investigations were found to be inconsistent with the history and after excluding all the organic causes of recurrent haemetemesis, the mother was taken into confidence, by carefully probing into the family and social issues. She revealed about her marital disharmony, that her husband was a chronic alcoholic, who physically abused the family members and did not lend any financial support. After initial hesitation, the mother