Case Presentation of Munchausen Syndrome
In this article, the authors present a rare case of epidural abscess following epidural analgesia for chronic pain management. While epidural analgesia is most commonly used for post-operative pain control, recent advances in pain management means an increasing use of epidural analgesia for both terminal and non-terminal pain syndrome.1 While mild side effects of epidural analgesia are fairly common, it is rare to encounter serious infectious complications (meningitis and epidural abscess) or epidural hematoma.1-3
This particular case had unexpected and confounding aspects that ultimately led to a diagnosis of Munchausen Syndrome. Munchausen Syndrome, also known as “Munchausen Syndrome by proxy,” is a psychological disorder characterized by stimulated illness, pathological lying, and wandering from one to another medical service.4-6 Despite being widely reported, little attention have been paid to this syndrome.5 While the probability of encountering a patient who self-harms is small, it does occur and this is offered as a cautionary report.
A 43-year old gentleman presented to the pain clinic complaining of right-sided chest wall pain radiating from the back to the anterior chest wall, almost corresponding to the T6-7 dermatomal area. This pain appeared following thoracotomy for pleurodesis for repeated pneumothoraces to the right side. Multiple attempts were made to control his reported pain using antidepressants, anticonvulsants, and a trial of opiate therapy. All attempts failed to control his pain. His past medical and surgical history was negative for drug abuse, diabetes, or any immunosuppressive disorder.
He was scheduled for insertion of thoracic epidural catheter with continued infusion of local anesthetic agent and morphine to attempt to control his pain. An epidural catheter was inserted between the level of T7 and T8 using the classical approach under aseptic conditions. The catheter threaded to the level of T5-6. A continuous infusion of morphine and bupivacaine mixture was used. During the infusion, the patient expressed 50-60% pain relief.
However, on the third day, he started to complain of fever and an increase in pain extending into the right scapular region. He also complained of severe low back area and dysesthetic pain into both lower extremities. Examination showed a temperature of 38 degrees centigrade (100.4 degrees farhenheit) with exquisite tenderness into the paraspinal muscle in the thoracic region. His blood culture was positive for gram-positive cocci (staphylococcus aureus and staphylococcus epidermis). Anaerobic and gram negative bacilli were also isolated in the same culture.
Immediate MRI revealed an epidural collection of fluid extending from the T4 to the T7 epidural space. A neurosurgical consult was requested and led to a recommendation for an urgent T5 to T7 laminotomy and drainage of an epidural abscess. Post-operatively, the patient was maintained on nafcillin 2gm IV q 6 hours, and after ten days of antibiotic therapy, the patient was allowed to go home and continued on oral morphine 100mg, 2 tablets q 8 hours with 30mg of MSIR for breakthrough pain in between. The patient had antibiotic therapy for six weeks.
Three months after the incident, the patient was re-admitted to another hospital because of cellulitis to both upper extremities and sepsis. Result of the culture from the subcutaneous abscess was also positive for staphylococcus aureus and E-coli. The patient, however, was kept under surveillance under the suspicion that his malady may have been self-induced. On the fourth day in Intensive Care, one of the nurses witnessed the patient injecting himself with his own feces in the bathroom.
The patient was confronted by the psychologist and he then admitted that he was injecting himself with his own feces and previously had introduced his own feces into the epidural catheter. The patient was then admitted to the psychiatric hospital where he was maintained on a psychotropic agent.
Spinal epidural abscess (SEA) is a rare complication following the insertion of an epidural catheter.1,2 It is one of the more serious complications of epidural analgesia.1 Although local skin infection of the epidural catheter is relatively common, ranging from 4-12%, the occurrence of epidural abscess is rare.2 The incidence of SEA has been calculated at 0.6 to 0.77 occurrences per thousand catheter days.1 Most of the epidural abscesses that have been reported are in patients who have had catheter insertion for a prolonged period of time (more than 3 days), or they have an immunosuppressive disorder (i.e. diabetes, chemotherapy, or were IV drug abusers). In thisr patient, this was not the case.1,2
SEA can occur spontaneously in 1 out of 10,000 hospital admissions in the USA.1 The spread of infection is either by hematogenous spread, from local skin infection (through the catheter), or direct contamination (the injected local anesthetic).1-3 Early detection and aggressive treatment is important since delayed therapy can result in poor neurological outcomes. In addition, SEA symptoms can vary and may present a few weeks later. It is generally accepted that early decompression of the SEA and long term antibiotic therapy is ideal treatment (usually 4-6 weeks). While staphylococcus strains are the most common infecting organisms (83%),2,3 the lab work in this case isolated multiple organisms from the blood culture and thus aroused suspicion. While thoracic SEA have been associated with poor outcomes, in this case the diagnosis was made early enough that, with aggressive therapy, he recovered completely.1-3
Diagnosis of Munchausen Syndrome
Munchausen Syndrome is characterized by a triad feature of simulated illness, pathological lying (pseudologia, pseudophantastica) and wandering from place to place (peregrination).4 Munchausen Syndrome accounts for probably less than 10% of all factitious disorders seen in hospitals.4,5 The main features include fabrication of physical symptoms and psychiatric symptoms with no apparent motivation other than to adopt the patient role. The patient may also stimulate symptoms, including contamination of urine with blood, intentionally aggravating a pre-existing illness, or even sometimes self-inducing disease by eating contaminated food or, as in this case, injecting himself with his own fecal material.4,5
Southall has suggested electronic video surveillance to uncover Munchausen Syndrome. However, that can be very difficult to do on a routine basis unless warranted by suspiciously unexpected and confounding findings.5,6
Upon confirmation of Munchausen Syndrome in a chronic pain patient, optimal treatment would be a team approach that includes the primary care physician, a psychologist, and a pain physician.5