Rosen & Barkin's 5-Minute Emergency Medicine Consult (464 page)

Treatment should be limited to stabilization of life or limb threats caused by acts of self-harm

• Identify objective physical illness and treat as appropriate
  
• Document history and findings suggestive of factitious illness
  
• List of all the aliases, addresses, and date of births that the patient is known to use
  
• Summarize the patient’s known modus operandi (the factitious histories and behaviors that he or she has presented with)
  
• Ensure that the information will be communicated or available to all doctors who are likely to come into contact with the patient
  
• Confrontation of the patient in the ED is controversial and should only occur when unambiguous evidence is gathered
  
• Report Munchausen syndrome by proxy to child protective services
  

FOLLOW-UP

• Injuries and disease caused by self-harm
  
• Munchausen by proxy:
  
  • When the diagnosis is suspected but there is not enough evidence to have child protective services take custody
    
• Observation to collect evidence of faking disease:
  
  • May also allow setting to rule out rare organic etiologies
    
• To establish a long-term plan to prevent future self-harm and iatrogenic adverse events
  
• Psychiatric admission may be of benefit, but it is rarely accepted by the patient
  

• Medical stability
  
• Not an active threat to harm self
  
• Appropriate referral for medical and psychiatric follow-up arranged
  

• May offer psychiatric referral as a method of dealing with stress caused by illness
  
• Psychiatric providers located directly in medical settings (e.g., primary care physician office) may be more accepted. Overall, this is a chronic illness with poor prognosis
  

Maintain contact between the patient and an identified provider for that patient.

• Kenedi CA, Shirey KG, Hoffa M, et al. Laboratory diagnosis of factitious disorder: A systematic review of tools useful in the diagnosis of Munchausen’s syndrome.
  N Z Med J.
  2011;124:66–81.
  
• Mehta NJ, Khan IA. Cardiac Munchausen syndrome.
  Chest.
  2002;122(5):1649–1653.
  
• Robertson MM, Cervilla JA. Munchausen’s syndrome.
  Br J Hosp Med
  . 1997;58(7):308–312.
  
• Souid AK, Keith DV, Cunningham AS. Munchausen syndrome by proxy.
  Clin Pediatr (Phila)
  . 1998;37(8):497–503.
  
• Steel RM. Factitious disorder (Munchausen’s syndrome).
  J R Coll Physicians Edinb.
  2009;39:343–347.
  
• Stern TA. Munchausen’s syndrome revisited.
  Psychosomatics.
  1980;21:329–336.
  
• Walker EA. Dealing with patients who have medically unexplained symptoms.
  Semin Clin Neuropsychiatry
  . 2002;7:187–195.
  

See Also (Topic, Algorithm, Electronic Media Element)

Abuse, Pediatric

CODES

301.51 Chronic factitious illness with physical symptoms

BASICS

• Amanitin/phalloidin:
  
  • Species:
    
    • Amanita phalloides
      (“death cap”)
      
    • Amanita virosa
      /
      Amanita verna
      (“destroying angel”)
      
    • Galerina marginata
      ,
      Galerina venenata
      
  • Mechanism:
    
    • Cyclopeptide toxins inhibit RNA polymerase 2, which kills GI epithelium, hepatocytes, nephrocytes
      
• Gyromitrin:
  
  • Species:
    
    • Gyromitra esculenta
      (“false morels”)
      
    • Other
      Gyromitra
      spp.
      
  • Mechanism:
    
    • Inhibits pyridoxal phosphate
      
    • Damage to RBCs, hepatocytes, neurons
      
• Muscarine:
  
  • Species:
    
    • Inocybe
      (several species)
      
    • Clitocybe
      (several species)
      
  • Mechanism:
    
    • Parasympathomimetic
      
• Coprine:
  
  • Species:
    
    • Coprinus atramentarius
      (“inky caps”)
      
  • Mechanism:
    
    • Blocks acetaldehyde dehydrogenase
      
    • Causes disulfiram-like reaction if mixed with alcohol
      
• Ibotenic acid/muscimol:
  
  • Species:
    
    • Amanita pantherina
      (“the panther”)
      
    • Amanita muscaria
      (“fly agaric”)
      
  • Mechanism:
    
    • GABA agonists
      
• Psilocin/psilocybin:
  
  • Species:
    
    • Psilocybe
      and
      Panaeolus
      spp. as well as others
      
  • Mechanism:
    
    • Similar structure to lysergic acid diethylamide, effect serotonin receptor
      
• Gastric irritants:
  
  • Many various mushrooms, including those normally considered edible
    
• Orellanine:
  
  • Species:
    
    • Cortinarius
      (several species)
      
  • Mechanism:
    
    • Direct renal toxicity
      
• Tricholoma equestre
  (“man on horse”):
  
  • Rhabdomyolysis-inducing mushrooms
    
  • Unidentified myotoxin
    

DIAGNOSIS

• Amanitin/phalloidin:
  
  • Nausea
    
  • Vomiting
    
  • Abdominal cramps
    
  • Bloody diarrhea
    
  • Clinical course:
    
    • Onset of symptoms delayed 6–36 hr with development of GI symptoms
      
    • Transient latent phase may last 2 days (no pain/symptoms)
      
    • Can progress to hepatic or renal failure and death in 2–6 days
      
    • Most lethal mushroom toxins
      
• Gyromitrin:
  
  • 1st 5–10 hr:
    
    • Abdominal cramps
      
    • Nausea/vomiting
      
    • Watery diarrhea
      
  • Later symptoms:
    
    • Weakness
      
    • Cyanosis
      
    • Confusion
      
    • Seizures
      
    • Coma
      
• Muscarine:
  
  • Cholinergic symptoms include:
    
    • Miosis
      
    • Salivation
      
    • Lacrimation
      
    • Sweating
      
    • Diarrhea
      
    • Flushed skin
      
    • Nausea
      
    • Bradycardia
      
    • Bronchoconstriction
      
  • Onset usually within 1 hr (may be delayed)
    
• Coprine:
  
  • Disulfiram-like reaction within minutes to hours when combined with alcohol:
    
    • Flushing
      
    • Sweating
      
    • Nausea/vomiting
      
    • Palpitations
      
• Ibotenic acid/muscimol:
  
  • Relatively rapid onset of 30–120 min
    
  • GABA agonist effects include:
    
    • Hallucinations
      
    • Dysarthria
      
    • Ataxia
      
    • Somnolence/coma
      
  • Glutamatergic effects (mainly pediatrics):
    
    • Seizures
      
    • Muscle cramps/myoclonic movements
      
• Psilocin/psilocybin:
  
  • Rapid onset, usually resolves in 6–12 hr
    
  • Visual hallucinations
    
  • Alteration of perception
    
  • Mydriasis
    
  • Tachycardia
    
  • Fever and seizures in children
    
• Gastric irritants:
  
  • Group of toxins that cause nausea, vomiting, intestinal cramps, and watery diarrhea
    
  • Onset 30 min to 3 hr, usually resolved in 6–12 hr
    
• Amanita smithiana:
  
  • Nausea/vomiting
    
  • Headache
    
  • Sweating
    
  • Chills
    
  • Low-back pain
    
  • Polydipsia
    
  • Clinical course:
    
    • May progress to oliguria and acute renal failure
      
    • Markedly delayed onset of symptoms (2–14 days)
      
• T. equestre
  :
  
  • Acute rhabdomyolysis:
    
    • Myalgias/arthralgias
      
    • Hematuria/dark urine
      
    • Decreased urine output
      
  • Dehydration