- Email: [email protected]
Surreptitious warfarin ingestion
Child Abuse dr Negko, Vol. 9, pp. 349-352, Prmted in tlx U.S.A. All rights nxened.
0145-2134185 $300 + .oO Copyright 6, /9R5 Pergamon Press Ltd
1985
SURREPTITIOUS
WARFARIN
SUSANNE T. WHITE, M.D.,
INGESTION M.P.H.
Department of Pediatrics, Schoolof Medicine, University of North Carolina, Chapel Hill, NC and Pediatric Teaching Service,
Wake
Area Health Education Center, Wake County Medical Center. 3ooO New Bern Ave., Raleigh, NC 27610
KAREN VOTER, M.D. AND JOAN PERRY, M.D. Department of Pediatrics, School of Medicine, University of North Carolina. Chapel Hill Abstract-Munchausen by proxy has been reported involving children who have been given various drugs or toxins. In addition, there is a body of adult literature regarding covert anticoagulant ingestion. This is a case of an I Imonth-old female who appears to combine features of both of these syndromes. This child presented with an acute left hemorrhagic otitis media. The physical examination was unremarkable except for the following: weight, fifth percentile: left external auditory canal filled with blood with the right external canal and tympanic membrane being normal; andseveral scattered 1 x 2 cm firm, movable, nontender. purple nodules on extremities, chest and forehead. The coagulation studies were consistent with Vitamin K deficiency secondary to anticoagulant ingestion. A serum warfarin study confirmed our suspicions. The mother was noted to have a dependent relationship with her child and characteristics of those involved in Munchausen by proxy: falsifying information and thwarting medical assessment. In addition, she displayed some of the characteristics found commonly in anticoagulant malingerers. She was depressed, with limited medical knowledge, and had access to warfarin. The mother was admitted for inpatient psychiatric care and the patient placed with an extended family member. This case report describes the use of an anticoaguI~t to induce illness in a child by a psychologically ill mother. This form of child abuse must be considered in the differential diagnoses of hemorrhagic disorders. Resume-On a pris l’habitude d’appeler syndrome de Munchausen par procuration les situations 00 un enfant a ete intoxiqut par une toxine ou un mtdicament volontairement par un ad&e. La litttrature contient Cgalement des renseignements abondants sur l’ingestion cachee d’anticoagulants. Les auteurs ont observe une fillette de 11mois qui a ett intoxiquee avec un anticoagulant repondant ainsi rj la definition du syndrome de Munchausen par procuration. La fillette a ete soumise B l’attention medicale B cause dune otite moyenne gauche h~morragique. Le poids de l’enfant etait sur le percentile 5, le conduit auditif exteme gauche itait rempli de sang et le conduit a drone etait normal; en plus il y avait plusieurs nodules viola& non douloureux, mobiles de I A 2 cm de diametre sur les extremites. le thorax et le front. L’ttude de la erase montrait des anomalies compatibles avec une insuffisance en vitamine K secondaire B l’ingestion d’anticoagulants. Un taux sanguin de Warfarin a confirme ce diagnostic. La mere presentait des caracteristiques deja d&rites dans le syndrome de Munchausen par procuration. une relation trts dependante avec I’enfant, des informations faussees et la tendance a egarer le jugement medical par une anamntse fausse. Elle presentait aussi des caracteristiques qu’on trouve chew les gens qui simulent par les anticoagulants. Elle etait dtprimee. avec des notions medicales minimes et avait a&s & la Warfarin. On a hospital&e cette mere en psychiatric et le bebe a ite place aupres d’autres membres de la famille. II s’agit done ici dun rapport concernant une mere perturbee psychologiquement induisant une maladie par un anticoagulant chez son enfant. Cette forme de maltraitance d’enfant doit naturellement etre considerte lorsqu’on fait un diagnostic de coagulopathie a cet age.
SURREPTITIOUS WARFARIN INGESTION to induce factitious disease is well documented in the adult literature [l-4]. Patients are characterized as women in the 20- to 3%yearold age range who are affiliated with the field of medicine (nurses, medical students, pharmacists. veterinarians. etc.) or elderly patients who have had previous supervised therapy with these drugs. A variety of motives are cited for the nontherapeutic use of warfarin including murder. suicide, abortion. error and malingering. The most common of these is malingering in which the patient purposely enters into a relationship with the physician which is based on 349
350
Susanne
T. White.
Karen
Voter and Joan
Perr!
deception. In order to continue the relationship. the patient has a need to pre~~lt hcrhrlt‘ ,I\ being ill. Munchausen by proxy is becoming increasingly recognized. This is a form of child ;tbu\e which is somewhat unusual in that the child is made to appear serioubl\ ill in order to obtain medical care. Previously reported cases have included factitious uriiar? abnarmallties [5]. mismanagement of diabetes [6], frequent and unusual infections [7]. and nonaccidental potsoning [El. These cases have in common that the illness. or appearance of ilInes\. i.\ a rehult of parental (usually maternal) actions. The histories which accompany the findings are falsified. and the consequences of the action are severe for the child both in diagnositc evaluation 2nd therapy. The mother tends to demand attention from the staff and yet manipulates the situation to thwart medical assessment of the true situation. The followmg report describes such features of both diseases in a pediatric case. CASE REPORT An 1 l-month-old black female was well until two months prior to admission when she was diagnosed to have gastroenteritis with dehydration requiring hospitalization. The gastroenteritis resolved and she was discharged after 12 days. Subsequently. she had two hospitalizations for evaluation of intermittent vomiting and failure to thrive. Her workups during these admissions included normal upper gastrointestinal roentgenograms and metabolic studies. Emesis was reported by the mother but never observed by the medical personnel. The patient was discharged and followed weekly as an outpatient for weight checks. Over the next three weeks she was treated with trimethoprim-sulfamethoxazole for acute hemorrhagic otitis media then erthyromycin ethylsuccinate-sulfisoxazole acetyl for persistent otitis media and tinally placed on amoxicillin. The patient returned on the day of admission because of recurrence of gross bloody discharge from her left ear and multiple hematomas. The mother denied the child had a history of fever, URI symptoms, trauma, ingestion of other drugs. bruising. or bleeding from other sites. She also denied a family history of bleeding disorders or anemias. The social history is significant in that the mother is 21 years old. single. and lives with her parents. The mother was a nurse’s aide prior to delivery of this child and was treated \vith warfarin for deep vein thrombosis prior to pregnancy. HOSPITAL COURSE The admission physical exam included normal vital signs. weight 7.22 kg (5%). height 70 cm (.500/c),and head circumference 46 cm (75%). Examination of the ears re\ealed a left external auditory canal filled with blood and an easily visualized right tympanic membrane that was entirely normal. The skin was remarkable for several scattered 1 by 2 cm firm. movable and nontender purple nodules on her upper and lower extremities, anterior and left lateral chest, and forehead. The remainder of her exam was unremarkable. Admission lab values included: WBC EOOO/mm3 with 18% neutrophils, 76Y lymphocytes. and 5% monocytes; hematocrit 29.7%. hemoglobin 9.8 gm/dl. and platelet count 346.000. Serum electrolytes. glucose, creatinine, liver function tests, and sweat chloride test were normal. Urine analysis was unremarkable. Coagulation studies revealed PT of 53 seconds (control 12). PTT greater than 180 (control 34), and TCT 18 (control 16). In order to correct the abnormal coagulation studies. she was given 2 mg. of Vitamin Kl intramuscularly. Because the bleeding persisted. eight hours later she was given an additional I mg of Vitamin Kl intravenously. One hour later. she received 70 cc. of fresh frozen plasma. Her bleeding stopped nine hours after the fresh frozen plasma. This pattern of response is typically seen with the excessive anticoagulants. e.g.. warfarin. which require!, high dose
Munchausen
351
by proxy
Vitamin K replacement. This is in contrast to hypoprothrombinemia of Vitamin K deficiency which usually responds to small doses of Vitamin Kl or K3. Congenital. circulating anticoagulants (e.g., lupus), and hepatic Vitamin K deficiency responds to neither Vitamin Kl nor K3. Because of our suspicion of warfarin ingestion which the mother emphatically denied. a blood sample was sent to the National Medical Services. Inc. in Pennsylvania. The warfarin level was 3.8 me/ml which is a pharmacological active level. DISCUSSION Munchausen by proxy syndrome can be a serious form of child abuse. If not immediately recognized. it may evolve into the death of the child. There are many different symptoms in this syndrome [9]. This case has the characteristics of a hemorrhagic disorder. Because of the laboratory results, the first etiologic cause considered was warfarin ingestion. Warfarin is an ingredient in some rodenticides, but it is unlikely to have produced this picture, unless it had been ingested chronically. A single dose of rat poison may depress the prothrombin time to therapeutic levels but is unlikely to depress it to hemorrhagic levels [IO]. This was the patient’s second episode of bleeding over three to four weeks which suggests repeated doses of warfarin ingestion and would make accidental ingestion less likely. The psychodynamics of the mother and child were of major concern. The patient’s mother had some of the characteristics [3, 41 of those who ingest warfarin to create a factitious disease: limited medical knowledge. extensive reading of medical books, and access to the drug. The mother was withdrawn. lacked motivation. and was anorexic with weight loss. She lacked socialization and cried on many occasions. The mother prevaricated in many instances concerning family members. She felt unloved and undesired by her family (this was denied by her parents). When issues of her daughter were discussed, the mother became defensive. She felt no one else could care for her daughter, and with the exception of a few hours had not left the child since her birth. When initially confronted with our suspicions, the mother threatened to take the child out of the hospital. Following this discussion. custody of the child was taken from the mother. at which time she became hysterical. The mother was thought to be depressed but not suicidal and was referred to the psychiatric inpatient service. She has never admitted to administering the warfarin to her daughter before or after the psychiatric admission. In the literature [2-41 malingering lasted for years before the patient admitted to taking anticoagulants. Because this case is pending prosecution, detailed information concerning the mother’s psychological status is being withheld. The infant was removed from the home and placed with an aunt. She is now growing at the 50 percentile for weight and height. She is to remain in foster care until litigation is resolved. This case report is presented to describe another example of the use of a drug to induce illness in a child to meet psychological needs of the parent. This form of child abuse needs to be considered in the differential diagnosis of bleeding disorders. Addendum Mother pleaded guilty to felonious child abuse (maximum will depend on psychological improvement.
sentence,
5 years).
Sentencing
REFERENCES 1. STAFNE.
W. A.. M3E. A. E. Hypoprothrombinemia due to Dicumarol in a malingerer: 35:910-911 (1951). 1 BOWIE. E. J. TODD. M. et al. Anticoagulant malingerers (The “Dicumarol-Eaters”). -’ .Medrcrne 37:855-864 (1965). Inrernal
Case report.
Annals of
Medrine
Amerrcan Journal
of
352
Susanne
T. White.
Karen
Voter and Joan
Perr!
3. ANGLE, D. P., RATNOFF. 0. D. et al. The anticoagulant malingerer. ,-Lwa/.r qt fnrrrttul .\fed/crw 73:67-72 (1970). 4. O’REILLY, R. and AGGELER. P. M. Overt anticoagulant ingestion: Study of 25 patients and review of ~orld literature. Medicrne 55:389-399 (1976). 5. MEADOW, R. Munchausen syndrome by proxy: The hinterland of child abuse. Luncer 11:?43-346 (1977). 6. CANTWELL. H. Child protective services in parental mismangement of diabetes. nie Dfuheric Edtrcuror 10:41-43 (1984). 7. SCHWARTZ, W. Bacteriologically battered baby. Annals of Emergency ,Medme 11:205-707 ( 1982). 8. ROGERS, D. et al. Non-accidental poisoning: An extended syndrome of child abuse. Br~rsh .Medrcu/ Jourrtul 1:793-796 (1976). 9. MEADOW, R. Munchausen syndrome by proxy. Archives of Diseases of Chddhood 57:92-98 ( 1982). 10. BREWER, E. and HAGGERTY, T. Toxic hazards rat poisons I-Warfarin. The .Yew Ep$mfJound of.Cfedrcrrte 257:145-146 (1957).
0145-2134185 $300 + .oO Copyright 6, /9R5 Pergamon Press Ltd
1985
SURREPTITIOUS
WARFARIN
SUSANNE T. WHITE, M.D.,
INGESTION M.P.H.
Department of Pediatrics, Schoolof Medicine, University of North Carolina, Chapel Hill, NC and Pediatric Teaching Service,
Wake
Area Health Education Center, Wake County Medical Center. 3ooO New Bern Ave., Raleigh, NC 27610
KAREN VOTER, M.D. AND JOAN PERRY, M.D. Department of Pediatrics, School of Medicine, University of North Carolina. Chapel Hill Abstract-Munchausen by proxy has been reported involving children who have been given various drugs or toxins. In addition, there is a body of adult literature regarding covert anticoagulant ingestion. This is a case of an I Imonth-old female who appears to combine features of both of these syndromes. This child presented with an acute left hemorrhagic otitis media. The physical examination was unremarkable except for the following: weight, fifth percentile: left external auditory canal filled with blood with the right external canal and tympanic membrane being normal; andseveral scattered 1 x 2 cm firm, movable, nontender. purple nodules on extremities, chest and forehead. The coagulation studies were consistent with Vitamin K deficiency secondary to anticoagulant ingestion. A serum warfarin study confirmed our suspicions. The mother was noted to have a dependent relationship with her child and characteristics of those involved in Munchausen by proxy: falsifying information and thwarting medical assessment. In addition, she displayed some of the characteristics found commonly in anticoagulant malingerers. She was depressed, with limited medical knowledge, and had access to warfarin. The mother was admitted for inpatient psychiatric care and the patient placed with an extended family member. This case report describes the use of an anticoaguI~t to induce illness in a child by a psychologically ill mother. This form of child abuse must be considered in the differential diagnoses of hemorrhagic disorders. Resume-On a pris l’habitude d’appeler syndrome de Munchausen par procuration les situations 00 un enfant a ete intoxiqut par une toxine ou un mtdicament volontairement par un ad&e. La litttrature contient Cgalement des renseignements abondants sur l’ingestion cachee d’anticoagulants. Les auteurs ont observe une fillette de 11mois qui a ett intoxiquee avec un anticoagulant repondant ainsi rj la definition du syndrome de Munchausen par procuration. La fillette a ete soumise B l’attention medicale B cause dune otite moyenne gauche h~morragique. Le poids de l’enfant etait sur le percentile 5, le conduit auditif exteme gauche itait rempli de sang et le conduit a drone etait normal; en plus il y avait plusieurs nodules viola& non douloureux, mobiles de I A 2 cm de diametre sur les extremites. le thorax et le front. L’ttude de la erase montrait des anomalies compatibles avec une insuffisance en vitamine K secondaire B l’ingestion d’anticoagulants. Un taux sanguin de Warfarin a confirme ce diagnostic. La mere presentait des caracteristiques deja d&rites dans le syndrome de Munchausen par procuration. une relation trts dependante avec I’enfant, des informations faussees et la tendance a egarer le jugement medical par une anamntse fausse. Elle presentait aussi des caracteristiques qu’on trouve chew les gens qui simulent par les anticoagulants. Elle etait dtprimee. avec des notions medicales minimes et avait a&s & la Warfarin. On a hospital&e cette mere en psychiatric et le bebe a ite place aupres d’autres membres de la famille. II s’agit done ici dun rapport concernant une mere perturbee psychologiquement induisant une maladie par un anticoagulant chez son enfant. Cette forme de maltraitance d’enfant doit naturellement etre considerte lorsqu’on fait un diagnostic de coagulopathie a cet age.
SURREPTITIOUS WARFARIN INGESTION to induce factitious disease is well documented in the adult literature [l-4]. Patients are characterized as women in the 20- to 3%yearold age range who are affiliated with the field of medicine (nurses, medical students, pharmacists. veterinarians. etc.) or elderly patients who have had previous supervised therapy with these drugs. A variety of motives are cited for the nontherapeutic use of warfarin including murder. suicide, abortion. error and malingering. The most common of these is malingering in which the patient purposely enters into a relationship with the physician which is based on 349
350
Susanne
T. White.
Karen
Voter and Joan
Perr!
deception. In order to continue the relationship. the patient has a need to pre~~lt hcrhrlt‘ ,I\ being ill. Munchausen by proxy is becoming increasingly recognized. This is a form of child ;tbu\e which is somewhat unusual in that the child is made to appear serioubl\ ill in order to obtain medical care. Previously reported cases have included factitious uriiar? abnarmallties [5]. mismanagement of diabetes [6], frequent and unusual infections [7]. and nonaccidental potsoning [El. These cases have in common that the illness. or appearance of ilInes\. i.\ a rehult of parental (usually maternal) actions. The histories which accompany the findings are falsified. and the consequences of the action are severe for the child both in diagnositc evaluation 2nd therapy. The mother tends to demand attention from the staff and yet manipulates the situation to thwart medical assessment of the true situation. The followmg report describes such features of both diseases in a pediatric case. CASE REPORT An 1 l-month-old black female was well until two months prior to admission when she was diagnosed to have gastroenteritis with dehydration requiring hospitalization. The gastroenteritis resolved and she was discharged after 12 days. Subsequently. she had two hospitalizations for evaluation of intermittent vomiting and failure to thrive. Her workups during these admissions included normal upper gastrointestinal roentgenograms and metabolic studies. Emesis was reported by the mother but never observed by the medical personnel. The patient was discharged and followed weekly as an outpatient for weight checks. Over the next three weeks she was treated with trimethoprim-sulfamethoxazole for acute hemorrhagic otitis media then erthyromycin ethylsuccinate-sulfisoxazole acetyl for persistent otitis media and tinally placed on amoxicillin. The patient returned on the day of admission because of recurrence of gross bloody discharge from her left ear and multiple hematomas. The mother denied the child had a history of fever, URI symptoms, trauma, ingestion of other drugs. bruising. or bleeding from other sites. She also denied a family history of bleeding disorders or anemias. The social history is significant in that the mother is 21 years old. single. and lives with her parents. The mother was a nurse’s aide prior to delivery of this child and was treated \vith warfarin for deep vein thrombosis prior to pregnancy. HOSPITAL COURSE The admission physical exam included normal vital signs. weight 7.22 kg (5%). height 70 cm (.500/c),and head circumference 46 cm (75%). Examination of the ears re\ealed a left external auditory canal filled with blood and an easily visualized right tympanic membrane that was entirely normal. The skin was remarkable for several scattered 1 by 2 cm firm. movable and nontender purple nodules on her upper and lower extremities, anterior and left lateral chest, and forehead. The remainder of her exam was unremarkable. Admission lab values included: WBC EOOO/mm3 with 18% neutrophils, 76Y lymphocytes. and 5% monocytes; hematocrit 29.7%. hemoglobin 9.8 gm/dl. and platelet count 346.000. Serum electrolytes. glucose, creatinine, liver function tests, and sweat chloride test were normal. Urine analysis was unremarkable. Coagulation studies revealed PT of 53 seconds (control 12). PTT greater than 180 (control 34), and TCT 18 (control 16). In order to correct the abnormal coagulation studies. she was given 2 mg. of Vitamin Kl intramuscularly. Because the bleeding persisted. eight hours later she was given an additional I mg of Vitamin Kl intravenously. One hour later. she received 70 cc. of fresh frozen plasma. Her bleeding stopped nine hours after the fresh frozen plasma. This pattern of response is typically seen with the excessive anticoagulants. e.g.. warfarin. which require!, high dose
Munchausen
351
by proxy
Vitamin K replacement. This is in contrast to hypoprothrombinemia of Vitamin K deficiency which usually responds to small doses of Vitamin Kl or K3. Congenital. circulating anticoagulants (e.g., lupus), and hepatic Vitamin K deficiency responds to neither Vitamin Kl nor K3. Because of our suspicion of warfarin ingestion which the mother emphatically denied. a blood sample was sent to the National Medical Services. Inc. in Pennsylvania. The warfarin level was 3.8 me/ml which is a pharmacological active level. DISCUSSION Munchausen by proxy syndrome can be a serious form of child abuse. If not immediately recognized. it may evolve into the death of the child. There are many different symptoms in this syndrome [9]. This case has the characteristics of a hemorrhagic disorder. Because of the laboratory results, the first etiologic cause considered was warfarin ingestion. Warfarin is an ingredient in some rodenticides, but it is unlikely to have produced this picture, unless it had been ingested chronically. A single dose of rat poison may depress the prothrombin time to therapeutic levels but is unlikely to depress it to hemorrhagic levels [IO]. This was the patient’s second episode of bleeding over three to four weeks which suggests repeated doses of warfarin ingestion and would make accidental ingestion less likely. The psychodynamics of the mother and child were of major concern. The patient’s mother had some of the characteristics [3, 41 of those who ingest warfarin to create a factitious disease: limited medical knowledge. extensive reading of medical books, and access to the drug. The mother was withdrawn. lacked motivation. and was anorexic with weight loss. She lacked socialization and cried on many occasions. The mother prevaricated in many instances concerning family members. She felt unloved and undesired by her family (this was denied by her parents). When issues of her daughter were discussed, the mother became defensive. She felt no one else could care for her daughter, and with the exception of a few hours had not left the child since her birth. When initially confronted with our suspicions, the mother threatened to take the child out of the hospital. Following this discussion. custody of the child was taken from the mother. at which time she became hysterical. The mother was thought to be depressed but not suicidal and was referred to the psychiatric inpatient service. She has never admitted to administering the warfarin to her daughter before or after the psychiatric admission. In the literature [2-41 malingering lasted for years before the patient admitted to taking anticoagulants. Because this case is pending prosecution, detailed information concerning the mother’s psychological status is being withheld. The infant was removed from the home and placed with an aunt. She is now growing at the 50 percentile for weight and height. She is to remain in foster care until litigation is resolved. This case report is presented to describe another example of the use of a drug to induce illness in a child to meet psychological needs of the parent. This form of child abuse needs to be considered in the differential diagnosis of bleeding disorders. Addendum Mother pleaded guilty to felonious child abuse (maximum will depend on psychological improvement.
sentence,
5 years).
Sentencing
REFERENCES 1. STAFNE.
W. A.. M3E. A. E. Hypoprothrombinemia due to Dicumarol in a malingerer: 35:910-911 (1951). 1 BOWIE. E. J. TODD. M. et al. Anticoagulant malingerers (The “Dicumarol-Eaters”). -’ .Medrcrne 37:855-864 (1965). Inrernal
Case report.
Annals of
Medrine
Amerrcan Journal
of
352
Susanne
T. White.
Karen
Voter and Joan
Perr!
3. ANGLE, D. P., RATNOFF. 0. D. et al. The anticoagulant malingerer. ,-Lwa/.r qt fnrrrttul .\fed/crw 73:67-72 (1970). 4. O’REILLY, R. and AGGELER. P. M. Overt anticoagulant ingestion: Study of 25 patients and review of ~orld literature. Medicrne 55:389-399 (1976). 5. MEADOW, R. Munchausen syndrome by proxy: The hinterland of child abuse. Luncer 11:?43-346 (1977). 6. CANTWELL. H. Child protective services in parental mismangement of diabetes. nie Dfuheric Edtrcuror 10:41-43 (1984). 7. SCHWARTZ, W. Bacteriologically battered baby. Annals of Emergency ,Medme 11:205-707 ( 1982). 8. ROGERS, D. et al. Non-accidental poisoning: An extended syndrome of child abuse. Br~rsh .Medrcu/ Jourrtul 1:793-796 (1976). 9. MEADOW, R. Munchausen syndrome by proxy. Archives of Diseases of Chddhood 57:92-98 ( 1982). 10. BREWER, E. and HAGGERTY, T. Toxic hazards rat poisons I-Warfarin. The .Yew Ep$mfJound of.Cfedrcrrte 257:145-146 (1957).