Amna Khalil  ( Department of Otolaryngology, Patel Hospital, Karachi, Pakistan )
Syed Akbar Abbas  ( Department of Otolaryngology, Patel Hospital, Karachi, Pakistan )
Talha Qureshi  ( Department of Otolaryngology, Patel Hospital, Karachi, Pakistan )
Shafqat Ali  ( Department of Otolaryngology, Patel Hospital, Karachi, Pakistan )
Bushra Ayub  ( Department of Otolaryngology, Patel Hospital, Karachi, Pakistan )

Munchausen syndrome is a rare psychiatric illness that includes mimicking a group of medical conditions, in which a person repeatedly harms him or herself or falsely misinterprets any medical condition when he or she is not actually sick, in order to achieve health care attention. Underdiagnosis of this syndrome leads to irrelevant use of medical assets. Here, we document an interesting and rare case of a young girl presented in the outpatient department of the Otolaryngology department of Patel Hospital with episodes of bleeding from her ear, which is a rare presentation of Munchausen syndrome. Her complete physical, otolar yngological, haematological and radiological examination failed to reveal any clue towards a particular diagnosis. Hence a diagnosis of Munchausen syndrome was made by exclusion of other possibilities of ear bleeding, and it was considered as a case report after taking duly signed written consent from the patient. This report will help in increasing the self-knowledge and perception of different clinical based presentations of this syndrome in medical practitioners, in order to avoid overlooking such cases. Further exploratory work is required in this regard to discover the etiology and predisposing factors and to develop new treatment strategies.

Keywords: Ear canal, Haemorrhage, Munchausen Syndrome, Attention, Self-knowledge.

https://doi.org/10.5455/JPMA.72100

Introduction

Munchausen syndrome is a rare psychiatric illness that includes mimicking a group of medical conditions, in which a person repeatedly harms him or herself or falsely misinterprets any medical condition when he or she is not actually sick, in order to achieve health care attention.



It is a mental disorder having significant association with severe emotional disturbances and should be considered in the differential diagnosis when there is a difficult to explain presentation of a patient.¹ It is named after a literary character called Baron von Munchausen, a German military officer from the 18th century, who travelled around the world telling incredible stories about his imaginary feats. ^2,3 In 1951, Richard Alan John Asher reported the first case of Munchausen syndrome in the Lancet. ³ People with Munchausen syndrome often present with a history of recurrent hospitalization, with an irrelevant and dramatic medical history. ¹ They are eager to undergo any invasive medical interventions as well. ² They intentionally cause harm to their body in order to get hospitalized, switching themselves to different hospitals once they are exhausted with the treatment options given in a medical  setting, resulting in the irrelevant use of medical assetsand making it one of the more exacting and complicated diagnoses in the given healthcare setup. ³ Here, we report a unique and interesting case of a young girl presented in our outpatient department with bleeding from her ear. Bleeding from an ear is a rare presentation of Munchausen syndrome, in which the patient shows blood stains in the ear appearing to come from the ear itself. Bleeding from the ear is ear drainage containing blood. The most common cause of bleeding from the ear is a ruptured or perforated eardrum. It can also be due to more serious conditions, such as trauma to the head or cancer of the external auditory canal. ⁴ Our patient presented with such interesting findings, excluding all the above mentioned causes of ear bleeding, which makes this case worth mentioning. This report will help in increasing the self-knowledge and perception of different clinical based presentations of this syndrome in medical practitioners, in order to avoid overlooking such cases.

Case Report

A 19 year old female, with no known comorbid conditions, presented in the outpatient department of the Otolaryngology department of Patel Hospital in the month of March, 2018, with complaints of 3-4 episodes of bleeding from her right ear when she was alone in her room in the evening for the last one week. The bleeding was sudden in onset, bright red in colour, severe in intensity, and not associated with pain, fever or any other otologic symptoms (i.e. otalgia, hearing loss, tinnitus, and vertigo). There was no history of any trauma or any other predisposing factors. Also, no aggravating or precipitatingfactors were identified. There was no history of bleeding from any other site. On examination, the right ear appeared normal externally. There were no signs of any trauma. The external ear and otoscopic examination of the tympanic membrane appeared normal. The examination of the rest of the ear and the general physical examination was  normal with no signs of anaemia, jaundice, cyanosis, petechiae, or visible pulsations or bleeding from any other  sites, including the nose, gums, or skin; no lymphadenopathy or visceromegaly was found, excluding systemic diseases. There was no history of any substance abuse or suicide attempts. On further enquiry from her mother, she gave a history of self-inflicted trauma and disclosed that her daughter had gone through emotional stress due to some family issues. However, her past medical, surgical and personal history did not reveal anything significant. The patient was then counselled and sent home, and was advised to take pictures whenever bleeding from the right ear occurred. However, to rule out any underlying diseases, her base line tests, including CT scan of the temporal bone, were also carried out, which appeared to be normal. According to her family, she did not attempt any further act of selfinflicted injury or harm, and confessed that there were no episodes of bleeding.

Discussion

Bleeding from the ear has many causes, including tumours, trauma, or a perforated tympanic membrane, but the patients suffering from this syndrome can present with otologic manifestations, and therefore, it should be considered in the differential diagnosis when other ear abnormalities are excluded after a thorough evaluation. Clinical presentations that are more worrisome and stubborn with adverse consequences are the distinguishing features of Munchausen syndrome. ³ As bleeding from any site in an individual can be an alarming symptom, it attracts the attention of healthcare workers, further leading to hospital admission; this is one reason why factitious disorders such as Munchausen syndrome often present with bleeding from unusual sites. ⁵ The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists the following criteria for diagnosing a case of factitious disorder:3 a) Causing injury or disease in a thoughtful manner to deceive or making up physical or psychological signs for the same purpose. b) Acting as a sick or injured person or having problems in functioning. c) Deceiving continually without gaining any benefit. d) Mental disorders are unable to explain these kinds of behaviour. Patients with genuine causes of similar indications may not appear different than patients with factitious diseases. Hence, such patients are extremely difficult to recognize, as their psychiatric abnormalities are not appreciated due to lower doubtful ability of health care workers. ⁵ They usually present with a fake medical history, causing medical practitioners to prescribe unnecessary medications, which may result in iatrogenic diseases. According to a case study, some predisposing factors identified and related to this syndrome included the loss of a beloved one - such as a parent or a sibling – during childhood, any emotional disturbance or crucial sickness at a very young age, a personality disorder, and being a medical professional. ⁶ The aim of these patients is to gain sympathies from their family and society, as well as medical consideration, and it feels great for them when their diagnosis becomes a challenging task for medical practitioners. ³ The important prognostic factors of these patients are early diagnosis, initial psychotherapy, and the presence of dispiritedness or any mental sickness. ³ The overall management of Munchausen syndrome is very exacting and complicated and requires better knowledge of the clinical features of factitious disorders as well as patience on the part of the medical practitioner before labelling the patient, in order to prevent a disastrous outcome. A strong relationship should be established in collaboration with the psychiatrist to provide effective health care support to individuals suffering from this syndrome. These patients should be called for regular follow up visits in a mental health care setup so as to help improve their underlying psychiatric conditions. ⁷

Conclusion

Bleeding from the ear is not uncommon, but it's a worrisome clinical condition. Management includes a multidisciplinary approach with thorough evaluation, correct diagnosis and involvement of a psychotherapist, as it all saves time and surplus use of medical resources and also protects the patient from any aggressive medical interventions. Recognition of this psychiatric disease requires adequate medical and social attention. This report will help in increasing the self-knowledge and perception of different clinical presentations of this syndrome in order for medical practitioners to avoid overlooking such cases. Further exploratory work is required in this regard to discover the etiology and predisposing factors of this syndrome and to find out new treatment strategies.

Disclaimer: No disclaimer was declared by the authors.

Conflict of Interest: No conflict of interest was declared by the authors.
Funding Disclosure: No funding disclosure was declared by the authors.

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