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Factitious disorder imposed on another: A paediatric case report documented using hair analysis
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International audience. Background. - Factitious disorder imposed on another (previously called Munchhausen syndrome by proxy) is a form of abuse where a caregiver deliberately produces or feigns illness in people under their care, frequently a child, so that they receive medical attention that gratifies the caregiver. Objective. - A case of factitious disorder imposed on another is described in a child aged 16 months following toxicology hair analysis. Case report. - The case involves a 16-month-old child who has been reported to have gone to accident and emergency 32 times since birth, of which 13 visits were followed by the child being hospitalised for several days in various different healthcare structures. Besides the digestive and ENT troubles, the reasons for hospitalisation were essentially neurological signs such as trembling or abnormal movements, always indicated by the mother. None of the explorations carried out (notably neurophysiological) allowed an unequivocal explanation to be found for the neurological symptoms of the child as reported by the mother. During the periods of hospitalisation, no malaise episode was detected. About four months before the actual diagnosis was made, following an admission into hospital for the umpteenth time and once again following the indications given by the mother, the existence of the beginnings of an epileptic syndrome was noted justifying putting in place an anti-epileptic treatment using levetiracetam. Further episodes of tonic-clonic seizures, while under treatment, were observed, this time by healthcare professionals; these attacks were sufficiently suspect that finally, 2 months later, the hypothesis of factitious disorder imposed on another was mentioned. The first toxicological analyses show the presence of lamotrigine at a toxic concentration (74 mg/L) in the blood of the child, which may explain the symptoms observed several months earlier. Analysis of the child's hair was required to confirm if the child has been exposed to lamotrigine - the mother's anti-epileptic treatment - since birth. Methods. - Hair lock (18 cm) was decontaminated twice and then segmented (4 segments of 4 cms) to cover the period in question. Each segment was cut into small pieces (< 1 mm) followed by a liquid-liquid extraction process and analysed by LC-MS/MS. Results. - The results confirmed regular lamotrigine use during the previous fifteen months (45, 63, 96, and 102 ng/mg of hair starting from the most proximal segment). Levetiracetam and 7-aminoclonazepam were identified in the segments of hair corresponding to the periods of treatment. Discussion/conclusion. - Without ruling out from the results obtained the likelihood of in utero exposure (the child was not breast fed), hair analysis has confirmed that the child was exposed to lamotrigine since birth. Evidence of repeated overdoses of this drug will have caused the onset of the observed clinical neurological signs (a paradoxical effect of anti-epileptic medication) that led to the diagnosis of true epilepsy and the implementation of an anti-epileptic treatment. The mother was identified as having factitious disorder imposed on another and the child was placed in care. No further recurrence of a convulsion has been observed since the epileptic treatment has been stopped. This case illustrates the difficulty in diagnosing this serious and potentially very dangerous psychological illness, where the objective of the sufferer is always to attract attention via the victim. (C) 2020 Societe Francaise de Toxicologie Analytique. Published by Elsevier Masson SAS. All rights reserved.
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