Munchausen syndrome and Munchausen syndrome by proxy in dermatology

Dermatitis Artefacta: A Retrospective Descriptive Study on 46 Patients

INTRODUCTION

Self-induced dermatoses are self-inflicted skin lesions, whose occurrence patient denies responsibility for.

OBJECTIVES

The aim of this study was to retrospectively investigate all the clinical records of dermatitis artefacta (DA) in order to put special focus on: a) epidemiological aspects; b) location, shape and additional features of the lesions; c) availability of psychiatric details in the records.

METHODS

A retrospective observational descriptive study on 46 patients affected by dermatitis artefacta was conducted from January 2015 to March 2021. The only inclusion criterion was clinical or histological diagnosis of DA in patients for which we had clinical images.

RESULTS

The most frequent type of lesions were erosions/excoriations and ulcers (14/46, 30.4% and 13/46, 28.3% respectively) followed by ecchymoses (9/46, 19.5%), vasculitis-like lesions (5/46, 10.9%), crusted plaques (3/46, 6.5%), scales (1/46, 2.2%) and erythema (1/46, 2.2%). Thirty-three percent of the medical records generically referred to the presence of psychiatric disorder, but none of them included a specific psychiatric diagnosis.

CONCLUSIONS

In our study the main dermatologic lesions observed in DA were represented by excoriations and ulcers and that the shape and location of the lesions are essential for a correct diagnosis.

Factitious dermatitis in children and adolescents is highly comorbid with psychiatric disorders

OBJECTIVE

Factitious dermatitis (FD) is a psychocutaneous disorder characterized by self-induced skin lesions. FD is related to mental illness, but the correlation is poorly defined in the pediatric population. Our study aims to investigate the risk of psychiatric disorders diagnosed after the FD diagnosis in children and adolescents.

METHODS

We conducted a retrospective cohort study over a seven-year period (2016-2022) to measure the incidence and risk ratio of psychiatric disorders in patients under age 19 years. The FD cohort was defined as patients with FD (International Classification of Diseases, ICD-10-CM: L98.1); the control cohort was defined as patients who attended a regular dermatology visit by applying a diagnostic code of disease of the skin and subcutaneous tissue (ICD-10-CM: L00-99).

RESULTS

A total of 453 patients were identified for analysis. We found that FD patients were more likely to be diagnosed with anxiety disorder (Relative risk [RR] 7.63; P < 0.001), obsessive-compulsive disorder (RR 6.20; P < 0.001), attention-deficit hyperactivity disorder (RR 4.90, P < 0.001), depression (RR 2.27; p = 0.02), sleep disorder (RR 2.23; P = 0.01), impulse disorder (RR 2.20; P = 0.04), and conduct disorder (RR 2.14; P = 0.04) within 1 year following the diagnosis of FD.

CONCLUSION

FD is highly comorbid with psychiatric disorders. Though some practitioners believe FD could result from experimental or recreational behavior in children and adolescents, possible underlying psychiatric disorders should never be overlooked.

Update on Diagnosis and Management of Onychophagia and Onychotillomania

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

Panniculitis in Children

Panniculitides form a heterogenous group of inflammatory diseases that involve the subcutaneous adipose tissue. These disorders are rare in children and have many aetiologies. As in adults, the panniculitis can be the primary process in a systemic disorder or a secondary process that results from infection, trauma or exposure to medication. Some types of panniculitis are seen more commonly or exclusively in children, and several new entities have been described in recent years. Most types of panniculitis have the same clinical presentation (regardless of the aetiology), with tender, erythematous subcutaneous nodules. Although the patient's age and the lesion site provide information, a histopathological assessment is sometimes required for a definitive diagnosis and classification of the disorder. In children, most panniculitides are lobular. At present, autoimmune inflammatory diseases and primary immunodeficiencies have been better characterised; panniculitis can be the presenting symptom in some of these settings. Unexplained panniculitis in a young child should prompt a detailed screen for monogenic immune disorders because the latter usually manifest themselves early in life. Here, we review forms of panniculitis that occur primarily in children, with a focus on newly described entities.

A case report and literature review: Factitious disorder imposed on another and malingering by proxy

Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians’ differential. This case of a 2-year-old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient’s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child’s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful caregivers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Munchausen by proxy syndrome mimicking childhood-onset systemic lupus erythematosus

Childhood-onset systemic lupus erythematosus (cSLE) is a chronic inflammatory multisystem autoimmune disease that requires multiple differential diagnoses. Munchausen by proxy syndrome (MBPS) is a form of child abuse, where a caregiver intentionally creates a medical history and induces or fabricates signs or disease in a patient. To our knowledge, there is no case report of MBPS mimicking cSLE diagnosis. We reported herein a 9-year-old male patient, with a history of multiple hospitalizations due to seizures with altered levels of consciousness. The mother reported malar rash, photosensitivity, alopecia, arthralgia, arterial hypertension, macroscopic hematuria, seizure and positive antinuclear antibodies. In the other service, he was treated with intravenous methylprednisolone, prednisone and mycophenolate mofetil. At 8 years and 8 months, he was admitted to our tertiary center with history of fever and macroscopic hematuria. Laboratory examinations were normal, including negative for antinuclear antibodies, anti-double stranded DNA, anticardiolipin, anti-Ro/SSA, anti-La/SSB, anti-RNP and anti-Sm antibodies. Multiple urine cultures revealed the presence of Enterococcus faecium, Acinetobacter sp., Stenotrophomonas maltophilia and Serratia marcescens, without any association with pyuria. At 8 years and 9 months, he was readmitted at emergency room with history of severe fever, headache, vomiting, photophobia, phonophobia and dizziness. The physical examination showed agitation, confusion, ataxic gait, slurred speech, horizontal nystagmus, painful facial expressions, tachycardia and weight loss. Brain magnetic resonance angiography and cerebrospinal fluid analysis were normal. During hospitalization, he had an acute episode of epistaxis and otalgia with excoriation in the auditory canal. At that moment, the suspicion of MBPS mimicking cSLE was raised and phenytoin intoxication was confirmed (peak phenytoin concentration was 45.4 mcg/mL, therapeutic range 10-20 mcg/mL). The mother and the patient were immediately separated, and she was replaced by another legal guardian. One week later, the neurological and other signs and symptoms were completely resolved. The child was placed under paternal custody with a court order and moved to another state. After that, the mother reported phenytoin use for her child and was referred to psychiatric follow-up. In conclusion, the first case of MBPS mimicking cSLE, resulting in multiple unnecessary examinations and treatments with delayed diagnosis was reported.

Factitious disorder: a systematic review of 455 cases in the professional literature

OBJECTIVE

Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature.

METHOD

A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD.

RESULTS

A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD.

CONCLUSIONS

Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

Folie a deux and delusional disorder by proxy: an atypical presentation

Delusion of parasitosis is a rare condition characterised by an individual harbouring the delusion of being infested with insects or parasites. We report a rare and interesting case of delusion of parasitosis presenting as folie a deux, that is, the delusion is shared by both the parents of an 18-month-old child, with proxy projection of parental delusion on the child. The case highlights the rare concomitant occurrence of two psychocutaneous disorders and emphasizes the importance of early recognition and appropriate intervention to safeguard the well-being of the child.

Intractable Postoperative Wounds Caused by Self-Inflicted Trauma in a Patient with Cutaneous Munchausen Syndrome Presenting as a Pyoderma Gangrenosum-Like Lesion

A 50-year-old Japanese woman consulted the emergency department of our hospital for bleeding due to an intractable postoperative wound on the lower abdomen; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis. She presented with a painful ulcer on her right lower abdomen. She also presented with multiple scars, skin grafts on the extremities, and a missing left lower leg, the causes for all of which were unexplained. The results of her blood test were normal, except for the hemoglobin level. Histology of the skin biopsy specimen from the ulcer did not show any specific findings. The previous surgeon who had performed the laparoscopic cholecystectomy revealed that surgical wound dehiscence had occurred during her admission. After a body restraint had been applied, the ulcer improved. Medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer. During that admission, she refused to consult with the department of psychiatry, al-though the staff suspected mental disorders. Therefore, we diagnosed her with cutaneous Munchausen syndrome. After vacuum-assisted closure (VAC) therapy had been performed to prevent her from traumatizing the ulcer again, it rapidly became granulated and reepithelialized. Munchausen syndrome is characterized by feigning physical symptoms to seek attention. Patients self-inflict numerous lesions, keep getting admitted to different hospitals, and feign acute illness, usually spectacular diseases. VAC therapy may be effective for preventing patients with cutaneous Munchausen syndrome from traumatizing their wounds.

[Self injury in adolescence]

Self-injury often occurs for the first time in adolescence. The current classification distinguishes several groups: (1) factitious disorder imposed on self and factitious disorder imposed on another, (2) nonsuicidal self-injury (NSSI) and (3) obsessive-compulsive (OCD) and related disorders. The differential diagnosis includes a wide spectrum of psychiatric diseases, including borderline personality disorder (BPD), inherited disorders like Lesch-Nyhan syndrome (LNS) and also body modifications. In all these cases, self-harm is a subphenomenon. This review focuses on typical dermatological pictures.