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Dr. Kitchens is Chief, Medical Service, North Florida/South Georgia Veterans Health System, and Professor of Medicine, University of Florida.
Correspondence to: Craig S. Kitchens, MD, Department of Medicine, University of Florida, Box 100277, Gainesville, FL 32610-0277; e-mail: craig.kitchens{at}med.va.gov
Elsewhere in this issue of CHEST (see page 1704), Highland and Flume report their involvement with a patient with cystic fibrosis. They initiated all the appropriate tests but, apparently from the very beginning, had doubts regarding this case: somehow things didn’t add up. They continue by constructing a list of their positive criteria supporting the patient’s true diagnosis, Munchausen syndrome. With the correct diagnosis, they then set out to offer care but, as is the rule with this disorder, the patient escaped from the hospital before help could be implemented.
Every case of Munchausen syndrome is different but usually starts with everything being almost too good—the patient helps too much with the diagnosis, armed with a bewildering amount of supporting facts, carrying sheaves of paperwork (to include results from previous diagnostic studies such as in this case), and appearing most helpful and gracious. However, things usually begin to soon fall apart. The patient’s knowledge base, no matter the ruse, soon belies itself, as the facts that the patient has are out of step with that which they have presented so far. Additionally, the personality disorder—most commonly borderline personality—reveals itself in the patient’s inability to maintain useful working relationships with anyone around them. In the case reported by Highland and Flume, the physical examination did not support chronic lung disease, failing to corroborate the supposed disease. They also discovered that the "diagnostic" laboratory report that she carried with her (and promptly presented), namely a sweat chloride test, was fabricated.
Patients with this syndrome become quite knowledgeable about their illness-of-choice. Whereas the source of information differs from case to case, in this case it appeared to be that the patient had been romantically involved with another patient with cystic fibrosis, thereby gaining intimate knowledge of that disease. Of interest, Feldman1 reported that the Internet is now a new source of a great deal of information on disease processes by those with this syndrome, as well as a vehicle to narrate their tales of woe to a wide audience via chat rooms. While the Internet is definitely useful, Culver et al2 showed that as much as one third of the information contained on a medical electronic bulletin board is erroneous. As two of the four cases reported by Feldman1 were alleging to have cystic fibrosis, one questions whether the case reported herein might have been among them.
Pulmonary manifestations of Munchausen syndrome are not very common, comprising only a small percentage of feigned illnesses.3 These include hemoptysis (coughing up blood collected from a variety of mechanisms, including laceration of the posterior tongue3 ), artifactually low oxygen saturation (from placing tape between the finger tip and the pulse oximeter4 ), pulmonary infiltrates (aspiration of talcum powder4 ), or subcutaneous emphysema (injection of large quantities of air into the face and neck5 ). This report adds cystic fibrosis.
Despite extensive experience with and multiple reports of Munchausen syndrome, it is not totally understood, if for no other reason than the lack of willingness of patients to provide the time or answers the medical profession seeks. These patients have total insight of their ruse, thereby precluding the centrality of finding a hidden motive; additionally, their "illness" is their lifestyle, so they have no desire to improve. The fact that they almost always are not blatantly psychotic prevents institutionalization against their will. In only select cases have in-depth analyses taken place.6 Feldman and Ford,7 in an interesting book, discuss what is known about the illness and offer their opinions from a psychiatric point of view.
Every time a case of Munchausen syndrome is diagnosed, there are multiple mixed reactions from professional staff.8 Many physicians become very irate because they have "missed the diagnosis," but it is really more due to the fact that they were taken advantage of, as the doctor-patient relationship was bastardized from the very beginning. It remains a fact, however, that the most common reason for the tardiness (usually 4 to 7 days) of the diagnosis of Munchausen syndrome is that no one even considered it. All experienced clinicians hold the possibility of factitious disease, to include Munchausen syndrome, in their differential diagnosis. The diagnosis of Munchausen syndrome does not depend on the fact that a patient does not have a disease that can be clearly understood (ie, a diagnosis by exclusion), but depends on positive data, nine of which are listed by Highland and Flume, all of which this patient displayed, therefore supporting an affirmative (correct) diagnosis.
The diagnosis in this case was confirmed by discovering that the key laboratory test report was altered. Whereas such a maneuver is of rather low sophistication given the methods of such patients, laboratory deception (namely altered and feigned results) is a very popular way for these people to enter into and perpetuate the circus of Munchausen syndrome.9
References
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