Susan M. came in with an infected, dime-sized ulcer on the side of her tongue. I assumed she had bit her tongue and it got infected. I instructed her to gargle with Listerine three-times a day and I prescribed an antibiotic. It almost healed over the next couple of weeks but then came back with a vengeance. I screened for lupus and cultured for Herpes simplex virus but results were negative. When the ulcer was even larger two months later, I shook my head, stumped. I'd never seen anything like it. I worried it might be a mouth cancer since it was a non-healing sore so I referred her to an oral surgeon, so he could biopsy the ulcer and rule out mouth cancer. Imagine my shock when he called me after the office visit and said the margins of the ulcer were too crisp and clean for cancer. He suspected it was self-induced so he confronted her. Turns out, she intentionally cut off chunks of her tongue with kitchen scissors to get sympathy and medical attention, a condition known as Munchausen's syndrome. This older oral surgeon had even seen one other case in his career.
In a more serious case of Munchausen, a nursing instructor in town was contaminating bags of IV fluid with her own feces and then infusing the murky fluid into her veins. Stool is loaded with a bacteria called E. coli, which can cause septic shock. This nurse would show up in the Emergency room with plummeting blood pressures (think 60/20) and temperatures over 103 degrees. At every hospitalization, her blood cultures grew out E.coli. Normally, E. coli sepsis is caused by a kidney infection that seeds bacteria into the blood. But this woman's urine never cultured positive. So how was the E.coli getting into her blood? It just didn't make sense. We performed a colonoscopy to see if she had diverticulitis or Crohn's disease or any colon condition that could be seeding the bacteria into her blood stream. No, her colon was healthy. What was going on?
I finally clenched the case when she was rushed to the ER by co-workers after three months of good health. While performing her exam, I noticed a fresh venous puncture wound on her left forearm with a large hematoma, like she had started an IV in her left forearm but the vein had collapsed. Why was there a puncture wound and collapsed vein? The ER nurses had not yet drawn blood or started an IV so there was no reason for the fresh puncture wound . . . unless she was inflicting it herself! We then did a specific subtype culture that confirmed the E.coli in her blood matched that of her own feces and not an outside source, such as a food poisoning. When confronted with what she was doing, she denied it, but a psychiatrist was finally able to get her to confess. Like most Munchausen patients, she didn't want to get better. She craved pity and the considerable attention and flowers she received every time she came to the hospital in septic shock. Thus, once we were "on" to her, she refused psychiatric care and switched doctors and hospitals.
Munchausen patients are a challenge to diagnose as most of us can't imagine cutting off chunks of our own tongues or injected feces into our own blood streams. Most patients were abused or neglected as children and learned they could get pity/attention when they were sick. Most will deny they self-inflict injury. When confronted, they become hostile and defensive. They refuse psychiatric care and then switch doctors/hospitals so they can start the cycle all over again.