|Year : 2014 | Volume
| Issue : 3 | Page : 123-124
Munchausen syndrome by proxy masquerading as pyoderma gangrenosum
Ramesh Kumar, Jitendra Bhuria, Prafull Mehta, Suresh Jain
Department of Dermatology, Venereology, and Leprology, Government Medical College, Kota, Rajasthan, India
|Date of Web Publication||30-Oct-2014|
Department of Dermatology, Venereology, and Leprology, Government Medical College, Kota, Rajasthan - 324 001
Source of Support: None, Conflict of Interest: None
Child abuse is a major public health crisis and is on the rise. Dermatologists are frequently involved in its evaluation in differentiating abusive injuries from accidental injuries and in excluding pathological conditions that may mimic abuse. Munchausen syndrome by proxy (MSBP) is a rare form of child abuse where the parents or caretaker, intentionally causes an illness in the child for her own self-serving psychological needs. A 6-year-old orphan girl presented with spontaneous ulcers over bilateral lower limbs since last 6 months. The girl was investigated thoroughly in detail for possible causes of ulcers but nothing came out. Diagnosis of MSBP was firmly established in the case.
Keywords: Battered child syndrome, factitious disorder, Munchausen syndrome, pyoderma gangrenosum
|How to cite this article:|
Kumar R, Bhuria J, Mehta P, Jain S. Munchausen syndrome by proxy masquerading as pyoderma gangrenosum. Indian J Paediatr Dermatol 2014;15:123-4
|How to cite this URL:|
Kumar R, Bhuria J, Mehta P, Jain S. Munchausen syndrome by proxy masquerading as pyoderma gangrenosum. Indian J Paediatr Dermatol [serial online] 2014 [cited 2020 Dec 4];15:123-4. Available from: https://www.ijpd.in/text.asp?2014/15/3/123/143667
| Introduction|| |
Battered child syndrome (BCS) is a form of child abuse with complex psychosocial and legal implications that can adversely affect the physical and psychological well-being of the child and at times can be potentially life-threatening. Munchausen by proxy syndrome (MBPS) is a relatively rare form of child abuse that involves the exaggeration or fabrication of illnesses or symptoms by a primary caretaker. Furthermore known as "medical child abuse," MBPS was named after Baron von Munchausen, an 18 th -century German dignitary known for making up stories about his travels and experiences in order to get attention. "By proxy" indicates that a parent or other adult is fabricating or exaggerating symptoms in a child, not in himself or herself. Munchausen by proxy syndrome is a mental illness and requires treatment. It is estimated that up to 90% of children with physical abuse have cutaneous signs of abuse and dermatologists are frequently involved in the diagnosis. 
| Case report|| |
This was a case report of a 6-year-old female orphan child presented to the skin out-patient department with the multiple spontaneous ulcers over the bilateral lower limbs for last 6 months with her caretaker. She was a known case of paraplegia. As per history, ulcers were sudden in onset, intermittent and used to develop in night, which were usually noticed by caretaker in the morning. Lesions used to heal in 3-4 weeks with atrophy, meanwhile used to develop new lesions. When patient was asked about the lesions, the findings of history revealed some interesting facts. Child gave history of ghost who used to come in the night and bite her legs. Then, detailed history revealed that her female caretaker used to burn her legs with burning coal. The female caretaker was questioned separately. She initially denied but later on she admired. On clinical examination, lesions were multiple, well-defined, irregular, round and angulated, superficial and deep ulcers of variable size from 3 cm to 5 cm with slight hyperpigmented border and normal surrounding skin [Figure 1]. Scarring of old healed ulcers was present. According to history of both patient and caretaker with morphology of the lesions, the diagnosis of Munchausen syndrome by proxy (MSBP) was firmly established in the case.
|Figure 1: Ulcers of variable size with slight hyperpigmented border and normal surrounding skin|
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| Discussion|| |
In MBPS, an individual, usually a parent or caregiver causes or fabricates symptoms in a child. The adult deliberately misleads others and may go as far as to actually cause symptoms in the child of some specific disease. In a review of 451 victims of MSBP, majority of perpetrators were biological mothers (76.5%) or fathers (6.7%).  Grandparents and unrelated child-care providers are included in the list of potential perpetrators. 
In general, the cause is a need for attention and sympathy from doctors, nurses and medical personals. Sometime also cause for the satisfaction in deceiving individuals who they consider to be more powerful than them self. Because the parent or caregiver appears to be so caring and attentive, often no one suspects any wrongdoing. Most of the time, evidence of unresolved trauma or loss reactions in mothers is seen.  Diagnosis is very difficult due to the ability of the parent or caregiver to misguide doctors and induce symptoms in their child. Often, the perpetrator is familiar with the medical profession and knowledgeable about how to induce illness or impairment in the child. Medical personnel often overlook the possibility of MBPS because it goes against the belief that parents and caregivers would never deliberately hurt their child. Most victims of MBPS are preschoolers and there is equal sex ratio of children.
| Conclusion|| |
Hence, it is important for the dermatologist to have BCS and MSBP in the differential diagnoses and be competent in evaluating these disorders. A multidisciplinary team effort is essential in evaluating such cases and dermatologists should be aware and be well informed about this condition that can be potentially lethal but easily overlooked.
| References|| |
|1.||Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol 2006;23:311-20. |
|2.||Sheridan MS. The deceit continues: An updated literature review of Munchausen Syndrome by Proxy. Child Abuse Negl 2003;27:431-51. |
|3.||Shaw RJ, Dayal S, Hartman JK, DeMaso DR. Factitious disorder by proxy: Pediatric condition falsification. Harv Rev Psychiatry 2008;16:215-24. |
|4.||Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry 2005;187:328-33. |