View source for WBR0502

{{WBRQuestion
|QuestionAuthor={{AO}}
|ExamType=USMLE Step 1
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|Prompt=A 7-year-old boy was brought to the clinic by his mother on account of fever (T-103.9F), cough and wheeze for the past 6 days.  The mother also stated that the child had a decreased oral intake for 3 days, and decreased urine output for 2 days.  Over the last 24 hours, the child developed nausea, vomiting, and diarrhea.  The parents have recently separated and it has affected the boy’s grades in school.  The child's past medical history included neurofibromatosis, asthma, seizure disorder, attention-deficit/hyperactivity disorder, and pneumonia.  Current medications included methylphenidate, albuterol, and amoxicillin.  He had no known drug allergy.  Mother has neurofibromatosis and insulin-dependent diabetes mellitus.  Physical examination revealed a well-nourished, lethargic, and ill-appearing boy.  His temperature was 96.5°F (35.8°C), pulse rate was 129 beats per minute, blood pressure was 110/58 mm Hg, and respiratory rate was 28.  Over the next two days, there were recurrent hypoglycemic episodes, plasma glucose level of 33 mg/dL (60–110 mg/dL) which was more pronounced at night shortly before the mother left for work, and miraculously normalized during the day after intravenous glucose administration.  Serum insulin level of 2344 µU/mL (5–25 µU/mL) and a C-peptide level of 0.9ng/mL (0.8–4.0 ng/mL) during the first hypoglycemic episode.

Which of the following explains the cause of the boy’s hypoglycemia?






|Explanation=[[Munchausen syndrome by proxy]] is a pattern of behavior in which a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological, behavioral, and/or mental health problems in those who are in their care. In this vignette, the child was been injected insulin as demonstrated by the markedly elevated plasma insulin level despite a normal serum C-peptide level, and the mother was most likely responsible.  

Munchausen syndrome by proxy should be suspected in the following scenarios:
* Persistent or recurrent illness that cannot be explained
* Discrepancies between clinical findings and history
* Symptoms that occur only when the mother (or suspected perpetrator) is present
* Symptoms or treatment course that is not clinically consistent
* A working diagnosis that is less plausible than Munchausen syndrome by proxy
* A mother who welcomes even painful medical tests for her child, is constantly at the bedside, and has previous medical experience, yet seems less concerned than the medical staff about the health of her child
* Family history of sudden or unexplained infant death

|AnswerA=Malingering
|AnswerAExp=Incorrect.  This is fabricating or exaggerating the symptoms of mental or physical disorders in order to attain a "secondary gain" which may include financial compensation, avoiding school, work or military service, obtaining drugs, getting lighter criminal sentences, or simply to attract attention or sympathy.  These complaints cease with attainment of the secondary gain.
|AnswerB=Munchausen’s syndrome by proxy
|AnswerBExp=Correct.  This happens when illness in a child is caused by a caregiver.
|AnswerC=Adjustment disorder
|AnswerCExp=Incorrect.  This is a condition where an individual is unable to adjust to or cope with a particular stressor, like a major life event.  Symptoms may include anxiety or depression, and which lasts for less than 6 months.
|AnswerD=Munchausen syndrome
|AnswerDExp=Incorrect.  [[Munchausen syndrome]] is a psychiatric factitious disorder wherein those affected exaggerate diseases, illnesses, or psychological trauma to draw attention, sympathy, or reassurance to themselves. It is also sometimes known as hospital addiction syndrome, thick chart syndrome, or hospital hopper syndrome.  There is a history of multiple hospital admissions and willingness to receive invasive procedures.

|AnswerE=Somatization disorder
|AnswerEExp=Incorrect.  [[Somatization disorder]], a.k.a  Briquet's syndrome or [[hysteria]], is characterized by recurring, multiple, clinically significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms.  Individuals with somatization disorder typically visit many doctors in pursuit of effective treatment
|RightAnswer=B
|WBRKeyword=Munchausen syndrome by proxy
|Approved=No
}}