A-13-Year-Old Bangladeshi Girl Presented with Haematochezia: A Case of Munchausen Syndrome Volume 51- Issue 3

Md Moulud Hussen¹, Rajib Kanti Dey², Md Benzamin³*, Tuhin Barua Tamal³, Kanchan Kumer Deb⁴ and SM Sajjadul Haq⁵

• ¹Medical officer, Mount Adora Hospital, Bangladesh
• ²Medical officer, Sheba Poly Clinic, Bangladesh
• ³Department of paediatrics, Sylhet M A G Osmani Medical College, Bangladesh
• ⁴Department of paediatric Surgery, Sylhet M A G Osmani Medical College, Bangladesh
• ⁵Dakshin Surma upazilla health complex, Bangladesh

Received: July 02, 2023;   Published: July 13, 2023

*Corresponding author: Md Benzamin, Department of paediatrics, Sylhet M A G Osmani Medical College, Sylhet, Bangladesh

DOI: 10.26717/BJSTR.2023.51.008115

Abstract PDF

Munchausen syndrome is a mental condition in which the patient intentionally causes harm to themselves or others to play the sick character. Self-inflicted bleeding is just one of the many complaints and clinical indicators that these people may exhibit. This case study presents a Munchausen syndrome patient who presented with fresh per-rectal hemorrhage. The unrelated symptoms triggered a comprehensive workup that was unhelpful and forced a rethinking of the patient’s care strategy.

Keywords: Mental Condition; Self-Inflicted Bleeding; Haematochezia; Munchausen Syndrome; Bangladeshi

Munchausen syndrome is a mental disorder in which the patient intentionally produces or simulates disease symptoms and receives needless therapy to attract the attention of healthcare personnel [1]. Dr. Richard Asher initially reported it in 1951, relating the deception to Hieronymus Karl Friedrich von Munchausen’s deception [2]. Modern medicine is attempting to do away with eponyms; MS is now referred to as a factitious condition inflicted on oneself. MS is classified as a “factitious disorder” in the Tenth Revision of the International Classification of Diseases and the Fifth Revision of the Diagnostic and Statistical Manual of Mental Disorders under the heading “Somatic Symptom and Related Disorders” [3,4]. This disorder is also known as hospital addiction, poly-surgical syndrome, and professional patient syndrome [5]. According to a recent review, factitious illnesses were assessed to be prevalent in general medical and psychiatric settings at 0.6% to 3%, and in other specialty clinics at 0.02% to 0.9% [6]. It is unknown how common this condition is in Bangladesh [5]. A 13-yearold Sylhet girl who frequently complained of rectal bleeding and stomach pain in consultations and who was a diagnostic challenge for some time before being identified as having Munchausen syndrome is one of the interesting cases we have chronicled.

A 13-year-old female presented to a gastroenterology consultation with a one-year history of recurrent rectal bleeding. The bleeding was fresh and painless, and it happened at the end of defecation with regular stool consistency. She had no history of prolonged bleeding because of an injury or tooth extraction. She had menarche at the age of eleven, had regular menstruation, and reported using 1-2 pads per day for 5-6 days each month. She has no family members with a bleeding condition. She had no drug history, no contact with patient of tuberculosis, and no other chronic condition. Her father died two years ago, and she had three brothers. The rest of the family is in good health. She saw multiple doctors for this illness, and she additionally evaluated herself into two hospitals. But her issue is still unresolved. At the time, she had been taken to Dr. Benzamin’s pediatric liver research center and nutrition clinic at Mount Adora Hospital in Sylhet. We undergo a complete physical examination after admission, including peri-anal and digital rectal examinations. She has no pallor, but has normal vitals, and a healthy anthropometric profile. The right hand’s fingertips had a few minors, healed scars. No organomegaly was present. After summarizing the earlier investigations, we scheduled a colonoscopy. Complete blood count, bleeding, and clotting time, SGPT, CRP, PT with INR, APTT, vWF, s. creatinine, abdominal ultrasound, and chest x-ray were normal. Additionally, the colonoscopy was normal. We released her because there was no rectal bleeding while she was in the hospital, and we were clueless. We advised her mother to keep a careful eye on her and capture a picture in case there was any further bleeding. She came back to see us after 7 days and displayed an image of her soiled stool. We carefully examined the image and discovered that there was fresh blood spread drop by drop over the typical stool and bloody painting around the stool (Figure 1). We then grow suspicious and perform a complete physical examination once more. Now, we discovered many puncture marks on the tips of her right hand’s fingers (Figure 2). When we asked the girl what caused her finger lesions, she was unable to provide a convincing response. The condition is subsequently identified as Munchausen syndrome, and a psychiatrist is consulted.

Figure 1

Figure 2

The factitious condition known as Munchausen syndrome primarily manifests as physical signs and symptoms that should prompt hospitalization or doctor visits. Bleeding is a common complaint among Munchausen syndrome patients, and because it is a concerning sign, it frequently necessitates thorough testing and hospitalization [7,8]. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) gives the following criteria for diagnosing a case of factitious disorder:

a) Making up physical or mental signs or symptoms or causing an injury or illness on purpose to trick someone,
b) Pretending to be sick, hurt, or have trouble functioning,
c) Keeping up the lie even though there is no obvious benefit or reward,
d) The behavior can’t be explained by another mental disorder, like a delusional disorder or another psychotic disorder [9].

There were a few case reports in which patients presented with a variety of gastrointestinal symptoms, including anorexia, abdominal pain, hematemesis, and haematochezia [10,11]. Our patient has had haematochezia for the past year. A case report from Bangladesh describes a girl who presented with multiple sites of hemorrhage, including gastrointestinal bleeding. A brief review of the literature revealed that there are several risk factors for this disease, including severe childhood illness, loss of a loved one, personality disorder, and employment in the health care sector [12]. The majority of cases present with a typical manifestation of a disease or pathology, and physicians are intensely focused on this. Thus, these patients have delayed diagnosis [7]. Our case has a typical presentation for lower gastrointestinal pathology, and a straightforward clue from a photograph of the patient’s stool and a puncture mark on the patient’s fingers provides insight into the diagnosis. The repeated hospitalizations and invasive medical and surgical procedures that MS patients undergo frequently result in iatrogenic effects [10,11]. We diagnosed our case prior to any significant complications and provided counseling to the mother and patient.

Factitious causes should always be considered when the source of hemorrhage is unclear, especially when the patient presents with a dramatic but inconsistent medical history and an out-of-the-ordinary behavior. We became suspicious as, patient was symptom free during hospital admission period, pattern of blood stain in stool was unrelated to any condition and multiple puncture mark over the tip of fingers, which leads to diagnosis.

a) Human subjects: Consent was obtained or waived by all participants in this study.
b) Conflicts of Interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
c) Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
d) Other Relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

All the doctors and staffs of Dr. Benzamin’s Pediatric Liver Research Center and Nutrition Clinic.

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