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PubMed1964

FACTITIOUS STROKES.

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Cerebrovascular Disorders↗
PubMed2005

Difficult wounds: an update.

The purpose of this collective review is to describe revolutionary advances in the treatment of Gardner's syndrome (GS), pseudofolliculitis barbae, nasal septal perforation, factitious wounds, and hidradenitis suppurativa (HS). Gardner's syndrome or familial polyposis has various manifestations that appear to be controlled by a single genetic locus. Apart from the large bowel adenomas, which are always present, a common extracolonic symptom of Gardner's syndrome is the occurrence of epidermal cysts. These cysts can be seen before the intestinal polyps are evident. Because epidermal cysts in patients with Gardner's syndrome are always benign, we excise these cysts using incisions that are commonly used for rhytidectomy. Pseudofolliculitis barbae, a pseudofolliculitis caused by ingrown hairs, effects 85% of blacks who shave their beards. When this disease is allowed to progress to keloid formation, we use a surgical approach that includes excision of the keloidal scar, meticulous debridement of all residual ingrown hairs in the underlying wound, and coverage of the defect with a split-thickness skin graft. More recently, laser therapy has revolutionized the treatment of pseudofolliculitis barbae and has enabled a cure for the first time for those plagued with this disorder and for whom a beardless face is acceptable. Nasal septal perforation is a well recognized complication of septal surgery. Other iatrogenic causes of perforation include cryosurgery, electrocoagulation for epitaxis, nasotracheal intubation, or nose packing. In recent years drugs such as cocaine account for an increasing number of perforations. It has only been with the use of an external approach for the repair of the nasal septal defect that surgical closure has become easier and more reliable. The external approach allows for greater surgical closure and enables the surgeon to use both hands with the aid of binocular vision to mobilize and suture local mucosal advancement flaps and the intraseptal connective tissue grafts. More recently, surgeons have repaired large septal perforations with a radial forearm free flap. Because of its availability and deep emotional significance, the skin is a common site for self-destructive behavior with the development of factitious skin wounds. When suspected, psychiatric care must proceed immediately. Second, the ulcer can then be healed by appropriate techniques and wound repair. It is important to emphasize that the treating physician must first confront the patient, and then a psychiatrist should provide appropriate psychotherapy. Hidradenitis suppurativa is an inflammatory disease of the skin and subcutaneous tissue that occurs in apocrine-gland-bearing areas distributed in the axilla, mammary nipple areola, mons pubis, groin, scrotum, perineum, perianal region, and umbilicus. The condition has an insidious onset. The susceptibility of women's axillary skin to hidradenitis suppurativa may be related, in part, to the practice of axillary removal of hair with a safety razor. Consequently, the use of safety razors must be avoided and replaced with the use of an electric razor. The method of treatment will vary with the stage of the disease. Treatment of the chronic stage of axillary hidradenitis suppurativa is primarily surgical. More recently, carbon dioxide laser treatment, with healing by secondary intention, is proving to be a rapid, efficient, and economic treatment of this difficult wound.

Epidermal Cyst↗
PubMed2000

Pseudomalabsorption of levothyroxine: a case report.

A 51-year-old woman who had been treated with levothyroxine sodium because of hypothyroidism after total thyroidectomy for thyroidal cancer was admitted to our hospital for persistent hypothyroidism despite large dose administration of levothyroxine (600 microg/day). The patient complained of severe general fatigue and body weight gain. Free thyroxine, free triiodothyronine and thyrotropin levels were 0.97 ng/dl, 1.55 pg/ml and 24.51 microU/ml, respectively, under oral administration of levothyroxine. Levothyroxine loading test performed by liquid form, pulverized tablets via nasogastric tube and intravenous administration revealed no evidence of malabsorption or metabolic disorder of levothyroxine, although oral intake of tablets was ineffective due to her factitiousness. We report here a possible case of "pseudomalabsorption of levothyroxine" to emphasize the clinical recognition of this disorder in patients with resistant hypothyroidism.

Dose-Response Relationship, Drug↗
PubMed2001

[Auto-induced eosinophilic panniculitis: a diagnostic dilemma].

Eosinophilic panniculitis is characterized by a prominent infiltration of subcutaneous fat with eosinophils. The clinical spectrum of lesions that display pathologic changes of eosinophilic panniculitis is diverse, but nodular lesions are the most common. The factitial eosinophilic panniculitis are exceptional, show a pleomorphic pattern of findings and are associated with personality disorders. Its main challenge is to establish the correct diagnostic. We report an unusual case of factitial nodular febrile panniculitis of the left forearm and proximal arm in an 16 year-old girl. She admitted that the lesions were self-inflicted by autoinjection of several farming products as attempted suicide. We describe the clinical, radiological and histopathological features as well as the differential diagnosis of this type of panniculitis.

Adolescent↗
PubMed2001

Psychocutaneous disorders.

Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.

Humans↗
PubMed1986

Psychotic symptoms in borderline personality disorder.

In a pilot study of 13 patients with borderline personality disorder, analysis of brief psychotic symptoms was done. Derealization and depersonalization were the most common symptoms, but drug-free hallucinations were also observed. The symptoms did not appear to be factitious.

Adolescent↗
PubMed1985

Brightness-sense and optic nerve disease.

We describe a simple device used to compare the sense of brightness in the two eyes. An investigation of brightness-sense with this device in normal persons and patients with optic nerve disease, maculopathies, cataract, and factitious visual impairment shows that brightness testing can provide useful information supplementary and complementary to conventional clinical and laboratory investigations. Impairment of brightness-sense was a consistent finding among patients with optic neuropathies and, in some cases, brightness testing appeared to be more sensitive than other techniques in establishing the presence of disease. Brightness-sense was also used to monitor the course of the patient's illness. Abnormalities were also found among some patients with unilateral maculopathies, but significant intereye differences in brightness-sense were not encountered among normal persons or patients with cataracts. Patients with factitious visual loss gave variable responses, and the nature of their disorder could be identified by the inconsistency of their responses.

Adolescent↗
PubMed1999

Munchausen syndrome by proxy and intra-alveolar haemosiderin.

Munchausen syndrome by proxy is characterised by the invention of a false history and/or the deliberate inducement of a factitious illness by parents in their child. First reported as a disorder of mothers, this syndrome is now recognised to have male perpetrators. One of the most common characteristic presentations is with the child allegedly suffering repeated apnoeic attacks. These are in fact deliberately induced episodes of upper airway obstruction. The children of these parents are at great risk of serious harm or death if not recognised. The identification of smothering at autopsy is fraught with difficulty and the presence of intra-alveolar haemosiderin has been claimed to be a marker of previous smothering. A case of Munchausen syndrome by proxy is presented where there were deliberate acts of repeated partial smothering and where the finding of intra-alveolar haemosiderin at autopsy provided additional supportive evidence of smothering.

Airway Obstruction↗
PubMed1990

Surreptitious ingestion of a long-acting vitamin K antagonist/rodenticide, brodifacoum: clinical and metabolic studies of three cases.

The vitamin K metabolism of three patients with factitious purpura due to brodifacoum ingestion was studied. These patients, who presented with bleeding disorders due to deficiency of the vitamin K-dependent blood clotting proteins, were refractory to vitamin K1 at standard doses and required fresh frozen plasma to control bleeding until large doses of vitamin K1 were used. Metabolic studies demonstrated a blockade in vitamin K utilization, consistent with the presence of a vitamin K antagonist, but the patients denied use of anticoagulants. Warfarin assays were negative. We show that the factitious purpura in each patient was due to the surreptitious ingestion of brodifacoum, a potent second generation long-acting vitamin K antagonist used as a rodenticide. The coagulopathies responded to long-term therapy with large doses of vitamin K1. The serum elimination half-time for brodifacoum ranged from 16 to 36 days in these patients. The anticoagulant effect is of long duration, requiring chronic vitamin K treatment. With increasing availability of new rodenticides, factitious purpura due to surreptitious ingestion of these potent vitamin K antagonists is emerging as a new problem, previously associated with warfarin, with important implications for diagnosis and treatment.

4-Hydroxycoumarins↗
PubMed1978

Life threatening self-mutilation of the nose.

Potentially life threatening self-mutilation of the nose in a patient with a severe passive aggressive character disorder is described. The phenomenological and psychodynamic features of this case are contrasted with those of schizophrenia and factitious dermatoses with similar excoriations.

Adult↗
PubMed2004

Trigeminal trophic syndrome--report of four cases and review of the literature.

BACKGROUND: Trigeminal trophic syndrome is a unilateral, frequently crescent-shaped neurotrophic ulceration of the face occurring after injury to the trigeminal nerve. The appearance of the ulcers resembles other disease entities such as granulomatous disease, neoplasm, vasculitis, infection, and factitial dermatitis. OBJECTIVES: The objectives of this study are to increase awareness of this disorder and to emphasize the importance of eliciting a thorough neurologic history when evaluating facial ulcerations. METHODS: Four cases are reported and, using MEDLINE, the English and non-English literature from 1982 to 2002 is reviewed. RESULTS: Including this report, there have been 60 cases of trigeminal trophic syndrome reported from 1982 to 2002. The age at presentation ranged from 14 months to 93 years. Time of onset from injury to the trigeminal ganglion or its branches and the development of the ulcers ranged from 2 weeks to 30 years. One-third of the patients had undergone trigeminal nerve ablation for the treatment of trigeminal neuralgia and another third had a history of stroke. Other causes included craniotomy, head trauma, herpes infection. CONCLUSION: The majority of cases of trigeminal trophic syndrome are associated with a history of stroke or trigeminal nerve ablation. Successful surgical outcome can be achieved if the underlying neurologic pathology is addressed before the reconstructive procedure.

Adult↗
PubMed1982

Sickle cell shape and structure: images and concepts (1840-1980).

I. First observations of "crescentic particles" in animals. II. The first five descriptions of sickle shaped red cells in man. III. Relationship of sickling to the state of oxygenation of the hemoglobin. a) Forerunners: the sickling is reversible. b) Discoverers: sickling as result of asphyxia. IV. Sickle cell trait ("latent sickling"). V. Presence of hemoglobin rod-like structures in sickle cells. a) Indirect evidence. b) Observation of the surface of the cells by electron-microscope shadow casting technique. c) Electron microscopy of the interior of the cells. VI. Irreversible sickle cells. VII. Heterogeneity of sickling disorders. a) Association with other hemolytic anemias. b) Non-Hb S sickling. c) Factitious sickle cell shapes. VIII. Myelin forms and agglutination of sickle-cells. IX. Sickle cell shapes. a) Drepanocytes: mechanism of formation. b) Discodrepanocytes (holly-leaf forms). c) Echino-drepanocytes. d) Stomato-drepanocytes. e) Sphero-drepanocytes.

Anemia, Sickle Cell↗