Munchausen Syndrome by Proxy in a Saudi Child

Abstract

Case ReportsMunchausen Syndrome by Proxy in a Saudi Child Suliman Al-Jumaah, MD Abdullah Al-Dowaish, MD Haysam Tufenkeji, and MD Husn H. FrayhaMD Suliman Al-Jumaah From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh. Search for more papers by this author , Abdullah Al-Dowaish From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh. Search for more papers by this author , Haysam Tufenkeji From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh. Search for more papers by this author , and Husn H. Frayha Address reprint requests and correspondence to Dr. Frayha: Consultant, Section of Infectious Diseases, Department of Pediatrics, (MBC-58), King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia. From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh. Search for more papers by this author Published Online:1 Sep 1993https://doi.org/10.5144/0256-4947.1993.469SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionMunchausen syndrome by proxy (MSBP) is a rare form of child abuse defined as the fabrication of a child’s medical history and/or medical symptoms by a parent with the intent of securing unnecessary medical evaluations, procedures and hospitalizations [6,14]. It was first reported by Meadows in 1977 [6]. The deception often is repeated on numerous occasions, resulting in many hospitalizations, considerable morbidity and sometimes, death.Prevalence of Munchausen syndrome by proxy has not been examined and seems impossible to assess because of difficulty in documenting the diagnosis. Many pediatric deaths with undetermined cause may very well be due to MSBP [6]. Reports of this phenomenon have varied from cases where parents falsified the history or altered laboratory specimens to cases where parents actively induced symptoms such as cardiorespiratory arrest [12], apnea [3], bleeding [1,17], diarrhea, hypernatremia [5], vomiting [13], and hypoglycemia [9], which mimic known disorders or present diagnostic dilemma. Munchausen syndrome by proxy was reported from many countries. However, in Saudi Arabia only one case of suspected Munchausen syndrome by proxy was reported [2]. This is the first report of a confirmed case of Munchausen syndrome by proxy in Saudi Arabia.CASE REPORTThe patient is a 15-month-old Saudi female who was well until 13 months of age when she developed fever, cough and ulcerative lesions which occurred acutely and involved the mouth and lips. She subsequently developed feeding difficulty and was admitted to a hospital in Riyadh but was discharged after five days with no improvement. She was readmitted to another hospital for approximately two weeks where she was treated with intravenous acyclovir for a suspected herpetic stomatitis and with intravenous antibiotics and oral nystatin. The mouth ulcers progressively got worse and thus, the patient was referred to King Faisal Specialist Hospital and Research Centre (KFSH&RC) for further investigation.Family history revealed that she is a child from a second marriage. She had a sister who had similar presentation and required several admissions to the hospital for treatment of mouth ulcerations, severe respiratory distress necessitating mechanical ventilation and necrotizing tracheobronchitis. Extensive immunologic and microbiologic investigations were normal. She developed necrotizing tracheobronchitis and respiratory failure at the age of three years and expired with undetermined diagnosis. She has a brother three years old who is well. Her father is 50 years old and her mother is 24 years old.On admission, the child was febrile and irritable but active and conscious. Her weight and height were at the 25th and 10th percentile, respectively. There were severe ulcerative lesions involving the buccal mucosa, palate, tongue and the angles of the mouth with overlying whitish plaques. She had inspiratory crepitations on the right side of the chest. The remainder of her physical examination was unremarkable.The patient was initially investigated to rule out immune deficiency in light of the family history of a similar problem. Chest x-rays showed evidence of apical and posterior pneumonia of the right upper lobe. Viral cultures from the mouth lesions were negative. CBC showed high WBC (22,000) and microcytic hypochromic anemia, which was confirmed later to be due to iron deficiency. Immunological workup showed normal immune globulin level (IgG 8.9 g/L, IgM 2 g/L and IgA 0.04 g/L). Nitro blue tetrazolium dye reduction test was normal. Lymphocyte blastogenesis showed depressed response to concavelin A and PHA. The child was started on ceftriaxone and she promptly improved. Fungal cultures from the mouth lesions were negative but because she had been on nystatin treatment at the time the specimen was taken and because of the compatibility of the clinical findings with fungal lesions, she was treated with nystatin topically and later fluconazole orally. The mouth ulcers gradually improved and she was discharged from the hospital on fluconazole. Several hours after discharge, the patient was readmitted because of recurrence of mouth ulcers and respiratory distress which occurred following vomiting. The possibility of gastroesophageal reflux was entertained and the patient was subjected to barium swallow which showed no abnormalities. Endoscopy showed mild inflammation at the lower end of the esophagus. Biopsies from the lower esophagus and gastric mucosa did not show any significant pathology. Biopsy from oral mucosa showed nonspecific chronic inflammatory changes; no fungus was seen or isolated. The mouth ulcers gradually improved on oral nystatin and the patient was prepared for discharge when she suddenly developed acute mouth ulcers following what the mother reported as vomiting.On examination the child was distressed, drooling, and had fresh ulcers involving oral mucosa and the corners of the mouth, extending to the infra-auricular area. These lesions were typical of acute chemical injury and it was clear from their location that they were inflicted. The child was suspected of having Munchausen syndrome by proxy based on the fact that the symptoms were not compatible with any disease process, the mouth lesions appeared only when there was a threat of discharge and the extensive investigations, which did not lead to a definitive diagnosis.After consultation with nursing, social services, psychiatry, and clinical psychology, the mother was confronted with the diagnosis and she admitted to using “Flash” (a type of caustic lye, a detergent), in order to induce the mouth lesions in her child. Subsequently, she repeated the confession in the presence of her husband and other family members. The mother was referred to the psychiatry service for evaluation and support and the child was kept under strict observation. Subsequently the child’s mouth lesions improved without specific therapy, supporting the diagnosis of MSBP. On discharge, the child was doing well except for the residual fibrosis that developed at both mouth corners. Risk of recurrence was explained to the father prior to discharge.DISCUSSIONMunchausen syndrome by proxy has been reported in Saudi Arabia but to our knowledge, this is the first proven case. The diagnosis in this case was suspected based on the following: 1) Clinical picture which was incompatible with any known disease process and the negative diagnostic workup. 2) The occurrence of mouth lesions whenever there was a threat of discharge from the hospital. The diagnosis was confirmed when the mother admitted to using a corrosive to inflict the mouth lesions in her child in order to prolong hospitalization and stay away from home. As happened in this case, it is not unusual for children who are ultimately diagnosed as MSBP to be subjected to a variety of investigations to exclude medical illnesses before the diagnosis of MSBP is suspected.Although nonaccidental poisoning, as a form of child abuse, has been reported before [11], the presentation in this patient with alkali ingestion was unusual when compared with the simulated illnesses commonly reported in the literature. (Fever of unknown origin [7], failure to thrive, chronic diarrhea [4], cardiorespiratory arrest [12], apnea [3], rashes, cystic fibrosis [10], and convulsions [12]). However, this picture should heighten the awareness of the expanding variety of presentation of this syndrome. Despite the mother’s denial, there is a good possibility that the patient’s sister may also have been a victim of the same condition. This would be in agreement with the reported 25% to 30% rate of multiple Munchausen syndrome by proxy [1].Mothers of children with Munchausen syndrome by proxy were described to be caring and loving and to have good relationships with medical and nursing staff in pediatric wards [6]. Most of them had some medical and nursing knowledge [6] which allowed them to plan and exaggerate the details of their children’s illness in order to ensure more prompt medical care. The mother’s personality in this case was different in that she was not caring well for her child, she was frequently depressed and she slept most of the time. Her relationship with the nurses and physicians was poor. From the reported literature [1], mothers with multiple Munchausen syndrome by proxy were more likely to be behaviorally or psychologically abnormal than those who have committed MSBP to one child. Most of these mothers had a history of marital problems, psychiatric disturbance, and suicide attempt [1,8,9]. Mothers of children affected by MSBP may be diagnosed as having Munchausen syndrome in up to 20% of cases and those are less likely to respond to aggressive psychotherapy [6,9].In managing children with MSBP, if fabrication is suspected, the child must be separated from the mother in order to find out if symptoms and signs occur in her absence. Social work and psychiatric involvement should always be an integral part of the management. In our case, the family provided good support for the mother and the child.Once suspicion is confirmed, the plan of action is similar to that of a child with nonaccidental injury in that the child should be kept under close supervision [8]. Separation from the parents may be necessary if close supervision cannot be ensured.Prognosis for children with Munchausen syndrome by proxy is bleak. Follow-up of children with Munchausen syndrome by proxy indicated the mortality rate to be as high as 22% [6]. Children with MSBP may suffer Munchausen disease as adults [5,8]. Moreover, detection and reporting may be low, which prompted some authors to speculate that many pediatric deaths may have been due to MSBP. It is hoped that increased awareness of this condition will help in its early detection so that morbidity and mortality can be prevented.ARTICLE REFERENCES:1. Alexander R, Smith W, Stevenson R. "Serial Munchausen syndrome by proxy." Pediatr. 1990; 86(4):581-5. Google Scholar2. Al-Mugeiren M, Ganelin R. "A suspected case of Munchausen syndrome by proxy in a Saudi child." Ann Saudi Med. 1990; 10(6):662-5. Google Scholar3. Berger D. "Child abuse simulating “near miss” sudden infant death syndrome." J Pediatr. 1979; 95(4):554-6. Google Scholar4. Fenton AC, Wailoo MP, Tanner MS. "Severe failure to thrive and diarrhea caused by laxative abuse." Arch Dis Child. 1988; 63(8):978-9. Google Scholar5. Mcguire TL, Feldman KW. 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Volume 13, Issue 5September 1993 Metrics History Accepted23 December 1992Published online1 September 1993 InformationCopyright © 1993, Annals of Saudi MedicinePDF download