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Keywords:

  • hypoglycaemia;
  • Munchausen's syndrome by proxy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Ben-Chetrit E, Melmed RN (Hadassah University Hospital, Jerusalem, Israel). Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient (Case Report). J Intern Med 1998; 244: 175–8.

A 73-year-old woman with multiple myeloma experienced four episodes of loss of consciousness, convulsions and profuse sweating whilst she was in the hospital. A thorough investigation in the department of medicine disclosed that with each attack, she had a serum glucose <1.6 mm L−1, insulin level >1400 pMol L−1 (N – <150) and a normal level of serum C-peptide. Since she had no anti-insulin antibodies (which may rarely exist in multiple myeloma), a diagnosis of exogenous injection of insulin was made. A search for a possible perpetrator discovered that the patient had a daughter who was a surgical nurse and who was genuinely concerned whenever she was told that her mother was about to be discharged from the hospital. If she was the perpetrator in the present case, then it is possible that the motive for such an action was to postpone the mother's discharge from hospital. This case is an example of a ‘factitious disease by proxy’ in an elderly patient. The aim of the present report is to alert the medical personnel to the possibility that Munchausen's syndrome by proxy may also occur in the elderly.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Meadow, a paediatrician, described cases in which parents factitiously and repeatedly presented their children as suffering from a particular symptom or clinical condition [ 1]. The condition, which he termed Munchausen syndrome by proxy (MBP), was characterized by considerable persistence on the parents' behalf about the existence of the supposed clinical problem, their frequent success in evading detection for the factitious state for prolonged periods, as well as the not infrequently dangerous (and sometimes fatal) course for the involved child of all kinds of unnecessary interventions for purposes of investigation or treatment. Although the first reports of this condition appeared in the paediatric and general medical literature around 20 years ago, and although elderly patients may be in a clinical state similar to that of small children, namely wholly dependent on their environment and unable to communicate effectively, reports of MBP in the elderly are surprisingly rare. We report here a case of MBP which we recently encountered.

Case report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

A 73-year-old woman was hospitalized in the orthopaedic department because of a pathological fracture of her right humerus. Ten months previously she was diagnosed as having multiple myeloma. On the fourth day of hospitalization in the orthopaedic department she suddenly lost consciousness and developed uncontrolled tonic movements accompanied by profuse sweating. Physical examination following this episode revealed an obese patient in delirium with a normal temperature. The blood pressure was 150/90 mmHg and the pulse rate 104 beats per minute. Her right arm was in a cast.

Laboratory tests showed a normal blood count. Serum level of total protein was 62 g L−1, albumin 35 g L−1, and there was no paraproteinaemia. The serum glucose concentration was 1.5 mm L−1 at the time of loss of consciousness. The patient was transferred to the Department of Medicine for further evaluation and treatment. Within the next 10 days the patient experienced three more attacks of hypoglycaemia, each time with loss of consciousness and convulsions. The serum glucose during these episodes were 0.7, 1.6 and 1.5 mm L−1, respectively. The fasting glucose concentration was 6.3 mm L−1. Abdominal ultrasonography and CT scan did not reveal any pancreatic pathology or sign of a solid tumour. Further studies revealed that the urine was negative for derivatives of sulfonylurea. Serum levels of insulin during two of the hypoglycaemic episodes were >1430 pMol L−1 and 1421 pMol L−1, respectively (normal fasting serum insulin <150 pMol L−1). The C-peptide levels were 0.24 and 0.08 nMol L−1, respectively (normal range of fasting serum C-peptide, 0.18–0.62 nMol L−1). (These results were confirmed by another independent laboratory.) Anti-insulin antibodies were not detected in the serum.

A diagnosis of exogenous insulin injection was made. Since the patient could not inject herself due to her physical disability (being bed-ridden with a broken forearm) it was assumed that the insulin was injected by someone else. The injection of insulin by a nurse in the department was excluded by thorough inquiry. This possibility was also excluded by the hypoglycaemia occurring in two separate departments (Orthopaedics and Medicine). It should be emphasized that the patient had two devoted daughters who took care of her and visited her almost every day. One of them was a nurse who seemed to be genuinely concerned when she was told that her mother was going to be discharged from the hospital. The attacks of hypoglycaemia ensured her continued hospitalization and postponed her discharge. The fact that we knew that the insulin was being injected by someone and that we were considering asking for police help in further investigating the problem, was explicitly conveyed to the daughters. The nurse daughter categorically denied any connection with the action. During a 18 month follow-up in a nursing home where she lived after discharge from the hospital, the patient did not experience any additional hypoglycaemic events. She subsequently died in the nursing home in septic shock.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Although elderly patients may have the same vulnerability to physical abuse as children in that they may be physically disadvantaged and able to communicate only poorly, there are surprisingly few case reports of MBP in the elderly. Insulin injection in the elderly has been used as a means of murder [ 2]. However, we have been unable to find another case report of insulin-induced hypoglycaemia as an expression of MBP in an elderly patient though such cases have been reported in the paediatric literature [ 2]. The present case describes an elderly lady with multiple myeloma who had recurrent episodes of hypoglycaemia. Her presence in the hospital and new onset attacks of hypoglycaemia raised the possibilities of either myeloma associated hypoglycaemia, an iatrogenic complication or an incidental tumour. The various imaging techniques employed failed to detect an islet cell tumour, retroperitoneal sarcoma, or soft tissue neoplasms that may either produce a hypoglycaemic factor or themselves metabolize glucose leading to hypoglycaemia. The finding of very high fasting insulin levels in her serum excluded the possibility of myeloma associated insulin-like growth factor II secretion [ 3]. However, a central question raised concerned the source of the insulin, i.e. whether endogenous or exogenous. In such cases the measurement of C-peptide level concomitantly with the serum insulin level may be very helpful as the C-peptide levels should follow the insulin levels in the serum when its source is endogenous. In our patient, the lower than normal C-peptide levels in the presence of extremely high serum insulin levels confirm that endogenous insulin secretion was inhibited, thus leaving exogenous administration as the only possibility. Nevertheless, in the case of multiple myeloma the patient may also develop monoclonal low affinity anti-insulin antibodies. These antibodies bind insulin only weakly but not C-peptide [ 4]. Thus, when the insulin is released from these weak-binding antibodies the levels of the C-peptide are in the normal range. However, the failure of detection of these antibodies in this patient excluded this possible mechanism of myeloma associated hypoglycaemia and strengthened the diagnosis of exogenous administration of the hormone. Since the patient presented with hypoglycaemia and convulsions induced by the repeated surreptitious administration of insulin by another person, the diagnosis of MBP is appropriate. This diagnosis raises some serious unanswered questions: who injected her and why?

In MBP a patient, nearly always the mother, falsifies illness in her child or children by fabricating a history and or by producing symptoms or signs. The child presents to the doctor with a clinical problem that is unexplained, prolonged and usually unresponsive to various therapeutic measures [ 5]. Symptoms occur only in the presence of the perpetrator. Almost any clinical picture can be fabricated from cyanosis, apnea and seizures through diarrhoea, vomiting, bones and joints problems [ 6, 7]. In many cases the perpetrator has a close relationship with the hospital staff or other health profession associates and about third of them have had previous complete or partial nursing training [ 5]. The term ‘Munchausen syndrome by proxy’ is now considered to describe a form of child abuse. Recently it was suggested to limit the use of this term in the paediatric experience, to cases in which the perpetrator's, i.e. the parent's, behaviour is motivated by the need to assume the sick role and it should not be solely viewed as child abuse [ 8]. As there are so few cases reported in the adult literature, the psychological significance of this type of behaviour as it affects the elderly is not yet apparent. However, as may be deduced from the two cases described in the literature as well as our report, there could well emerge a greater variety of reasons in the adult form of the syndrome than occurs in children. For this reason, it seems that a final definition of diagnostic criteria in adults should await more clinical experience.

Sigal et al. described a 34-year-old man who injected his two female partners with gasoline after first surreptitiously sedating them [ 9]. This action resulted ultimately in the death of one of his partners and the second becoming paraplegic. The perpetrator was eventually given a 46 year jail sentence for manslaughter and attempted murder. Whilst in prison, he repeated his actions on a cell-mate with turpentine, sedative tablets, with syringe and needles stolen from the prison clinic [ 10]. Before his discovery, the perpetrator, like many involved parents of MBP patients, was regarded highly by the hospital staff for his considerable concern and continued attentiveness to his hospitalized partner. Smith&Ardern [ 11] described a 69-year-old patient who had been taken by his 55-year-old female companion, an ex-nurse, to consult surgeons for rectal bleeding over four years, and in addition had attended a dental clinic, a metabolic clinic, two neurology departments, two separate diabetic clinics, three psychiatric departments, a psychogeriatric unit, orthopaedic and urology clinics and a department of academic medicine. In addition he consulted five doctors privately for second opinions, and had two GPs during this time. All investigations had been normal in spite of a multitude of complaints. This case more closely resembles that usually seen in children in that the female companion, with her professional nursing background, was able to influence the patient of the need for continual medical attention and the medical attendant of the need for investigation, as an expression of her own neurotic needs.

In our patient several points are in accord with the diagnosis of MBP. First, the patient had recurrent episodes of symptomatic hypoglycaemia and convulsions induced by insulin injections. As already mentioned the patient was bed-ridden and her arm was in a cast so that she could not inject herself and therefore her ‘disease’ was produced by someone else. Secondly, the patient had a daughter who was a registered nurse, and therefore conversant with the effects and administration of insulin [ 5]. This same daughter was concerned about her mother's discharge from hospital and presumably could have staged this illness in order to prolong her admission, which in fact it did. This would have gained her mother better medical attention than she could have received in the nursing home. Similarly, the fact that the hypoglycaemic episodes ceased with her transfer to the nursing home would confirm that the intention was not to harm the patient but rather to gain her better medical attention. An attack of hypoglycaemia in the nursing home may have gone unnoticed for a period of time which would endanger the patient, as the institute tended to be understaffed and the nursing generally of a lesser standard. If the nurse daughter was the perpetrator in the present case, as seemed likely (in spite of her denial), then it is probable that the motive for such action would be secondary gain. The daughter seemed to be genuinely concerned whenever she was told that her mother was going to be discharged from the hospital and thus, induction of severe attacks of hypoglycaemia made sure of her continued hospitalization and postponed her discharge. When we told the nurse daughter that we were about to inform the police, she responded by welcoming the suggestion. However, as there were no further hypoglycaemic attacks and the patient appeared to have suffered the hypoglycaemia without harm, the police decided not to pursue the case.

Differentiating between natural and factitious illness may be extraordinarily difficult and requires the most careful and skilful clinical appraisal [ 8]. In the present case vigorous diagnostic effort combined with close follow-up confirmed the diagnosis of fictitious disease by proxy. The elderly and children resemble each other in their helplessness, vulnerability to harm and in the lack of power to resist or protect themselves. However, the rarity of this syndrome in the elderly suggests that cases are being missed by unsuspecting physicians. The aim of this report is to alert medical and nursing personnel to the possibility that Munchausen syndrome by proxy may also occur in elderly patients.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References