Munchausen’s syndrome refers to patients who injure their bodies and repeatedly request medical assistance due to these illnesses or factitious conditions. In the reported case, an 11-year-old girl was referred to the dermatology outpatient clinic, accompanied by her mother, who reported the appearance of red-pink spots on the skin, with a burning sensation, with one month of evolution. The patient has attended a pediatric emergency weekly, where intramuscular promethazine and intravenous corticosteroids were frequently prescribed, with reported improvement of the burning sensation. She was also seen at an allergy outpatient clinic, where she underwent contact examinations and was subjected to various dietary restrictions. On physical examination, red-pink spots were observed on the face, though sparing the mucous membranes. Some lesions were arranged in a linear pattern and pigment of the same color was observed in the hyponychium. Due to the weird clinical presentation, a gauze soaked in saline solution was rubbed in the cervical region and the pigmentation was removed. After 7 days, the patient returned without the stains and was referred to a psychiatrist. Inconsistent aspects of the lesions that were observed on physical examination, pointed to the correct diagnosis. Early identification of Munchausen’s syndrome helps to avoid iatrogenesis. In this paper we report a case of Munchausen Syndrome in a child, reviewing its main topics, and give awareness about the possible iatrogenesis induced when misdiagnosed.

dos Santos de Araujo ACG, Bernardo TT, de Almeida APM, Rezende HD, de Deus Mateus A, et al. The Munchausen’s Syndrome: A Diagnosis Not to Be Forgotten in Dermatology. Ann Pediatr Child Health 2020; 8(7): 1200.

• Factitious disorders
• Munchausen syndrome
• Munchausen syndrome by proxy
• Child

MS: Munchausen’s Syndrome

Munchausen’s syndrome (MS) refers to patients who deliberately cause injuries to their bodies, sometimes even injecting foreign materials to obtain hospital admission and care and repeatedly request medical assistance due to these illnesses or factitious conditions [1,2].

Freiherr von Münchhausen was a German soldier known for telling fanciful stories about his adventures which were then published and, soon after, translated into English by a German author who published the “Baron Munchausen’s”. In 1951, the term Munchausen’s syndrome was introduced to define that complex disease, fictitious, just like in the stories [3].

In children, MS by proxy is more common, and in this case, the caregiver is the one who causes the physical or psychological signs or symptoms, by making the injury directly, inventing facts on the history of the disease or even manipulating exam samples, such as blood and urine. Other vulnerable groups can be affected, like the elderly and mentally unstable people [2].

An 11-year-old girl was referred by the Pediatrics Emergency Service to a School Hospital in Campos dos Goytacazes, Rio de Janeiro. The patient was accompanied by her mother, who reported the appearance of red-pink spots on the face, cervical region, and upper limbs with a burning sensation of a one-month duration.

The patient attended weekly to the pediatric emergency, where intramuscular promethazine and intravenous corticosteroids were frequently prescribed, with reported improvement of the symptoms. During the period, she was also seen at the allergy outpatient clinic of another hospital in the city, where she performed contact tests and was submitted to several food restrictions. Subsequently, she used hydroxyzine 25mg 12-12hs and Prednisone 10mg/day for 1 week with partial improvement, but future recurrences. Antihistamines did not change the clinical picture.

The patient remained silent throughout the mother’s speech. Some lesions were arranged in a linear pattern and pigment of the same color was observed in the hyponychium (Figure 1).

Although the patient denied manipulation of any product, the assistant physician rubbed a gauze soaked with saline solution in the cervical region and the pigmentation was gone (Figure 1D). At that moment, the mother was surprised, and the daughter remained silent.

After some areas of pigmentation were removed, the child was then asked directly about what paint she was using to stain the skin and finally reported that she was playing with slime and lipstick.

The mother was then instructed to bathe the child herself, as she used to bath alone, already leaving the bathroom dressed, to discontinue all medications in use and suggested to speak with her daughter to clarify the ink’s origin. After 7 days she returned without any stain and remained silent (Figure 2). The patient was referred to the psychiatric service for a better investigation of the reasons that triggered this manifestation.

Patients with MS are intent on causing harm to themselves by simulating an illness or else they do so to get medical attention or be hospitalized. In general, their motivation is obscure and multifactorial and can be subdivided into long-term motivation and episodic triggers. Long-term motivations are caused by the search for affection, difficult childhood, coping mechanisms, and identity disorders, for example. While episodic triggers may be related to emotional distress and hospitalization for real illnesses [4]. Generally, they do not search for any financial gain, so the fraud occurs even in the absence of a recompense [5,6].Our patient was absent from school for the entire period of appearance of the spots but affirmed to like going to school.

In factitious disorders, the inducing of lesions can´t be explained by delirium or other psychotic disorder, but, psychiatric comorbidities are usually present [5,6]. Yates showed in a 2016 study that the most frequent comorbid diagnosis was a current or past diagnosis of depression, being described more frequently than personality disorder [7].

MS is an exclusion diagnosis, which must be made when it is possible to physically identify the actions of individuals who are related to a symptom simulated by him (such as the presence of syringes at the bedside), clinical and laboratory dissociation, ineffective responses to the proposed procedures, recurrent patterns of disease exacerbation, visits hospital care three or more times with the same symptoms or searching for national reference hospitals, even if the patient lives somewhere far away. Other indications can guide the attending physician for the diagnosis of this syndrome, such as detecting symptoms at times when there is no health professional or companion nearby, several surgeries or procedures that do not improve their symptoms, unusual understanding of medical terminology and procedures and inconsistency in the evolution of the disease [8,9]. When the skin is the target of MS clinical manifestations, the diagnosis should be considered when the lesions are spectacular, not being elucidated even with routine investigation techniques [2,5].

The sooner suspicion leads to better management. It is important to consider a factitious disorder from the beginning to recommending a psychiatrist earlier and protect these patients by avoiding overtreatment and iatrogenic injuries. Although, the dermatology field has a huge variety of clinical manifestations, and this kind of suspicion can be slightly hard for the general clinician, according to that, when an unusual clinical presentation need to be excluded a specialist evaluation becomes important [6].

In the case of the reported patient, some important characteristics were observed, such as a very bright red-pink rash different from any other skin condition, refractoriness to previously proposed treatments, the time of evolution of the lesions, the predominance of specific body areas, the presence of tincture under the patient’s nails and the preservation of specific areas, like alar nasal sulcus, nasal tip, ala nasi, labial contour and the previous area of the forearms. All these characteristics, added to the ease of removing the pigmentation, were sufficient to elucidate the diagnosis.

It is common for this diagnosis not to be considered because doctors are not as familiar with this disorder or patients do not have a profile that is consistent with reality. Often, MS can be confused with a systemic disease or correlated with health problems that already exist and have been cured. Often the diagnosis ends up being made when the doctor discovers the patient’s simulation technique (as in this case reported), by discovering items that incriminate him, by laboratory tests that suggest a local origin of the injury or the diagnosis is made by exclusion [10].

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5. American Psychiatric Association. Manual diagnóstico e estatístico de transtornos mentais. 5th ed. Schultz S, Bispo de Lima L, Bittencourt C, editors. Porto Alegre: Artmed Editora; 2015.

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7. Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. General Hospital Psychiatry. 2016; 41: 20-28.

8. Trajber Z, Murahovschi J, Candio S, Cury R, Gomide C, Klein E, Tofolo V. Munchausen’s syndrome by proxy: a case report of a girl with a recurrent factitious bleeding ear. Jornal de Pediatria. 1996; 72: 35-39.

9. F Ferri F. Ferri’s Clinical Advisor 2020. 1st ed. Providence: Elsevier; 2020.

10. Walls R, Hockberger R, Gausche-Hill M. Rosen’s emergency medicine: Concepts and clinical practice. 8th ed. Philadelphia: Elsevier/ Saunders. 2014.