Blood--but not bleeding--at a tracheotomy site: a case of Munchausen's syndrome.
Munchausen's syndrome is a factitious illness in which patients fabricate medical problems in order to receive medical attention. Their "symptoms" are typical of actual medical conditions and their history is dramatic yet plausible, but no pathology can be found on imaging and other investigations. We report the case of a young woman whose Munchausen's syndrome manifested as purported bleeding from a tracheotomy site. In actuality, she had drawn the blood from an arm vein and spattered it on her neck.
A factitious illness is one in which a patient consciously and deliberately presents with a self-induced injury or a false history in order to mislead a physician into making an erroneous diagnosis and administering some type of treatment. An underlying psychological disorder and a desire for secondary gain drive this deception. (1) Factitious illness is rare in otolaryngology, and it is different from malingering, which is not uncommon in otolaryngologic practice. Malingerers mislead doctors in order to acquire tangible gains, such as money and narcotics. Factitious illness is also different from a somatoform disorder, in which symptoms are involuntary. (2)
One of the more well-known factitious illnesses is Munchausen's syndrome, in which affected patients repeatedly seek treatment for nonexistent acute illnesses while reporting a dramatic yet plausible history. This condition was first described by Asher in 1951. (3) Asher named the condition after Karl Friedrich Hieronymous von Munchhausen (the anglicized spelling of the name is different from the German version), an 18th century (1720-1797) German baron and one-time mercenary officer in the Russian cavalry who was purported to be a teller of wildly exaggerated tales--a claim that itself may have been exaggerated. (For a refutation of von Munchhausen's possibly undeserved reputation, see Patterson's historical review entitled, "The Munchausen syndrome: Baron yon Munchhausen has taken a bum rap." (4))
Bleeding from a tracheotomy site has many possible causes. The most serious is an innominate artery fistula, which is associated with an 80 to 90% mortality rate. (5) In this article, we describe the case of a woman who claimed to have been bleeding from a tracheotomy site. It was later discovered that she had fabricated her history and symptoms, and she was ultimately diagnosed with Munchausen's syndrome. Although pulmonary manifestations of Munchausen's syndrome have been reported, (6) this appears to be the first documented case of tracheotomy bleeding associated with the disorder.
The patient was a young woman with a long and complicated medical history (therefore, only the history pertinent to this case will be described.) In March 2001, she had been admitted to an internal medicine intensive care unit for management of severe respiratory distress. She was 27 years old at the time. She was diagnosed with severe bronchial asthma and prescribed both systemic and inhaled steroids. She was also diagnosed with paradoxical vocal cord motion (PVCM) by an otolaryngologist. The PVCM was believed to be psychogenic and strongly associated with anxiety. She was started on an anxiolytic medication, and she underwent counseling for panic disorder at the recommendation of the psychiatry service. These measures appeared to alleviate her symptoms.
In April 2001, our service was consulted and asked to evaluate the patient to determine if the PVCM was contributing to her dyspnea. Our examination at that time revealed that her vocal fold motion was completely normal.
Later that month, the patient underwent a tracheotomy in another community. The procedure had been performed in response to her complaint of severe bronchial asthma attacks and to treat an apparent relapse of PVCM. During that hospital stay, the patient had capped the tracheotomy tube during the day, but she required mechanical ventilation at night because of the severe asthma.
In May 2002, the patient was diagnosed with bilateral avascular hip necrosis, which had developed as a complication of the chronic steroid use for asthma management. In October 2002, she underwent hip replacement surgery. Her hospital course was complicated by pneumonia and a hip wound infection with methicillin-resistant Staphylococcus aureus (MRSA). Both conditions were treated with long-term antibiotics. She was discharged home 5 days postoperatively on intravenous vancomycin.
Two days after discharge, the patient was readmitted for treatment of what she claimed was an exacerbation of her bronchial asthma. However, the admitting team's extensive evaluation, which included computed tomography of the chest and a ventilation-perfusion scan, detected no underlying pathology that could explain the exacerbation. The patient again required mechanical ventilation at night. By hospital day 18, the results of multiple tests and procedures remained essentially negative, and the medical service had decided to discharge her. However, as the discharge process was under way, the patient reported that she had been bleeding from her tracheotomy site, and the front of her gown was soaked in blood. The bleeding episode had not been witnessed by anyone on staff. The otolaryngology service was consulted again.
The patient, now 28 years old, was cooperative as we attempted to obtain a detailed history. She said she had worked as a physical education teacher and had played competitive sports. She also claimed to have worked in the nursing field in the past and that her mother had experience in the nursing field, but those details were unclear.
On physical examination, the patient was thin and appeared to be healthy. The tracheotomy tube was in a satisfactory position, and her airflow was unimpeded. The tracheotomy tract, which had been placed 15 months earlier, was well established, and granulation tissue was minimal. Findings on a flexible endoscopic examination of the nasopharynx were normal, as were the results of a flexible endoscopic tracheobronchial examination through her tube. When we attempted to reassure her that the results of our examinations were normal, she became visibly upset and wanted to continue discussing the episode of tracheotomy bleeding. We recommended routine tracheotomy care and a reassessment if the bleeding recurred. Discharge was postponed.
Three days later, our service was contacted again. The patient claimed to have just experienced an even more severe episode of tracheal bleeding. In fact, she said that the force of the hemorrhage had been sufficient to propel blood all the way to the ceiling. Indeed, blood was visible on the ceiling over her bed. The flexible endoscopic examinations were repeated, but the results remained negative. When we informed the patient of these findings, she became hostile and began to wave several blood-stained gauze sponges at us.
The patient was moved to a hospital room that was in the line of sight of the nurses' station so that she could be watched more closely. Late one night soon thereafter, a nurse witnessed the patient draw blood from a vein in her arm and then squirt it around her neck and on the ceiling. When confronted, the patient denied her actions.
The patient was reevaluated by the psychiatry service, and she continues to undergo outpatient management of her psychiatric condition.
Patients with Munchausen's syndrome fabricate problems whose "symptoms" are typical of actual medical problems. These patients are usually intelligent, and their deception is sophisticated. They frequently claim that they or a close relative have had medical training. (7) Most of these patients are between the age of 20 and 30 years at presentation. Many have serious personality disorders with borderline or sociopathic features. (1)
The true incidence of Munchausen's syndrome is unknown. Some authors believe that the incidence is over-reported because a single patient is often diagnosed by several different physicians. (2) Others believe that it is under-reported because so much deception is involved. (7)
Munchausen's syndrome carries significant morbidity and mortality. As our case demonstrates, feigned illnesses can have real complications. In retrospect, it is unlikely that our patient had asthma, but the severity of her purported symptoms demanded that she be treated. The asthma treatment led to hip necrosis with a subsequent MRSA infection that spread to the lungs.
The PVCM was an important aspect of this particular case because the differential diagnosis of this condition includes factitious disease. (8) Such a diagnostic clue should not be overlooked, especially when an otolaryngologist is presented with claims of physical problems that are not supported by findings on the workup.
The treatment of Munchausen's syndrome is difficult, and it requires the help of a psychiatrist. Treatment usually requires that a single primary care physician serve as the gatekeeper and approve all tests and procedures recommended by specialists. The psychiatry literature recommends that patients not be directly confronted with proof of their deception because this approach usually provokes patients into engaging in even more theatrics that sometimes culminate in self-harm. Psychiatrists recommend that clinicians attempt to phrase their discussion in a way that provides the patient with a way to concoct a face-saving explanation. Doing so may encourage the patient to cease with the factitious complaints and begin productive psychiatric treatment. Our patient was mismanaged in this regard.
Munchausen's syndrome is rare, and it is important that we recognize it to avoid becoming the instruments of pathology.
(1.) Gabbard GO. Treatments of Psychiatric Disorders. 3rd ed. Washington, D.C.: American Psychiatric Press; 2001:1825-32.
(2.) Zohar Y, Avidan G, Shvili Y, Laurian N. Otolaryngologic cases of Munchausen's syndrome. Laryngoscope 1987;97:201-3.
(3.) Asher R. Munchausen's syndrome. Lancet 1951;1:339-41.
(4.) Patterson R. The Munchausen syndrome: Baron von Munchhausen has taken a bum rap. CMAJ 1988;139:566, 568-9.
(5.) Goldenberg D, Ari EG, Golz A, et al. Tracheotomy complications: A retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000; 123:495-500.
(6.) Roethe RA, Fuller PB, Byrd RB, et al. Munchausen syndrome with pulmonary manifestations. Chest 1981;79:487-8.
(7.) Cohen NL, Breda SD, Lebowitz AS. Orogenic Munchausen syndrome. Am J Otol 1990;11:192-5.
(8.) Maschka DA, Bauman NM, McCray PB Jr., et al. A classification scheme for paradoxical vocal cord motion. Laryngoscope 1997;107:1429-35.
Bart Patenaude, MD; Robert Zitsch III, MD; Scot D. Hirschi, MD
From the Department of Otolaryngology, School of Medicine, University of Missouri-Columbia School of Medicine.
Reprint requests: Scot D. Hirschi, MD, Department of Otolaryngology, University of Missouri-Columbia School of Medicine, 1 Hospital Dr., Columbia, MO 65202. Phone: (573) 882-8175; fax: (573) 884-4205; e-mail: email@example.com
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|Author:||Hirschi, Scot D.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Oct 1, 2006|
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