Case Presentation:
The patient was a 14‐month‐old male presenting with feeding intolerance and failure to thrive with associated vomiting and diarrhea. His medical history was significant, including chronic emesis and poor weight gain with a Nissen fundoplication and G‐tube placed at 6 months of age, He had undergone an extensive negative evaluation in the past, including upper endoscopy, gastric emptying studying, and motility testing. While hospitalized, after persistent diarrhea on continuous GJ feeds, a central line was placed, and TPN was initiated. He developed multiorganism line sepsis with E. coli, alpha hemolytic Streptococcus and Streptococcus salivarius. Diarrhea persisted despite strict NPO status. Stool studies, including an assay for phenolphthalein, were negative. Because of growing concern over the possibility of Munchausen syndrome by proxy (MSBP), covert video surveillance was initiated. The mother of the child was observed giving multiple oral feedings despite strict NPO status. There was additional concern over maternal tampering with the child's diapers. A nurse entered the room immediately after the mother had changed a diaper and found it to be “cold and fizzing like Coca‐Cola.” The diaper was sent to pathology and was negative for any stool or plant material, epithelial cells, or bacteria. A caffeine level was done on the specimen and found to be positive at a level > 40 mg/L. The mother was confronted and confessed to feigning diarrhea in the child by pouring liquids, in this case Coca‐Cola, into her son's diapers. The diagnosis of MSBP was made, and the child was placed in protective custody. The child's “diarrhea” subsequently resolved, TPN was discontinued, and the central line removed, and the child was discharged after documented progressive weight gain on enteral feeds.
Discussion:
MSBP must be considered with unexplained persistent or puzzling recurrent illness when symptoms are not substantiated by diagnostic results or when treatments are not tolerated or ineffective. The estimated incidence of MSBP is 2.8 per 100,000 kids under 1 year of age, with a mean age at presentation and when eventually diagnosed of 25 and 40 months, respectively. Nearly 100% of cases involve gastrointestinal manifestations, with a significant number also with central lines and recurrent central line sepsis. Covert video surveillance is an effective diagnostic tool, with high rates of confirmation when the diagnosis is suspected. The diagnosis carries near 100% morbidity and a 9% mortality rate, with little known about successful treatment or long‐term outcomes.
Conclusions:
The diagnosis of MSBP must be in the differential and not simply a diagnosis of exclusion. With more advanced and complex therapies, the possibilities of deception are endless and new and more complex presentations will be seen, Pediatric hospitalists serve a crucial role in suspecting and identifying the warning signs in this potentially devastating and deadly diagnosis.
Author Disclosure:
R. Bode, Phoenix Children, employed/none.