1. Introduction

Hemoptysis is a medical emergency; it can be potentially life-threatening and is often a symptom of some underlying disease that may need medical attention. The causes of hemoptysis can be varied. Hence, any complaint of hemoptysis, trivial or otherwise, requires medical investigation. Hemoptysis for which no definite cause can be assigned usually involves lengthy and invasive diagnostic procedures.

Munchausen syndrome is a psychiatric disorder in which patients feign symptoms of physical diseases or disorders. Here we report two cases in which patients suffering from this disorder feigned hemoptysis and discussed the manifestations and etiology of the Munchausen syndrome.

Case report 1: Case of the blood-stained pillowcase

A 22-year-old woman arrived at the emergency room, complaining of daily hemoptysis occurring in the morning. The patient stated that she had noted fresh (bright red) and old (brown) blood on her pillowcase, which was confirmed by the patient’s mother.

Her past medical history was significant for anemia and migraine headache, but failed to reveal any pulmonary conditions. The patient was not currently taking any medications. She denied recent travel, and there was no significant family history revealed.

A physical exam revealed no abnormalities. The chest was clear with no adventitious sounds heard, and no cough was noted. Heart rate was regular, and no murmur was observed. The abdomen was soft and non-tender; no masses were palpated. Neurological exam revealed no deficits. A thorough exam of the mouth, nose, and throat did not shed any light on the reason for the patient’s hemoptysis. Vital signs were obtained and were essentially normal: temperature 37.2 degrees Celsius, blood pressure 110/75. Respiratory rate was 12 breaths per minute and easy; heart rate was 105 beats per minute, and oxygen saturation was 95%. Patient workup, including a technetium-99m labeled RBC scan, failed to identify any source of the bleeding.

The patient was admitted to hospital for monitory and further testing. On two occasions, the patient expectorated fresh blood (approximately one to two teaspoons) onto her pillowcase; however, these episodes were not witnessed by nursing or medical staff.

After extensive testing inckuding one CT SCAN of the chest, two bronchoscopies and ENT examination, no explanation for the patient’s bleeding could be found. The medical staff began to entertain the idea that the patient possibly had a factitious disorder and asked Psychiatry to evaluate the patient. The client was evaluated, and subsequently, a diagnosis of Munchausen syndrome was made. The patient’s parents were notified of the diagnosis. The patient signed herself out of the hospital AMA (against medical advice) and was offered outpatient counseling. The patient never revealed what method she had used to simulate the hemoptysis and this remained a mystery.

Case Study 2: Hemoptysis in a Young Male

A young male in his 20s arrived at the emergency room with a chief complaint of hemoptysis. He was actively expectorating fresh blood and was seen immediately by the emergency physician on duty who had the patient moved to an isolation room when it was discovered that he was in possession of anti-tuberculosis drugs.

It was determined that the patient had been seen by at least three other hospitals in the outlying areas for the same complaint. He had in his possession a voluminous file containing documentation related to prior treatment he had received, which included all of the tests that would be commonly ordered for hemoptysis. The patient had undergone many invasive procedures, including three fiberoptic bronchoscopies and an upper gastric endoscopy, but the documentation failed to reveal a possible cause for his condition.

Upon examination, the patient’s vital signs were normal: Temperature was 37.2 degrees Celsius; blood pressure was 124/78; respiratory rate was 16 and unlabored; heart rate was 98 and regular, and oxygen saturation was 96% on room air. ENT examination was unrevealing. The chest was clear. The abdomen was benign, and neurological examination findings were normal.

Things began to make more sense when an intern entered the patient’s room to perform a history and physical exam, only to note the patient furtively trying to hide an object in his hand. He quickly dropped the unknown object to the floor. The intern searched for the object and found a needle. After careful examination by the physician and the intern, several needle stick punctures were found on the tip of one of the patient’s fingers. The patient was confronted and admitted to simulating hemoptysis by sucking on the finger he had punctured and collecting the blood in his mouth, holding it there until a witness was present, at which time he would then spit the blood on the floor.

The physician on duty consulted a psychiatrist by telephone, who confirmed a diagnosis of Munchausen syndrome. The patient was discharged to undergo psychiatric evaluation and treatment.

2. Discussion

In both the cases reported here, patients complained of hemoptysis that was not directly witnessed by anyone. The patients had normal vital signs, and detailed examinations did not reveal any signs or causes of hemoptysis. In the first case, the Munchausen syndrome was diagnosed on suspicion of a psychiatric problem by medical staff, and the exact mechanism by which the patient induced feigned hemoptysis remained obscure. In the second case, the patient was caught red-handed trying to prick his finger with a needle to draw blood.

Munchausen syndrome is a term initially coined by Asher[1] used to describe a specific psychiatric disorder in which patients simulate completely factitious symptoms of diseases. They voluntary undergo invasive diagnostic procedures and interventions for their imaginary medical condition. Typically, these patients refuse psychiatric help when the factitious nature of their illness is recognized, and they go to multiple hospitals with the same complaints, where the same story is again repeated[2]. Usually the factitious nature of the patients’ complaints is revealed only after detailed examinations and procedures have proved inconclusive, wasting important resources and time.

Individuals suffering from Munchausen syndrome are frequently victims of parental neglect or abandonment, abuse, may have witnessed severe disease in family, or may have suffered genuine medical conditions requiring frequent hospitalizations during childhood or adolescence[2]. They are well aware of medical terminology and procedures[2, 3]. Three essential features of Munchausen syndrome have been recognized: recurrent, feigned illness; peregrination (wandering); and pseudologia fantastica (pathological lying with wildly exaggerated stories)[4]. Another variant of this complex disorder has been termed ‘Munchausen syndrome by proxy’ in which a parent either fabricates or induces an illness in their small child to solely gain medical attention[5]. Patients suffering from Munchausen syndrome are driven by the need of maintaining a sick role and not any external material gain such as financial or legal[6].

Gaining medical attention through self-inflicted hemoptysis in Munchausen syndrome has been reported in literature. There have been 23 documented cases so far [3, 7-12]. The cause of induced hemoptysis was varied, ranging from biting one’s tongue, injury to the pharynx, vomiting blood aspirated in a syringe from peripheral veins, etc. Baktari et al[13] reviewed 11 cases of factitious hemoptysis and reported that the patients suffering from Munchausen syndrome are generally young, with a mean age of 32 years. Further, it was reported that the method of simulating hemoptysis, if discovered, usually involves a self-inflicted wound[9].

Psychotherapy for treatment of the disorder is usually ineffective, and it has been suggested that a non-judgmental, direct approach exposing the patient’s falsehood may be more effective[14].

Our cases highlight the importance of clinicians being aware of the possibility of Munchausen syndrome where hemoptysis is not accompanied by a definite cause. Consideration of factitious complaints is rarely contemplated by clinicians due to ethical dilemmas. Munchausen syndrome is underrated and underreported since even when construction of a fabricated story by the patient is suspected, clinicians prefer to play it safe and offer the patient complete diagnostic options. Although the exact prevalence of Munchausen syndrome is not known and is difficult to determine, it is estimated that approximately 10 cases out of 1,288 are factitious (0.8%)[15]. The rarity of the disease is the prime reason correct diagnosis is often delayed.

Considering the burden these patients cause to health care and also to themselves, the medical community needs to be aware of the patient profile that may be most susceptible to this disorder. In this regard, more research is needed on this syndrome. Most importantly, the cases of Munchausen syndrome presented here emphasize the need for a centralized, computerized health care database in all communities that allows exchange of information among hospitals so that unnecessary waste of medical resources in the form of diagnostic interventions and time of trained medical personnel can be avoided.