Alimemazine poisoning as evidence of Munchausen syndrome by proxy: A pediatric case report

Hair analysis in postmortem investigations: Case of a skeletonized body

Analysis of hair collected from putrefied or skeletal bodies is always complex and must take into account several pitfalls, such as external contamination and contamination by biological fluids. This work presents a case of particular complexity. A skeletonized body was discovered on a country road. A tuft of brown hair, detached from the scalp, irregular in length, non-oriented, in contact with soil and vegetation, was removed. An anthropological examination was carried out and genetic samples were taken from the right femoral shaft. After about 10 washes with warm water and dichloromethane, the tuft of hair was analyzed without segmentation. General unknown screening was performed by liquid chromatography system coupled to a high-resolution mass spectrometry (LC-HRMS) after incubation in pH 9.5 borate buffer and liquid-liquid extraction. Specific Multiple Reaction Monitoring (MRM) methods for date rape drugs were carried out by liquid chromatography system coupled to a tandem mass spectrometry (LC-MS/MS). The anthropological examination allowed to determine that the victim was a female individual, over 60 years old, the death dating from 3 months to 1 year. Comparison of the DNA results with the Missing Persons Index led to the identification, a 60-year-old woman who disappeared 5 months earlier. Hair analysis showed the presence of oxazepam (361 pg/mg), nordiazepam (54 pg/mg), and alimemazine (5 pg/mg). The interpretation of these concentrations is extremely difficult due to the risk of degradation of the hair cuticle during prolonged stay in the soil, as well as of contamination by putrefactive fluids. The authors discuss the value of using multiple biological and non-biological matrices in this context to improve the interpretation of the results.

Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA)

Munchausen syndrome by proxy (MSBP) is well-known to clinicians, but its usage is discouraged now in favor of other terms placing emphasis on the victim. This study aims to determine the most common characteristics of perpetrators but only in case reports labeled as MSBP, published in PubMed literature in the past 15 years. MSBP has been described as a rare form of abuse due to illness falsification, where the perpetrator usually receives the diagnosis of factitious disorder imposed on another (FDIA). We extracted data from 108 articles, including 81 case reports. Almost all perpetrators were female (91% female, 1% female and male, 7% unreported). Twenty-three cases (28%) had a perpetrator with psychiatric diagnosis: factitious disorder imposed on self (10%), depression (9%), and personality disorders (7%). In more than one-third (36%) there was familial conflict or abuse. Fourteen cases (17%) had perpetrators working in healthcare. The most common type of falsification was induction (74%); however, 15% of cases had more than one type of falsification. The most common outcomes were: separation (37%); no follow-up (22%); imprisonment (14%); death of victim (12%); treatment of the perpetrator (10%); continued living together (4%); and suicide of perpetrator (1%). Recurrence was present in more than three quarters of cases. Our results reiterate that awareness of the most common findings in MSBP allows physicians to identify them in a clinical context.

[The development of the methods for the extraction, identification, and quantitative determination of alimemazine in the biological fluids from the laboratory animals under the acute poisoning conditions]

There is the present-day tendency toward prescribing atypical neuroleptics for the management of neurologic and psychic disorders. Alimemazine appears to be very frequently used for this purpose due to the broad spectrum of its actions. At the same time, cases of alimemazine poisoning with the fatal outcome have been described. The objective of the present study was determine alimemazine in the biological fluids from the laboratory animals under the acute poisoning conditions. The experiments were carried with the use of the Wistar rats having 200 g body weight. Alimemazine was isolated from their biological fluids (blood plasma and urine) using the liquid-liquid extraction techniques developed specially for the purpose of this study. Alimemazine was extracted and quantitatively determined by HPLC and HPLC/MS. The method for the isolation of alimemazine from the urine and blood plasma is described. The results of the study give evidence that the maximum amount of the substance of interest can be extracted from the blood plasma within 1 hour after the administration of the toxic dose of alimemazine and within 2 hours after the administration of its therapeutic dose. The maximum amount of alimemazine in the urine is found within 3 hours after the administration of its therapeutic dose to the laboratory animals. It is concluded that the proposed methods for the extraction of alimemazine from the biological fluids can be included in the scheme of the chemical toxicological analysis of this substance.

The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases

INTRODUCTION

Little is known about the perpetrators of medical child abuse (MCA) which is often described as "Munchausen's syndrome by proxy" or "factitious disorder imposed on another". The demographic and clinical characteristics of these abusers have yet to be described in a sufficiently large sample. We aimed to address this issue through a systematic review of case reports and series in the professional literature.

METHOD

A systematic search for case reports and series published since 1965 was undertaken using MEDLINE, Web of Science and EMBASE. 4100 database records were screened. A supplementary search was then conducted using GoogleScholar and reference lists of eligible studies. Our search yielded a total sample of 796 perpetrators: 309 from case reports and 487 from case series. Information extracted included demographic and clinical characteristics, in addition to methods of abuse and case outcomes.

RESULTS

Nearly all abusers were female (97.6%) and the victim's mother (95.6%). Most were married (75.8%). Mean caretaker age at the child's presentation was 27.6 years. Perpetrators were frequently reported to be in healthcare-related professions (45.6%), to have had obstetric complications (23.5%), or to have histories of childhood maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%).

CONCLUSIONS

From the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. Longitudinal studies are required to establish the true prognostic value of these factors as our method may have been vulnerable to publication bias.

Munchausen by proxy syndrome mimicking systemic autoinflammatory disease: case report and review of the literature

BACKGROUND

Systemic autoinflammatory diseases (SAIDs) represent a growing number of monogenic, polygenic or multifactorial disorders that are often difficult to diagnose.

CASE PRESENTATION

Here we report a patient who was initially erroneously diagnosed and treated for SAID. Symptoms consisted of recurrent fever, erythematous and/or blistering skin lesions, angioedema, susceptibility to bleeding, external ear infections and reversible anisocoria in the absence of laboratory evidence of systemic inflammation. After two and a half years of extensive diagnostic work-up and multiple empirical therapies, a final diagnosis of Munchausen by proxy syndrome (MBPS) was established.

CONCLUSIONS

The diagnosis of SAID needs to be carefully reassessed if measurable systemic inflammation is missing, and MBPS should be included in the differential diagnosis.