SELF*INDUCED
HEMATURIA
Rajeshwar
P.
Abrol,
MD,
Amy
Heck,
MD,
Louis
Gleckel,
MD,
and
Fred
Rosner,
MD
Jamaica,
New
York
Two
patients,
an
adult
and
a
child,
are
reported
who
presented
with
factitious
hematuria
secon-
dary
to
self-induced
finger
sticks
with
contami-
nation
of
unwitnessed
urine
samples.
Feigned
illness
of
this
kind
may
be
more
common
than
generally
appreciated.
In
1951,
Asherl
coined
the
term
Munchausen
syndrome
to
refer
to
a
bizarre
variant
of
chronic
factitious
illness
in
which
the
patient
self-induces
or
fabricates
signs
and
symptoms
of
serious
pathology,
such
as
hemorrhage,
fever,
seizures,
or
skin
lesions.
Such
pathologic
liars
often
travel
from
hospital
to
hospital
gaining
admission
by
means
of
dramatic
acts
of
illness
or
feigned
illness,
often
convincing
physi-
cians
and
psychiatrists
alike
of
underlying
organic
disease.
Less
commonly,
detailed
cases
of
children
are
reported,
rarely
with
psychiatric
background
to
explain
this
unusual
behavior.
We
report
two
patients,
an
adult
and
an
adolescent,
who
intentionally
contaminated
their
urine
specimens
with
drops
of
blood
from
self-inflicted
finger
sticks
to
gain
admission
to
the
hospital.
CASE
1
A
10-year-old
black
male
was
hospitalized
for
evaluation
of
blood
in
the
urine
of
1-week's
duration.
There
was
no
history
of
fever,
chills,
nausea,
vomiting,
From
the
Department
of
Medicine,
Queens
Hospital
Center
Affiliation
of
the
Long
Island
Jewish
Medical
Center,
Jamaica,
New
York,
and
the
Albert
Einstein
College
of
Medicine
of
Yeshiva
University.
Reprint
requests
should
be
addressed
to
Fred
Rosner,
MD,
Queens
Hospital
Center,
82-68
164th
Street,
Jamaica,
NY
11432.
dysuria,
polyuria,
frequency,
or
urgency.
The
patient's
parents
were
recently
divorced
and
the
father's
visitation
rights
were
limited
to
every
other
weekend.
The
patient
lives
with
his
mother,
her
live-in
boyfriend,
and
five
brothers
in
a
one-bedroom
apartment.
Dissatisfaction
with
his
living
conditions
and
a
fear
of
relating
problems
to
his
family
were
clear
during
the
interview.
Although
he
idolized
his
father,
he
never
spent
time with
him
and
his
mother
devoted
all
her
attention
to
her
boyfriend.
Direct
complaints
to
his
mother
appeared
to
be
met
with
resentment
and
not
with
increased
attention.
Physical
examination
was
entirely
normal.
The
only
abnormal
laboratory
finding
was
gross
hematuria.
During
his
hospitalization,
the
medical
staff
noted
that
the
patient
never
interacted
with
other
children
on
the
ward.
He
gladly
consented
to
provide
a
urine
specimen
for
analysis
on
a
daily
basis,
but
insisted
on
total
privacy
when
urinating.
After
several
days
a
nurse
noted
small
puncture
wounds
on
his
fingers,
which
he
at
first
claimed
were
caused
by
accidental
cuts
but
could
provide
no
further
details.
After
several
psychotherapeutic
sessions,
the
patient
admitted
to
sticking
his
finger
with
a
needle
and
dipping
his
finger
into
his
urine.
He
believed
that
the
only
way
he
could
see
his
father
more
often
was
to
be
hospitalized.
CASE
2
A
48-year-old
white
man
presented
with
severe
right-sided
abdominal
and
flank
pain.
He
stated
that
he
had
passed
kidney
stones
in
the
past
and
that
this
pain
was
similar
to
previous
episodes.
The
patient
appeared
in
moderate
distress
with
considerable
emphasis
on
his
right
flank
tenderness.
Abdominal
radiographs
showed
three
small
radio-opaque
densities
in
the
right
renal
JOURNAL
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127
SELF-INDUCED
HEMATURIA
area.
There
were
many
red
blood
cells
in
his
urine.
Right
renal
colic
was
diagnosed,
and
the
patient
was
treated
with
hydration
and
analgesia.
No
gravel
or
stones
were
found
on
examination
of
several
strained
urine
samples,
but
all
specimens
contained
many
red
blood
cells.
On
the
second
hospital
day
the
patient
offered
information
that
he
required
100
to
200
mg
of
intravenous
meperidine
(Demerolg)
every
3
hours
to
control
his
pain.
When
questioned
further
about
the
kidney
stones,
he
claimed
that
he
had
previously
asked
doctors
to
place
foreign
bodies
in
his
right
kidney
through
the
urethra.
He
also
admitted
that
whenever
he
provided
a
urine
sample
he
would
prick
his
finger
with
a
needle
and
allow
several
drops
of
blood
to
mix
in
his
urine
specimen.
When
offered
a
treatment
program
for
his
drug
addiction,
he
refused
and
promptly
signed
himself
out
of
the
hospital
against
medical
advice.
We
subsequently
learned
that
several
days
later
the
patient
presented
to
the
emergency
room
of
another
hospital
almost
500
miles
away
with
the
same
complaints.
DISCUSSION
Patients
with
Munchausen
syndrome
characteristi-
cally
travel
from
hospital
to
hospital,
feigning
acute,
sometimes
spectacular,
illnesses
and
submit
willingly
to
extensive
diagnostic
and
therapeutic
procedures.24
The
underlying
needs
of
patients
may
vary
considerable,
as
exemplified
in
our
two
cases,
from
drug
addiction
to
a
basic
need
for
emotional
attention.
Other
times,
the
patients'
psychiatric
needs
are
not
apparent.
Through
these
patients'
manipulations,
medical,
surgical,
and
psychiatric
services
are
often
disrupted,
and
patients
are
eventually
either
asked
to
leave
or
choose
to
sign
out
against
medical
advice
when
confronted
with
alternative
therapies,
as
was
clearly
the
case
with
our
second
patient.
Our
first
case
is
unusual
in
that
this
was
the
patient's
first
episode
of
fabrication
of
illness
and
it
occurred
at
a
young
age.
Similar
instances
of
factitious
hematuria
have
been
previously
reported
by
pediatricians,
but
these
are
usually
falsifications
by
the
mother.5-7
The
case
of
maternal
tampering
with
urine
samples
resulting
in
numerous
invasive
diagnostic
procedures
in
a
6-year-old
child5
is
a
serious
and
often
overlooked
cause
of
child
abuse,6
which
has
been
called
Munchausen
syndrome
by
proxy.5
Rarely,
an
implication
of
falsification
by
the
child
is
made,
but
without
proof.8
The
early
discovery
of
our
patient's
feigned
illness
contributed
to
a
clear
understanding
of
the
boy's
behavior
and
his
reasons
for
self-induced
factitious
illness.
With
further
counseling,
the
boy's
need
to
receive
attention
from
his
mother
and
spend
time
with
his
father
may
be
fulfilled.
Chronic
malingering
in
a
child
with
self-induced
hematuria
and
a
clinical
picture
of
renal
colic
has
been
reported.8
Although
reviews
of
Munchausen
syndrome
have
appeared
in
the
general
medical3
and
psychiatric4
literatures,
our
purpose
in
reporting
these
two
cases
is
to
call
attention
to
an
easily
missed
manifestation
of
this
entity
and
to
heighten
awareness
of
medical
practitioners
to
this
unusual
presentation
of
factitious
illness.
Acknowledgments
The
authors
are
indebted
to
Mrs
Annette
Carbone
for
typing
the
manuscript.
Literature
Cited
1.
Asher
R.
Munchausen's
Syndrome.
Lancet.
1951
;1:339-
341.
2.
Justus
PG,
Kreutziper
SS,
Kitchens
CS.
Probing
the
dynamics
of
Munchausen's
Syndrome.
Detailed
analysis
of
a
case.
Ann
Intern
Med.
1
980;93:120-127.
3.
Aduan
RP,
Fauci
AS,
Dale
DD,
et
al.
Factitious
fever
and
self-induced
infection.
A
report
of
32
cases
and
review
of
the
literature.
Ann
Intern
Med.
1979;90:230-242.
4.
Spiro
HR.
Chronic
factitious
illness.
Munchausen's
Syn-
drome.
Arch
Gen
Psychiatry.
1968;18:569-579.
5.
Meadow
R.
Munchausen-Syndrome
by
proxy:
the
hinter-
land
of
child
abuse.
Lancet.
1977;2:343-345.
6.
\'.isrub
S.
Baron
Munchausen
and
the
abused
child.
JAMA.
1978;239:752.
7.
Williams
C,
Bevan
VT,
et
al.
The
secret
observation
of
children
in
hospital.
Lancet.
1988;1
:780-781.
8.
Sneed
RC,
Bell
RF.
The
Dauphin
of
Munchausen:
factitious
passage
of
renal
stones
in
a
child.
Pediatrics.
1976;58:1
27-130.
128
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