A case of Munchausen syndrome by proxy

As a retired German cavalry officer, Karl Friedrich Hieronymous Freiherr von (Baron) Munchausen (172097) acquired a reputation as a raconteur of preposterous stories about his adventures as a soldier, hunter, and sportsman 1 . Asher in 1951 first reported patients who consistently produced false stories and fabricated medical evidence which led to needless medical investigations, operations and treatments 2 . Roy Meadow in 1977 described a condition, Munchausen syndrome by proxy, where the mother, a relative or a caregiver fabricated illnesses in children 3 . Since then, many reports of this condition have been published in the medical literature from allover the world.


Case Reports
A case of Munchausen syndrome by proxy L T Wijeratne 1 , B J C Perera 2 Sri Lanka Journal of Child Health, 2002; 31: 124-5 (Key words: Munchausen syndrome by proxy) As a retired German cavalry officer, Karl Friedrich Hieronymous Freiherr von (Baron) Munchausen (1720-97) acquired a reputation as a raconteur of preposterous stories about his adventures as a soldier, hunter, and sportsman 1 .Asher in 1951 first reported patients who consistently produced false stories and fabricated medical evidence which led to needless medical investigations, operations and treatments 2 .Roy Meadow in 1977 described a condition, Munchausen syndrome by proxy, where the mother, a relative or a caregiver fabricated illnesses in children 3 .Since then, many reports of this condition have been published in the medical literature from allover the world.
We report a case where, as a result of the manipulations of a very convincing clinical profile of a renal disease by the mother, a 12 month old child was submitted to numerous investigations and procedures which had the potential to harm the child.

Case report
A 12 month old child was admitted to our unit with a history of intermittent fever and straining during micturition of one month duration.The child had been marginally pre-term, was treated in the special care baby unit for jaundice and was later investigated for failure to thrive.She has had two previous admissions, one for a suspected head injury and the other for an allergic reaction to amoxycillin.She was kept in the "Renal Section" of the ward and investigated.A urine full report and a urine culture were normal.She remained afebrile and two further urine cultures were also negative.When she was about to be discharged from hospital, she developed frank haematuria, confirmed by microscopy.The mother then complained of reduced urine output.The blood pressure was 90/60 mm Hg, there was no _________________________________________ __ 1 Pre-registration House Officer, 2 Consultant Paediatrician, Lady Ridgeway Hospital, Colombo.

(Received on 26 March 2002)
oedema and the weight remained stable.The input/output chart, maintained by the mother, showed marked oliguria and consistently recorded retention of approximately 1500 ml of fluid everyday.The blood urea and serum creatinine were normal on several occasions.An ultrasound scan of the abdomen was completely normal.The haematuria gradually receded but the oliguria remained.The haematuria reappeared after a couple of days and the severity increased progressively.Clinically, the child remained quite normal and was found playing very often.
After about a month of repeated observation and investigation a cystoscopy under general anaesthesia and a renal biopsy were performed.Both were perfectly normal.
After all this time, one of the authors noticed that the child voided very clear urine during clinical examination of the abdomen.However the next sample of urine produced by the mother was grossly blood-stained.This episode aroused our suspicions; the child was kept under strict supervision by the ward staff and made to pass urine under direct observation.All the samples passed under supervision were completely clear.
When the mother was confronted with the evidence, she admitted to adding blood, obtained from the samples taken from other patients, to the urine of her child.
The mother was referred for psychiatric help but no significant disorder was detected.The child remains entirely well on follow-up in the outpatient clinic.

Discussion
Munchausen syndrome by proxy, a form of child abuse, should be suspected when there is an unexplained prolonged illness which shows difficulties in being sorted out even by experienced paediatricians.Often, the symptoms are there only in the presence of the mother or the care-giver.The investigation results are at variance with the clinical state of the child and treatment is apparently ineffective or poorly tolerated.The mother or the care-giver is often not as worried as the medical and paramedical staff.The condition is often seen in families where many members have had serious medical disorders or sudden unexplained deaths.Most of the children affected by this disorder are under 5 years of age 4 and some of them get re-abused even after diagnosis 5 .
Previous reports of this condition in Sri Lankan children have been related to gastrointestinal problems in an eight month old child and a respiratory condition in a five year old girl 6 .This is the first report of a fabricated renal disorder from this country and it led to the performance of potentially harmful investigations on the child.
To look for a single cause for this harmful behaviour would be naive.For some mothers, it may bring about a closer relationship with the spouse and for others it may provide a welcome distraction from personal and home difficulties 7 .Some like the sense of importance it gives them 8 .Most mothers who are referred to psychiatrists return without a definitive diagnostic label 7 .
As these children grow up, they may take part in deception themselves and become adults with the Munchausen syndrome.
Lack of awareness about this condition may result in serious repercussions in unfortunate children.As Roy Meadow so graphically expresses, "Most of us will feel saddened and perhaps ashamed of our repeated investigational assaults on the children, the result of us following our usual practice of trusting the mother and trying to help" 9 ; with hindsight, it seems such a tragic occurrence.With more and more cases being unearthed, it would be most useful to include this condition in the differential diagnosis of apparently baffling symptoms.