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In a determined search for the cause of a "factitial" ulcer of the jaw, consultation with 3 dentists was required before an underlying periapical abscess was discovered. Within 3 months of endodontic surgery, this ulcer of 12 years duration had completely healed and remains healed. Too often dental infection is neither suspected nor detected as a cause of skin disease.
Factitious lymphoedema should be taken into account in patients with recurrent oedema of a limb, characterized by a distinct border, pain and an onset discordant to the accused event.
In typical cases self-inflicted injuries in fictitious offences show a characteristic pattern of findings with multiple, uniform, and mostly superficial skin lesions. If the actors possess special experiences, knowledge or instruments--particularly in the field of medicine--the injuries inflicted by themselves may have an appearance whose autoaggressive origin is less obvious. The case of a 43-year-old nurse is reported who was admitted for surgical treatment with two cuts in the abdomen extending into the subcutis; she pretended to have been attacked by 2 masked men who stabbed her for xenophobic motives. In reality she had inflicted the cuts upon herself after applying a local anaesthetic. The necessary equipment (Scandicain, disposable syringes, stitch cutter) was taken from her place of work. Self-inflicted injuries specific to medical professions, as well as fictitious offences with atypical cut- and stab-wounds and the insinuated motives of the alleged offenders are discussed.
During a violent conflict, a young man was shot dead in front of a bar. The offender stated that he had acted in self defence after having been attacked with a knife. Taking into account the testimonies, the medical findings (f. ex. sonotomogram of the left femur) as well as the crime scene regarding the position of the body, it could not be excluded from the forensic point of view that a knife attack of the later victim had taken place. Nevertheless, the court convicted the man who had shot for murder and gave a life prison sentence.
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The clinical example is one of diarrhea induced by the surreptitious use of laxatives. A 45-year-old man had a 3-year history of diarrhea, which had been fully investigated, without a cause having been identified. His general health appeared to be affected little, but he had the clinical features of an associated depressive illness. The diagnosis of laxative abuse was supported by the finding of abnormally high concentrations of magnesium in fecal water. He admitted initially, and later denied, the surreptitious ingestion of laxatives. This example is discussed with regard to features that were typical and atypical of the syndrome of laxative abuse. The significant points to be appreciated are 1) that any chronic, watery diarrhea that has eluded diagnosis after an adequate investigation is possibly self-induced, and 2) that awareness of this syndrome and its prevalence in selected cohorts can lead to direct and inexpensive documentation of the diagnosis.
Hypoglycemia is a clinical and biological syndrome, caused by an abnormal decrease in plasma glucose levels to below 0.55 g/l (3.0 mmol/l). Hypoglycemia is responsible for non-specific signs and symptoms which should be noted in a particular pathological context, and for secretion of counterregulatory hormones (mainly glucagon and catecholamines). Difficulty in identifying the etiology is variable, based upon history and physical examination, and hormonal investigations or imaging procedures, according to the results. Drug-related hypoglycemia is the most frequent observed cause (mainly in insulin-treated diabetic patients, but many drugs may be involved), followed par toxicity (alcohol mainly). Tumor-induced hypoglycemia is secondary to inappropriate insulin secretion by a beta-cell pancreatic tumor (insulinoma), and, rarely to an extrapancreatic mesenchymal large tumor secreting IGF-II. Hypoglycemia is present in other diseases, such as hormonal deficiencies, hepatic, or renal failure, or acute cardiac insufficiency. Multifactorial hypoglycemia seems to be underdiagnosed, mainly in hospitalized, underfed older patients with severe disease or sepsis. Autoimmune hypoglycemia is rare, due to insulin or insulin-receptor autoantibodies. Reactive hypoglycemia is observed after gastrectomy, but true primitive hypoglycemia appears to be rare, with false excess diagnosis in the majority of the cases.
Physicians must have a high index of suspicion when patients have unexplained prolongation of the prothrombin time and bleeding in the absence of detectable warfarin. Several common rodenticides contain modified versions of warfarin that are not detectable in standard warfarin assays. We present a case of surreptitious brodifacoum ingestion in a patient who had years of unexplained bleeding and negative warfarin levels.
Social services estimated on September 1, 1997 that 221 individuals out of a population of about 16,000 in the whole of Ringkøbing County were believed to suffer from dementia. Citizens believed to suffer from dementia were offered an assessment by a trained nurse and a general practitioner. In the following six months, 119 people were screened by the nurse with the Mini Mental State Examination, the Geriatric Depression Scale-15 and Gottfries-Brane-Steen scale for evaluating functional deficiencies in demented patients. In addition, somatic and laboratory screening was done by the GP's. Approximately 40 citizens or 33% were not found to suffer from dementia but suffered from other illnesses. One year later all the GP's answered questionnaires concerning number of cases of depression, hypothyroidism, vitamin B12 deficiency or other illnesses not earlier known to the GP. Twenty-two diseases were identified and six patients improved.
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We report two cases of factitious diarrhoea caused by stool dilution. In the first report stools from a patient with chronic diarrhoea were found to have been diluted with urine, and the diarrhoea further compounded by surreptitious laxative misuse. In the second report, after prolonged investigation of high output ileostomy, the patient's ileal effluent was found to have been diluted with water. We conclude that factitious diarrhoea, in particular dilutional diarrhoea, is over-investigated and underdiagnosed. Stool weights, complete input/output measurement, analysis of stool osmolality and electrolytes, and laxative screening are essential in the investigation of chronic watery diarrhoea.
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Factitious HIV infection has been observed at our center in women presenting with a false history of HIV/AIDS. In a 2-year period, 4 women presented for HIV-related care, indicating they were HIV-seropositive, while repeated serologic testing revealed no evidence of HIV infection. In all cases, the women were either quite angry or appeared surprised when told that they did not have HIV infection. A common denominator in all 4 women was a history of prolonged sexual, physical, or emotional abuse. Three of the 4 had been to other physicians, changing doctors as soon as the absence of HIV infection was established. Appropriate psychiatric support is an important aspect in care of these women, although it may not be accepted. All presentations of HIV infection should be confirmed either by identifying hard-copy data of HIV test results or by retesting all patients before evaluation and treatment of presumed HIV-related illnesses.