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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 622-624

Munchausen syndrome presenting as recurrent ocular infection in a child


1 Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission05-Mar-2021
Date of Acceptance30-Apr-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Nirupama Kasturi
Department of Ophthalmology, JIPMER, Puducherry - 605006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_507_21

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  Abstract 


A 11-year-old immunocompetent boy presented with a painful loss of vision due to panophthalmitis in the left eye. The eviscerated specimen showed invasive mucormycosis, for which he was treated with topical and systemic antifungals. The child presented later with recurrent episodes of redness in the right eye. During hospitalization, we found that the eye drop vials were perpetually contaminated with an acidic agent. Based on a detailed review of history and examination, a factitious disorder was suspected and confirmed by a psychiatric evaluation.

Keywords: Munchhausen syndrome, panophthalmitis, recurrent conjunctivitis


How to cite this article:
Kaviyapriya, Chavhan P, Behera G, Kasturi N, Kaliaperumal S, Menon V, Kattimani S. Munchausen syndrome presenting as recurrent ocular infection in a child. Indian J Ophthalmol Case Rep 2021;1:622-4

How to cite this URL:
Kaviyapriya, Chavhan P, Behera G, Kasturi N, Kaliaperumal S, Menon V, Kattimani S. Munchausen syndrome presenting as recurrent ocular infection in a child. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 28];1:622-4. Available from: https://www.ijoreports.in/text.asp?2021/1/4/622/327694



Ocular munchausen syndrome is a factitious disorder in which patients present with self-inflicted ocular injuries produced due to subconscious psychological reasons. The patient presents to ophthalmologists through exaggerated and misrepresented signs and symptoms This abnormal health-care-seeking behavior, has the mere role of being taken care of as a helpless, dependent patient unlike malingering which is mainly for tangible gains.[1]


  Case Report Top


A 11-year-old boy was brought by his mother with a history of gross diminution of vision in his left eye associated with pain, redness, and discharge for three weeks. The patient had consulted elsewhere and was prescribed topical and systemic antibiotics for a presumed intraocular infection. Despite treatment, his left eye continued to worsen, and he was referred to us for further management. He had no prior history of ocular trauma, sinusitis, steroid intake, diabetes mellitus, or autoimmune diseases. His mother gave an account of multiple episodes of bleeding from aural, nasal, oral orifices during sleep in the recent past for which he was evaluated, and no intrinsic hemostatic defect was identified in the workup. The child belonged to a low socioeconomic background. His younger sibling died at seven months of age due to intracranial bleeding, and his father died following a snake bite four years ago, according to the mother. The child was moderately built and poorly nourished and general examination showed scabies infestation.

On ocular examination, the best-corrected visual acuity of the right eye was 6/6, and the left eye was the perception of light. Anterior segment examination of the right eye was normal. The left eye showed lid edema with erythema and tenderness in the periorbital region. Lid margins showed erosions with profuse purulent discharge and matting of eyelashes. The inferior half of the sclera appeared ischemic with overlying conjunctival defect and discharge. The cornea showed a large ulcer with diffuse stromal haze and the anterior chamber was filled with inflammatory exudates [Figure 1]a and [Figure 1]b. The patient was admitted and started on intravenous and topical antibiotics.
Figure 1: (a) Clinical photograph showing panopthalmitis in the left eye (b) Slit-lamp photograph showing hypopyon corneal ulcer with limbal ischemia in the lower quadrant (c) Clinical image of the left eye showing eviscerated socket (d) Histopathology showing fungal elements (red arrow)

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Despite treatment, his ocular condition worsened, and evisceration was done [Figure 1]c. Histopathology of the eviscerated specimen showed features resembling invasive mucormycosis [Figure 1]d but was negative for any fungal or bacterial culture. The patient was given a 3-week course of systemic antifungals, including Amphotericin B and Posaconazole, along with a topical preparation of 0.15% Amphotericin B eye drops with close monitoring of his renal parameters.

Post evisceration, the socket appeared healthy, and the patient was discharged with topical antibiotics. After one month, the child was brought by the mother with symptoms of pain, redness, and diminution of vision in the right eye. The visual acuity in the right eye was found to be 6/12. Slit-lamp examination showed conjunctival congestion in the inferior bulbar conjunctiva and fornix with a patch of conjunctival necrosis [Figure 2]a. Cornea had confluent superficial punctate keratitis on staining with fluorescein. A complete immunological workup was done, including serum immunoglobulins and lymphocyte function tests, which ruled out primary immunodeficiency disorders. Computed tomography of the left orbit showed no infective foci. Conjunctival swab culture of the right eye showed no growth, but the patient was started empirically on systemic and topical Liposomal Amphotericin B along with topical antibiotics and lubricants.
Figure 2: (a) Clinical photograph showing congestion in the inferior bulbar conjunctiva and fornix associated with conjunctival necrosis (b) Resolution of ocular congestion and (c) and (d) Recurrence after four months

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During the hospital stay, we noticed that the eye drop vials were contaminated overnight with a chemical having acidic pH, pungent odor, and producing froth [Figure 3]. A thorough psychiatric evaluation was done, which revealed an inconsistent history with the mother, child, and grandmother. The child had a high average intelligence quotient. A diagnosis of factitious disorder was made probably triggered by a seperation anxiety of the child from the mother after a second marriage. Supportive psychotherapy was advised.
Figure 3: (a) Photograph showing acidic pH on litmus paper and (b) Froth inside the eyedrop vial

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Patient was on follow up and four months later he presented with a similar history of acute onset severe pain, redness and blurring of vision in the right eye that developed overnight. On examination, his visual acuity was 4/60 in the right eye. The cornea had a total epithelial defect with diffuse edema and 3 clock hours of limbal ischemia superiorly [Figure 2]c, [Figure 2]d. The clinical picture was suggestive of chemical injury, though it was denied by both the patient and his mother. He was managed with topical antibiotics, lubricants, soft steroids and a bandage contact lens. His ocular condition improved in two weeks, with complete epithelial healing (BCVA: 6/6).

A psychiatry review was sought and both the patient and his mother underwent separate counseling sessions. Consultation liasion was done with clinical psychologist to address cognitive errors. Psychosocial stressors were addressed, possible future options were discussed in the form of graded separation of mother and child and enrollment in a boarding school set up for implementing the same. The child responded to counseling and was discharged with protective glasses.


  Discussion Top


Munchausen syndrome is a factitious disorder in which symptoms are induced or feigned, usually to gain attention, sympathy, or reassurance, and often have a psychological need to maintain a sick role.[2] Manifestations often involve multiple organ systems and result in consultations with various subspecialists. Self-induced ocular manifestations have been reported in the form of voluntary nystagmus, subconjunctival hemorrhages, recurrent conjunctivitis, endophthalmitis, corneal erosions and ulcerations, anisocoria from over instillation of mydriatics, and orbital cellulitis or abscesses.[3],[4],[5],[6],[7] Despite frequent reports in other medical specialties, ocular Munchausen syndrome is uncommon.

The diagnosis can be made only after extensive medical investigations. A high index of suspicion must be maintained when the reported history, clinical findings, and investigations are inconsistent. Recognition of this psychiatric disorder is essential for correct medical diagnosis and treatment, protecting the patients from unnecessary invasive and aggressive medical procedures, and preventing potentially severe eye damage. Mortality rates in these children can be up to 6–9%; therefore, early diagnosis is often lifesaving.

Diagnosis of Munchausen syndrome is challenging to make in the ophthalmic setting. In our patient, the socioeconomic background of the child, the history of unexplained bleeding manifestations,[8] the characteristic affectation of the inferior conjunctiva and fornix, with tissue ischemia and necrosis, along with identification of perpetual contamination of eye drop vials led to the diagnosis. Munchausen patients have little or no ability to control their self-destructive behavior.[9] A sympathetic and supportive approaches are required, and these patients should be urgently referred to a psychiatrist for supportive psychotherapy. A stepwise, supportive confrontation of the patient with the facts, in which continued therapeutic contact is offered and no proofs or confessions are demanded. The entire treating team should maintain an alert, transparent, empathic, and coping-oriented therapeutic approach. In the best case, the patient will be able to shed the pretense of disease.[10] A factitious disorder should be considered when there is any recurrent or persistent illness that cannot be explained or is not getting better with the appropriate treatment.


  Conclusion Top


Munchausen syndrome can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough and systematic evaluation. All physicians, including ophthalmologists, need to be aware of this condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bass C, Halligan P. Factitious disorders and malingering: Challenges for clinical assessment and management. Lancet 2014;383:1422-32.  Back to cited text no. 1
    
2.
Prabhu A, Abaid B, Sarai S, Sumner R, Lippmann S. Munchausen syndrome. South Med J 2020;113:198-200.  Back to cited text no. 2
    
3.
Rao P, Shah AR, Michelotti MM, Anderson B, Abbey AM, Jain N, et al. Bilateral acute endophthalmitis associated with Munchausen syndrome. Retin Cases Brief Rep 2015;9:177-80.  Back to cited text no. 3
    
4.
Anderton LC, Shah P, Doran RM. An unusual case of ocular Münchausen's syndrome. Acta Ophthalmol (Copenh) 1994;72:126-7.  Back to cited text no. 4
    
5.
Salvo M, Pinna A, Milia P, Carta F. Ocular Munchausen syndrome resulting in bilateral blindness. Eur J Ophthalmol 2006;16:654-6.  Back to cited text no. 5
    
6.
Minemura K, Nagahara M, Kaburaki T, Sakurai M, Araie M, Tanaka S, et al. Case of recurrent fungal endophthalmitis with suspected Munchausen syndrome. Nippon Ganka Gakkai Zasshi 2006;110:188-92.  Back to cited text no. 6
    
7.
Rosenberg PN, Krohel GB, Webb RM, Hepler RS. Ocular Munchausen's syndrome. Ophthalmology 1986;93:1120-3.  Back to cited text no. 7
    
8.
Uzuner S, Bahali K, Kurban S, Erenberk U, Cakir E. A pediatric case of factitious disorder with unexplained bleeding symptoms. Gen Hosp Psychiatry 2013;35:679.e7-8.  Back to cited text no. 8
    
9.
Gogandy MA, Aljarad A, Jastaneiah SS, Alfawaz AM. Self-inflicted eye injury. Ann Saudi Med 2017;37:245-50.  Back to cited text no. 9
    
10.
Hausteiner-Wiehle C, Hungerer S. Factitious disorders in everyday clinical practice. Dtsch Arztebl Int 2020;117:452-9.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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