Munchausen syndrome by proxy - A pathological dilemma

Munchausen syndrome by proxy - A pathological dilemma


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SAGE, Pathology Department, Christchurch Medicine. PO Box 4345 Christchurch N.Z.

RW 8yardt, JD Gilbert', RH 8urnell±. Departments of Histopathologyt & Paediatrics+, Women's and Children's Hospital & University of Adelaide. State Forensic Science', Adelaide, South Australia.

The medico-legal minefield attending medical misadventure in New Zealand is illustrated by this case. A woman arrested and died during thoracic surgery following inappropriate placement of a Stitinsky clamp on the pulmonary artery bifurcation during elective pneumonectomy. The procedure was undertaken for a pulmonary mass lesion incorrectly diagnosed clinically, and on frozen section, as a squamous cell carcinoma. Her .estate is seeking compensation, and the surgeon is likely to be charged with manslaughter. The definitions in New Zealand law of medical misadventure and its subsets "error" and "mishap" have been recently redefined by the Accident Rehabilitation and Compensation Insurance Act 1992, thus altering our unique, 20 year old, "no fault" compensation scheme. This change, the Coroners Act, Medical Practitioners Act, manslaughter provisions of the Crimes Act, loss of internal hospital professional medical review, commercialisation of public hospitals, and a shrinking health services resource base have all been variously implicated in apportioning "blame" for this incident. The practical difficulties ar~s~ng during interpretation by forensic pathologists of surgical interventions, and their useful resolution by technical assessors assisting the Coroner are highlighted.

Munchausen syndrome by proxy (MSBP) is a disorder in which a caretaker either simulates or causes an illness in a child and brings it 10 the attention of the medical profession in order to obtain ill-understood gratification. Repetitive attendance for medical assessment, investigation and treatment is characteristic, as is the complete absence of symptoms and signs, or dramatic resolution of the illness, in the absence of the offending parent. Knowledge of the cause of the child's illness is usually denied, The mortality and morbidity rate is significant. A recent series of sudden deaths and unusual apnoeic episodes in three infant siblings is presented to demonstrate particular difficulties in diagnosis that may occur. Case 1: An 11 week old girl died in hospital after unsuccessful reSUSCitation following an apnoeic episode. This was similar to 2 other recent episodes where she had oeen found by her mother cyanotic and gasping. Cardiopulmonary resuscitation was required on each occasion. Autopsy findings were conSistent with SIDS, although a unilateral facial rash raised the possibility of petechiae. Case 2: Approximately one year later, a 5 week old sister of the firs! infant was found dead in bed. Autopsy findings were minimal and consistent with SIDS. Case 3: A further year later a 12 week old sister presented with unusual apnoeic episodes which only occurred in the presence of her mother. In view of the previous history, covert inpatient video surveillance was undertaken. Following documentation of maternally·induced apnoea and subsequent police investigation, the mother pleaded guilty to charges of manslaughter in case 1 and causing grievous bodily harm in case 3. The diagnosis in Case 2 remains unchanged. The similarity of autopsy findings in infants who have died of SIDS or of manual suffocation makes the pathological diagnosis of the latter entity extremely difficult. Thus without a confession, the diagnosis of 'gentie battering' may not be possible even with quite strong circumstantial evidence.

Dr Martin School of 8001

Presenter: Dr John Gilbert. State Forensic Science. Adelaide.

FATAL ANAPHYLAXIS: A REVIEW OF RECENT ADVANCES IN POST MORTEM DIAGNOSIS S.M. Allpress', Department of Forensic Pathology, University of Auckland School of Medicine, Private Bag 92019, AuCkland, New Zealand. The autopsy findings in deaths attributed to anaphylaxis are nonspecific. Until recently the determination of death being due to anaphylaxis depended on (1) the temporal relation between exposure to purported allergen and rapid cardiovascular-respiratory deterioration, (2) autopsy findings supportive of acute cardiovascular and/or respiratory decompensation, and (3) exclusion of other causes of sudden death.

HAEMORRHAGIC SHOCK ENCEPHALOPATHY SYNDROME. D. Little*, Department of Forensic Medicine, Westmead Hospital, Westmead, N.S.W., 2145. Haemorrhagic shock encephalopathy syndrome (HSES) is an acute onset, uncommon disorder which occurs in children under 16 years of age_ It was first described in 1983 and subsequently over 100 cases have been reported world-wide.

Recent applications of radio-immunoassay techniques to post mortem blood specimens have allowed determinatio~ of serum tryptase levels (specific to mast cells, released on their degranulation in anaphylaxis) and detection of IgE to specific allergens implicated in anaphylactic events.

The diagnostic criteria are an abrupt onset of encephalopathy (coma and convulsions), shock, diarrhoea, disseminated intravascular coagulation, renal impairment, raised hepatocellular enzymes, falling haemoglobin and platelet counts, acidosis and negative blood and cerebrospinal fluid cultures.

This presentation reviews the recent medical literature on severe and/or fatal anaphylaxis, addressing issues of sensitivity, specificity, forensic applications and medicolegal implications.

Death is a frequent outcome, and most of the survivors have severe neurological damage. The aetiology of , the condition is unknown.

It is recommended that blood is taken at autopsy for determination of serum tryptase and IgE levels in all cases where fatal anaphylaxis is suspected.

A case of HSES occurring in a 2 year old girl will be presented. Presenter: Dr Dianne Little, Department of Forensic Medicine, Westmead Hospital.