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Munchausen Syndrome and Acute Aortic Dissection: Letter 1
CORRESPONDENCE
Munchausen Syndrome and Acute Aortic Dissection: Letter 1 To the Editor:
MISCELLANEOUS
We read with extreme interest the case report of the patient with Munchausen syndrome who presented simulating an acute dissection [1]. It is extremely likely that we had the opportunity to meet this troubled young man in our institution on two previous occasions. In the most recent instance, he presented to a small outside hospital with a convincing story of chest pain that could certainly be consistent with aortic dissection. Interestingly he had the added past history of heart transplantation in Germany. The underlying reason necessitating the transplant was aortic dissection with transection of the left main coronary artery. At presentation to the outside center, he was promptly transferred to our institution for ongoing management of his dissection after stabilization with beta blockade and significant amounts of narcotics for pain management. On arriving at our institution, the plausible nature of the story began to unravel. The drug and contrast allergies changed. The transplant medications and dosages were extremely unusual. Ultimately we discovered that he had changed the last letter of his last name. Once we had his correct name, his previous admission to our institution for a similar episode became available. At that point the incongruities in his story became obvious. The patient was approached in an attempt to clarify the issues and suggest that an accurate diagnosis by magnetic resonance imaging (MRI) be attempted without contrast. After significant amounts of narcotics and benzodiazepines, the MRI demonstrated a completely normal cardiac and aortic anatomy. Further investigation into this gentleman revealed that he has traveled extensively along the east coast of the United States from Winston-Salem, North Carolina up to Rhode Island. The recognition of this patient and his factitious disorder by the authors is to be commended. We felt the need, despite his unlikely history, to confirm normal anatomy before approaching the patient, after which he promptly left, despite our suggestions that we would be willing to assist him with a psychiatric consult. We write this to confirm the successful strategy that this patient has used, obviously on multiple occasions, and to commend the authors on there succinct case report outlining the issues with this patient. Lynn M. Fedoruk, MD John A. Kern, MD The University of Virginia Health System Division of Thoracic and Cardiovascular Surgery PO Box 800679 Charlottesville, VA 22903 e-mail: [email protected]
Munchausen syndrome and for highlighting another disorder in the differential diagnosis for aortic dissection. The case reported by the authors is very similar to a patient who presented to our service with the chief complaint of chest pain in January of 2003. At the time, this patient was 23 years of age and reported a history of Ehlers-Danlos syndrome (type IV), having undergone a previous sternotomy to exclude aortic dissection. The patient also had an extensive history of medical allergies and was very specific for the type of pain medications that relieved his symptoms. In addition, an extensive evaluation that included chest computed tomography, transesophageal echocardiography, and a medical genetics evaluation yielded no cardiovascular abnormalities. Similar to the case reported by Hopkins and colleagues [1], our patient also left against medical advice. On multiple occasions since his release from our care, we have received requests for transfer from outside medical centers (eg, CT, NJ, CA, MI, NC, and TX) regarding this specific patient. Each medical evaluation ultimately led to a normal aortic evaluation. A psychiatric evaluation was recommended on several occasions. Recently this patient returned to our medical area visiting nine different emergency centers during a 2-week period. We received requests for transfer for this patient on every occasion. Discussion with the referring physicians, however, revealed the same normal results regarding his cardiovascular evaluation and a psychiatric evaluation was eventually recommended. Unfortunately the patient refused further treatment and would leave the referring facility against medical advice. Again, we are very grateful to the authors for highlighting this disorder (Munchausen syndrome with concurring malingering) and appreciate that this may be considered in the differential diagnosis for chest pain caused by aortic dissection. It should be emphasized, however, that this should ultimately be a diagnosis of exclusion when entertaining aortic dissection. However, it is less gratifying to know that despite recognition of this psychiatric disorder the patient may refuse treatment only to continue to visit other medical institutions. Communication between medical centers remains integral to addressing issues such as these. Anthony L. Estrera, MD Hazim J. Safi, MD Department of Cardiothoracic and Vascular Surgery The University of Texas Medical School at Houston Memorial Hermann Heart and Vascular Institute 6410 Fannin St, Suite 425 Houston, TX 77030 e-mail: [email protected]
Reference 1. Hopkins RA, Harrington CJ, Poppas A. Mu¨nchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
Reference 1. Hopkins RA, Harrington CJ, Poppas A. Mu¨nchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
Munchausen Syndrome and Acute Aortic Dissection: Letter 2 To the Editor: We read with interest the article by Hopkins and colleagues [1] and compliment the authors for educating us regarding © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Reply To the Editor: The wonderful letters by Drs Fedoruk and Kern from Charlottesville, VA [1] and Drs Estrera and Safi from Houston, TX [2], commenting upon our article [3], add a number of important observations to what were likely visits by the same patient. First, the patient can change his history a bit (eg, to Ehlers-Danlos syndrome [Type IV] from Marfan’s) making the presentation sound complex yet plausible, thus initiating imaging studies, which along with the claimed discomfort inexorably leads to Ann Thorac Surg 2006;82:1948 –54 • 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2006.06.009
Munchausen Syndrome and Acute Aortic Dissection: Letter 1 To the Editor:
MISCELLANEOUS
We read with extreme interest the case report of the patient with Munchausen syndrome who presented simulating an acute dissection [1]. It is extremely likely that we had the opportunity to meet this troubled young man in our institution on two previous occasions. In the most recent instance, he presented to a small outside hospital with a convincing story of chest pain that could certainly be consistent with aortic dissection. Interestingly he had the added past history of heart transplantation in Germany. The underlying reason necessitating the transplant was aortic dissection with transection of the left main coronary artery. At presentation to the outside center, he was promptly transferred to our institution for ongoing management of his dissection after stabilization with beta blockade and significant amounts of narcotics for pain management. On arriving at our institution, the plausible nature of the story began to unravel. The drug and contrast allergies changed. The transplant medications and dosages were extremely unusual. Ultimately we discovered that he had changed the last letter of his last name. Once we had his correct name, his previous admission to our institution for a similar episode became available. At that point the incongruities in his story became obvious. The patient was approached in an attempt to clarify the issues and suggest that an accurate diagnosis by magnetic resonance imaging (MRI) be attempted without contrast. After significant amounts of narcotics and benzodiazepines, the MRI demonstrated a completely normal cardiac and aortic anatomy. Further investigation into this gentleman revealed that he has traveled extensively along the east coast of the United States from Winston-Salem, North Carolina up to Rhode Island. The recognition of this patient and his factitious disorder by the authors is to be commended. We felt the need, despite his unlikely history, to confirm normal anatomy before approaching the patient, after which he promptly left, despite our suggestions that we would be willing to assist him with a psychiatric consult. We write this to confirm the successful strategy that this patient has used, obviously on multiple occasions, and to commend the authors on there succinct case report outlining the issues with this patient. Lynn M. Fedoruk, MD John A. Kern, MD The University of Virginia Health System Division of Thoracic and Cardiovascular Surgery PO Box 800679 Charlottesville, VA 22903 e-mail: [email protected]
Munchausen syndrome and for highlighting another disorder in the differential diagnosis for aortic dissection. The case reported by the authors is very similar to a patient who presented to our service with the chief complaint of chest pain in January of 2003. At the time, this patient was 23 years of age and reported a history of Ehlers-Danlos syndrome (type IV), having undergone a previous sternotomy to exclude aortic dissection. The patient also had an extensive history of medical allergies and was very specific for the type of pain medications that relieved his symptoms. In addition, an extensive evaluation that included chest computed tomography, transesophageal echocardiography, and a medical genetics evaluation yielded no cardiovascular abnormalities. Similar to the case reported by Hopkins and colleagues [1], our patient also left against medical advice. On multiple occasions since his release from our care, we have received requests for transfer from outside medical centers (eg, CT, NJ, CA, MI, NC, and TX) regarding this specific patient. Each medical evaluation ultimately led to a normal aortic evaluation. A psychiatric evaluation was recommended on several occasions. Recently this patient returned to our medical area visiting nine different emergency centers during a 2-week period. We received requests for transfer for this patient on every occasion. Discussion with the referring physicians, however, revealed the same normal results regarding his cardiovascular evaluation and a psychiatric evaluation was eventually recommended. Unfortunately the patient refused further treatment and would leave the referring facility against medical advice. Again, we are very grateful to the authors for highlighting this disorder (Munchausen syndrome with concurring malingering) and appreciate that this may be considered in the differential diagnosis for chest pain caused by aortic dissection. It should be emphasized, however, that this should ultimately be a diagnosis of exclusion when entertaining aortic dissection. However, it is less gratifying to know that despite recognition of this psychiatric disorder the patient may refuse treatment only to continue to visit other medical institutions. Communication between medical centers remains integral to addressing issues such as these. Anthony L. Estrera, MD Hazim J. Safi, MD Department of Cardiothoracic and Vascular Surgery The University of Texas Medical School at Houston Memorial Hermann Heart and Vascular Institute 6410 Fannin St, Suite 425 Houston, TX 77030 e-mail: [email protected]
Reference 1. Hopkins RA, Harrington CJ, Poppas A. Mu¨nchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
Reference 1. Hopkins RA, Harrington CJ, Poppas A. Mu¨nchhausen syndrome simulating acute aortic dissection. Ann Thorac Surg 2006;81:1497–9.
Munchausen Syndrome and Acute Aortic Dissection: Letter 2 To the Editor: We read with interest the article by Hopkins and colleagues [1] and compliment the authors for educating us regarding © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Reply To the Editor: The wonderful letters by Drs Fedoruk and Kern from Charlottesville, VA [1] and Drs Estrera and Safi from Houston, TX [2], commenting upon our article [3], add a number of important observations to what were likely visits by the same patient. First, the patient can change his history a bit (eg, to Ehlers-Danlos syndrome [Type IV] from Marfan’s) making the presentation sound complex yet plausible, thus initiating imaging studies, which along with the claimed discomfort inexorably leads to Ann Thorac Surg 2006;82:1948 –54 • 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2006.06.009