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A factitious chronic disease&#44; which can be severe and disabling&#59; 2&#41; the pilgrimage&#58; individuals change hospitals&#44; cities or country when their objectives are unsuccessful or discovered&#59; 3&#41; <span class="elsevierStyleItalic">pseudologia fantastica</span>&#58; amazing stories are described with complete certainty&#46; Cases have been described in which parents have made their children sick to reap benefits&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">We present the case of a 31-year-old nurse on haemodialysis with a permanent pacemaker due to tachycardia&#47;bradycardia syndrome and chronic kidney disease with not well-defined cause&#44; who had been diagnosed a year prior&#46; She checked in at the emergency department reporting fever with chills&#44; anuria and general discomfort&#46;</p><p class="elsevierStylePara">Physical examination confirmed absence of blood pressure &#40;BP&#41; or pulse in the upper limbs&#44; skin pallor and signs of mild dehydration&#46; Heart rate&#58; 118 beats&#47;min&#44; respiratory rate&#58; 24 breaths&#47;min and temperature of 38&#46;5&#176;C&#46; The haemodialysis catheter showed signs of infection in the insertion site &#40;it was withdrawn and cultured&#41;&#46; The rest of the physical examination was normal&#44; with a preliminary diagnosis of septic shock by catheter infection&#46; The treatment included vasopressors and antimicrobials and patient was moved to the intensive care unit &#40;ICU&#41;&#46;</p><p class="elsevierStylePara">Upon arrival to the ICU the adequate skin perfusion contrasted with the diagnosed<span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">septic shock</span>&#46; There was no BP in the upper limbs&#44; since arteriovenous fistulae had been created in the forearms without reaching flow&#44; but the lower limps showed a BP of 150&#47;90mm Hg&#44; so the vasopressor treatment was terminated&#46; The patient refused to have a bladder catheter placed&#46; The initially diminished central venous pressure was normalised with hydration and a wide and clear diuresis was recovered&#46;</p><p class="elsevierStylePara">The analysed found&#58; leukocytosis &#40;18x10<span class="elsevierStyleSup">9</span>&#47;l&#41;&#44; anaemia &#40;108g&#47;l&#41; and high serum creatinine &#40;158&#181;mol&#47;l&#41;&#46; Other complementary studies&#44; including arterial blood gasometry&#44; ionogram&#44; glycaemia and urine sediment&#44; gave results within the normal limits&#46; The ultrasound showed kidneys and urinary tract of normal size and echogenicity&#46; On the third day&#44; creatinine levels had already reached normal values and there was no evidence of kidney disease&#46; Blood cultures with<span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">methicillin-resistant Staphylococcus aureus </span><span class="elsevierStyleItalic">were performed</span>&#46;</p><p class="elsevierStylePara">Faced with the evidence&#44; MS was strongly suspected and psychological assessment was requested&#46; In the interview&#44; the patient cooperated but refused to undergo a psychometric evaluation and denied having faked the symptoms or altered samples&#46;</p><p class="elsevierStylePara">The patient&#39;s profession &#40;nursing&#41; allowed her to carry blood samples to the laboratory&#44; where she supposedly would add a few drops of urine to raise the levels of creatinine significantly&#46; On many occasions haemodialysis was not concluded due to &#34;discomfort&#34;&#46; Patient always refused to undergo a renal biopsy&#44; despite it being appropiate&#46;<span class="elsevierStyleSup">5</span> It is speculated that the dysrhythmia could have been caused by self-prescription heart-rate altering drugs and that arteriovenous fistulae were damaged by the patient&#46;</p><p class="elsevierStylePara">Days later&#44; she was withdrawn from the haemodialysis programme&#46; To date&#44; she remains asymptomatic and has re-joined social life&#46; Motives could not be determined with certainty&#46;</p><p class="elsevierStylePara">There are certain criteria that allow us to suspect MS &#40;Table&#41;&#46; The diagnosis must be done with caution&#44; because a mistake can be fatal&#46; Psychological treatment depends on personality type and the likely aetiology&#44; although in most cases the patients evade treatment&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Mortality rates may be high due to body self-manipulation&#44; complications of procedures&#44; and hiding important medical information&#59; besides&#44; when they really become ill&#44; these patients can be ignored because of their history&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In conclusion&#44; MS should be considered in any patient with inconsistencies between their symptoms and the clinical tests&#46; Although it is a rare disease&#44; its diagnosis is essential for the serious consequences that it can cause on the patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11402&#95;16025&#95;33480&#95;en&#95;t111402&#95;i&#46;jpg" class="elsevierStyleCrossRefs"><img src="11402_16025_33480_en_t111402_i.jpg" alt="Main observations that point towards malingering and factitious disorders"></img></a></p><p class="elsevierStylePara">Table 1&#46; Main observations that point towards malingering and factitious disorders</p>"
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31 year old woman with Munchausen syndrome in haemodialysis. Case report and literature review
Mujer de 31 años con síndrome de Munchausen en hemodiálisis. Reporte de un caso y revisión de la literatura
, , Alain Cruz-Portellesb, Alain Cruz-Portellesb, Bernardo E. Fernández-Chelalab, Yuliet Peña-Castilloc
b Servicio de Terapia Intensiva, Hospital General Universitario V. I. Lenin, Holguín, Cuba,
c Servicio de Psicología Clínica, Hospital General Universitario V. I. Lenin, Holguín, Cuba,
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A factitious chronic disease&#44; which can be severe and disabling&#59; 2&#41; the pilgrimage&#58; individuals change hospitals&#44; cities or country when their objectives are unsuccessful or discovered&#59; 3&#41; <span class="elsevierStyleItalic">pseudologia fantastica</span>&#58; amazing stories are described with complete certainty&#46; Cases have been described in which parents have made their children sick to reap benefits&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">We present the case of a 31-year-old nurse on haemodialysis with a permanent pacemaker due to tachycardia&#47;bradycardia syndrome and chronic kidney disease with not well-defined cause&#44; who had been diagnosed a year prior&#46; She checked in at the emergency department reporting fever with chills&#44; anuria and general discomfort&#46;</p><p class="elsevierStylePara">Physical examination confirmed absence of blood pressure &#40;BP&#41; or pulse in the upper limbs&#44; skin pallor and signs of mild dehydration&#46; Heart rate&#58; 118 beats&#47;min&#44; respiratory rate&#58; 24 breaths&#47;min and temperature of 38&#46;5&#176;C&#46; The haemodialysis catheter showed signs of infection in the insertion site &#40;it was withdrawn and cultured&#41;&#46; The rest of the physical examination was normal&#44; with a preliminary diagnosis of septic shock by catheter infection&#46; The treatment included vasopressors and antimicrobials and patient was moved to the intensive care unit &#40;ICU&#41;&#46;</p><p class="elsevierStylePara">Upon arrival to the ICU the adequate skin perfusion contrasted with the diagnosed<span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">septic shock</span>&#46; There was no BP in the upper limbs&#44; since arteriovenous fistulae had been created in the forearms without reaching flow&#44; but the lower limps showed a BP of 150&#47;90mm Hg&#44; so the vasopressor treatment was terminated&#46; The patient refused to have a bladder catheter placed&#46; The initially diminished central venous pressure was normalised with hydration and a wide and clear diuresis was recovered&#46;</p><p class="elsevierStylePara">The analysed found&#58; leukocytosis &#40;18x10<span class="elsevierStyleSup">9</span>&#47;l&#41;&#44; anaemia &#40;108g&#47;l&#41; and high serum creatinine &#40;158&#181;mol&#47;l&#41;&#46; Other complementary studies&#44; including arterial blood gasometry&#44; ionogram&#44; glycaemia and urine sediment&#44; gave results within the normal limits&#46; The ultrasound showed kidneys and urinary tract of normal size and echogenicity&#46; On the third day&#44; creatinine levels had already reached normal values and there was no evidence of kidney disease&#46; Blood cultures with<span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">methicillin-resistant Staphylococcus aureus </span><span class="elsevierStyleItalic">were performed</span>&#46;</p><p class="elsevierStylePara">Faced with the evidence&#44; MS was strongly suspected and psychological assessment was requested&#46; In the interview&#44; the patient cooperated but refused to undergo a psychometric evaluation and denied having faked the symptoms or altered samples&#46;</p><p class="elsevierStylePara">The patient&#39;s profession &#40;nursing&#41; allowed her to carry blood samples to the laboratory&#44; where she supposedly would add a few drops of urine to raise the levels of creatinine significantly&#46; On many occasions haemodialysis was not concluded due to &#34;discomfort&#34;&#46; Patient always refused to undergo a renal biopsy&#44; despite it being appropiate&#46;<span class="elsevierStyleSup">5</span> It is speculated that the dysrhythmia could have been caused by self-prescription heart-rate altering drugs and that arteriovenous fistulae were damaged by the patient&#46;</p><p class="elsevierStylePara">Days later&#44; she was withdrawn from the haemodialysis programme&#46; To date&#44; she remains asymptomatic and has re-joined social life&#46; Motives could not be determined with certainty&#46;</p><p class="elsevierStylePara">There are certain criteria that allow us to suspect MS &#40;Table&#41;&#46; The diagnosis must be done with caution&#44; because a mistake can be fatal&#46; Psychological treatment depends on personality type and the likely aetiology&#44; although in most cases the patients evade treatment&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Mortality rates may be high due to body self-manipulation&#44; complications of procedures&#44; and hiding important medical information&#59; besides&#44; when they really become ill&#44; these patients can be ignored because of their history&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In conclusion&#44; MS should be considered in any patient with inconsistencies between their symptoms and the clinical tests&#46; Although it is a rare disease&#44; its diagnosis is essential for the serious consequences that it can cause on the patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11402&#95;16025&#95;33480&#95;en&#95;t111402&#95;i&#46;jpg" class="elsevierStyleCrossRefs"><img src="11402_16025_33480_en_t111402_i.jpg" alt="Main observations that point towards malingering and factitious disorders"></img></a></p><p class="elsevierStylePara">Table 1&#46; Main observations that point towards malingering and factitious disorders</p>"
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