Year : 2015 | Volume
: 26 | Issue : 6 | Page : 1279--1281
Acute kidney injury in a child: A case of Munchausen syndrome by proxy
Mukta Mantan, Dhulika Dhingra, Aditi Gupta, Gulshan Rai Sethi
Department of Pediatrics, Maulana Azad Medical College and Associated Hospitals, University of Delhi, Delhi, India
Department of Pediatrics, Maulana Azad Medical College, Delhi - 110 002
Renal and urologic problems in pediatric condition falsification (PCF) or Munchausen by proxy (MSP) can result in serious diagnostic dilemma. Symptoms of hematuria, pyuria and recurrent urinary tract infections have occasionally been described. However, MSP presenting as azotemia has not been previously reported. We describe the case of an unfortunate boy who had to undergo unnecessary hemodialysis for persistent hyperkalemia and azotemia before a final diagnosis of the falsification of investigations by the parents was made.
|How to cite this article:|
Mantan M, Dhingra D, Gupta A, Sethi GR. Acute kidney injury in a child: A case of Munchausen syndrome by proxy.Saudi J Kidney Dis Transpl 2015;26:1279-1281
|How to cite this URL:|
Mantan M, Dhingra D, Gupta A, Sethi GR. Acute kidney injury in a child: A case of Munchausen syndrome by proxy. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2023 Jan 29 ];26:1279-1281
Available from: https://www.sjkdt.org/text.asp?2015/26/6/1279/168672
Munchausen syndrome by proxy (MSP) is defined as "an intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role."  It is a relatively rare form of child abuse that involves the exaggeration or fabrication of illnesses or symptoms by a primary caretaker. It is named after Baron von Munchausen, an 18 th -century German diplomat known for making up stories about his travels and experiences to seek public attention. About 10% of the patients may die from the results of induced illness or from the interventions for the symptoms.  In a review of 135 cases from the United States, 25% of the subjects had renal and urological manifestations; the chief complaints were recurrent urinary tract infections (UTI), hematuria and calculi.  Some children underwent unnecessary urological procedures. Manifestations due to high doses of furosemide and administration of excessive oral sugars leading to polyuria and glucosuria have also been reported. A single case of recurrent acute renal failure was reported in an 18-month-old child due to poisoning by the mother.  We describe herewith a child who had underlying posterior urethral valve (PUV) for which he underwent surgical treatment at our hospital. During follow-up, multiple episodes of UTI were reported by the mother and, at the last admission, the child presented with highly deranged renal biochemistry, although the child was clinically normal. Close investigation into the matter led to the diagnosis of MSP syndrome.
A 10-year-old boy was admitted to the pediatric ward with complaints of high-grade fever, vomiting and abdominal pain. The child had a history of multiple admissions in the past. He was a known case of operated PUV with unilateral pelviureteric junction obstruction, dysfunctional bladder and recurrent UTI, with an underlying seizure disorder. The seizure disorder was idiopathic and was not related to the renal symptoms. The child had multiple admissions (32 admissions and eight surgical procedures) in different pediatric and pediatric surgery wards of our hospital. After the initial valve fulgration, he continued to have recurrent UTI for which he was evaluated multiple times. During each episode of UTI, the mother complained of high-grade fever with chills and dysuria. The urine examination during these episodes showed leukocyturia and occasionally grew organisms in urine, but there was no leukocytosis in the blood and the child was always well clinically. He received injectable antibiotics on multiple occasions. Isotope scan performed at different ages did not show any scarring or features of pyelonephritis. During the present admission, the child had similar complaints and hence a provisional diagnosis of UTI was made.
At admission, the child was stable, afebrile and was eating well. The initial biochemistry report showed urea of 415 mg/dL, serum creatinine of 22 mg/dL and gomerular filtration rate (GFR) of 3.2 mL/m 2. The serum electrolytes were highly abnormal; serum sodium was 119 mEq/L and serum potassium was 8 mEq/L. The child was however clinically well, conscious and alert and had no features of encephalopathy. The urine output recorded was normal. Repeat tests showed similar abnormalities in the reports. The highest recorded value of serum urea was 1000 mg/dL, creatinine was 48 mg/dL and serum potasium was 32 mEq/L during the hospital stay. The venous blood gas analysis was normal. Urine examination showed 2++ proteinuria and plenty of normal red blood cells. The serum complement C3 levels were normal and anti-streptolysin O and anti-nuclear antibodies were negative. The electrocardiogram did not show any changes of hyperkalemia. Abdominal ultrasound showed a single left kidney with intact cortico-medullary differentiation and had no evidence of hydronephrosis or calculus. The child was started on antibiotics and appropriate medical management for acute renal failure and underwent eight sessions of hemodialysis. Preand post-hemodialysis reports were highly discrepant; post-dialysis urea and creatinine levels were higher than the predialysis values. During the stay in the hospital, normal kidney function was also documented occasionally. The laboratory investigations and the clinical condition of the child were highly discrepant. Most of the renal functions and electrolyte values were reflective of urinary parameters rather than blood. Hence, a possibility of urinary contamination of blood sample was entertained. To confirm this suspicion, a blood sample retrieved from the child was divided into three parts. One sample was sent to the laboratory with the parents, another was taken by the doctor on duty and the third sample was sent in the name of another child. The sample sent with the mother showed high values of urea (>1000 mg/dL) and creatinine while the latter two samples showed normal results. Multiple samples were sent over the next two to three days under supervision, and were all normal. Hemodialysis and all other medications were stopped. When the parents were confronted, initially they were defiant but the mother later accepted her role in sample contamination. Although they were counselled, they refused any psychiatric help and have not come for follow-up subsequently.
The term MSP was coined by Meadow in 1977 to describe cases where the caretaker falsified and fabricated illness in a dependent child.
The precise incidence of the condition is not known; however, 451 cases published in over 154 journals were identified by the year 2003.  The most commonly reported symptoms of MSP in this review were apnea (26.8%), anorexia/feeding problems (24.6%) and diarrhea (20%). Among the renal manifestations reported in this review, 2.9% patients presented with hematuria, 2.2% with recurrent urinary infections and proteinuria was seen in 0.2% of the subjects. The review identified mothers as the most commonly implicated perpetrators (76.5%). Another publication identified urologic manifestations in 25% of the patients identified with MSP. 
A case of renal failure in a child following intoxication with ethylene glycol has been reported earlier.  There have been reports of addition of extraneous substances, including egg and human albumin, into the urine leading to false proteinuria and povidone iodine to mimic hematuria. ,, Factitious addition of stones into the urine samples have also been reported in a child who had presented with renal colic.  However, there is no report of addition of urine into the blood sample to mimic acute kidney injury. Other renal manifestations of MSP include urinary retention following excessive intake of anti-cholinergics and Bartter's syndrome following excessive intake of furosemide. 
Mortality due to the condition is high and most (up to 75%) of the deaths related to MSP occur in the hospital, often following overaggressive efforts of the treating team to make a diagnosis. In a retrospective review of 93 patients with MSP, 17 patients had central lines inserted for administration of medications or for providing parenteral nutrition.  Physicians should consider MSP as a possible diagnosis if there is evidence of recurrent illnesses without a defined cause, if discrepancies occur in biochemical findings and clinical condition and if the clinical course is inconsistent. Also the presence of a caretaker who does not object to repeated painful interventions in the child may be a pointer especially if he/she has previous medical experience. In our case, it appears that the child's previous surgery and repeated admissions helped the mother in creating false reports in the patient.
Repeated sessions of dialysis with no improvement in the child, absence of metabolic acidosis on blood gas analysis and signs of hyperkalemia on electrocardiography prompted us to reconsider our diagnosis and monitor the activities of the mother.
Conflict of interest: None declared.
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