Factitious hemoptysis. Adding to the differential diagnosis

Separating fact from factitious hemoptysis: a case report

A 61-year-old man with a history of testicular carcinoma and more recently diagnosed metastatic renal cell carcinoma was admitted because of recurrent submassive hemoptysis as evidenced by bright red blood in his bedside basin. Despite an exhaustive workup, including multiple invasive procedures, no cause of the bleeding was found. The diagnosis was Münchausen syndrome manifested as factitious hemoptysis via unusual and modern means. The case is a reminder to all members of the critical care team, from nurses to physicians: When dealing with the frustration of a recurrent problem with no clear answer, remain vigilant and remember the age-old advice to look at the patient… and trust your gut.

Bleeding manifestations apparently unrelated to coagulation or other organic disorders: A tentative classification and diagnostic clues

OBJECTIVE

To study the features of bleeding conditions apparently not associated with vascular, platelet, or clotting dysfunctions.

METHOD

Conditions that may meet these criteria are: Münchausen syndrome factitious or fictitious, suicidal or homicidal bleeding, bleeding due to self-punishment, stigmatization, the battered child syndrome, and psychogenic bleeding.

RESULTS

The importance of these variegate conditions is not trivial in clinical practice. Differential diagnosis may be difficult and involve other specialists besides hematologists. Occasionally, invasive procedures are involved.

DISCUSSION

The occurrence of bleeding in patients, without a clotting defect or a systemic disorder and a negative family history for bleeding represents a diagnostic challenge. A careful examination of the physical and psychological status of the patient and an appropriate evaluation of the environment in which bleeding occurs, is always needed.

A case with unexplained bleeding from multiple sites: munchausen syndrome by proxy

Munchausen syndrome by proxy (MBP) is an extreme form of child abuse where children were unnecessarily treated or investigated for medical conditions that were falsified by their caregivers. Here the authors report a 16-year-old female with the complaints of bleeding from multiple and unusual sites, including hemoptysis, hematuria, bloody tears, and bloody nipple discharge, all of which are only witnessed by her mother. Extensive investigation revealed no organic etiologies for bleeding. The diagnosis of MBP was put by a multidisciplinary team. The diagnosis of MBP must be kept in mind in conditions where there is no underlying organic pathology in a bleeding patient.

Hemoptysis in children

CONTEXT

Pulmonary hemorrhage and hemoptysis are uncommon in childhood, and the frequency with which they are encountered by the pediatrician depends largely on the special interests of the center to which the child is referred. Diagnosis and management of hemoptysis in this age group requires knowledge and skill in the causes and management of this infrequently occurring potentially life-threatening condition.

EVIDENCE ACQUISITION

We reviewed the causes and treatment options for hemoptysis in the pediatric patient using Medline and Pubmed.

RESULTS

A focused physical examination can lead to the diagnosis of hemoptysis in most of the cases. In children, lower respiratory tract infection and foreign body aspiration are common causes. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography. The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with close monitoring. Massive hemoptysis may require additional therapeutic options such as therapeutic bronchoscopy, angiography with embolization, and surgical intervention such as resection or revascularization.

CONCLUSIONS

Hemoptysis in the pediatric patient requires prompt and thorough evaluation and treatment. An efficient systematic evaluation is imperative in identifying the underlying etiology and aggressive management is important because of the potential severity of the problem. This clinical review highlights the various etiological factors, the diagnostic and treatment strategies of hemoptysis in children.

Acute respiratory failure leading to emergency intubation: An unusual manifestation of Munchausen's syndrome

Munchausen's syndrome is a contrived psychiatric disorder, in which patients present with an intentionally produced or feigned illness with the aim to assume the sick role and to gain medical attention. Patients may even seek the application of invasive procedures, sometimes with serious risk to life. We describe the case of a 38-year-old woman, who repeatedly presented with apparent respiratory failure leading to tracheal intubation and mechanical ventilation. In addition, we present a systematic review of the literature over respiratory and pulmonary manifestations of Munchausen's syndrome. This case report may contribute to the awareness among emergency physicians of Munchausen's syndrome as a differential diagnosis of respiratory failure. Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures.

A Rare Cause of Hemoptysis: Factitious Disorder

Hemoptysis is an important symptom that requires broad evaluation, including invasive procedures. Nevertheless, in a considerable number of patients, the cause of hemoptysis may not be adequately determined despite extensive investigations. Factitious hemoptysis is a manifiestation of Munchausen syndrome that describes a group of patients who intentionally produce or feign symptoms or disabilities. Although the disorder is rare, it is believed to be under recognized and under reported. Therefore, there is an urgent need for increased awareness of the disease in order to avoid unnecessary, expensive and sometimes dangerous medical treatment and manipulations. We report a case of Munchausen hemoptysis as a reminder that factitious origins should be added in the differential diagnosis of hemoptysis of unclear etiology.

Hemoptise fictícia na síndrome de Munchhausen: uma entidade a ser considerada no diagnóstico diferencial

A síndrome de Munchhausen resulta de um distúrbio psiquiátrico, no qual os pacientes conscientemente procuram demonstrar sinais e sintomas de doenças orgânicas graves. Foram encontrados na literatura 23 casos de hemoptise fictícia associada à síndrome de Munchhausen, dois com o mesmo mecanismo aqui descrito. Relata-se o caso de um paciente com diversas admissões hospitalares recentes por escarros sangüíneos, que resultavam em exaustivas investigações diagnósticas inconclusivas. Insistentemente questionado, confessou que aspirava o próprio sangue com uma seringa, armazenando-o na cavidade oral, e eliminando-o para forjar a hemoptise. A síndrome de Munchhausen deve ser considerada em pacientes com hemoptise de etiologia obscura.