Vol.2, No.5, 322-325 (2013) Case Reports in Clinical Medicine
Abdominal panniculitis as a presentation of
Munchausen Syndrome
Carlos Damas, Ahmed Al-Hindawi, Edoardo Ricciardi, Piero Rossi, Athanasios Petrou,
Antonio Manzelli*
Department of Upper Gatrointestinal and Hepato-Pancreato-Biliary Surgery, Royal Devon and Exeter Foundation Trust, Exeter, UK;
*Corresponding Author: Antonio.Manzelli@nhs.net
Received 4 May 2013; revised 13 June 2013; accepted 26 June 2013
Copyright © 2013 Carlos Damas et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Factitious disorde rs including Munchausen’s s yn
drome are encountered by all clinicians. A con-
siderable number of case s of Muncha usen’s syn-
drome are under-diagnosed in clinical practice.
We presen t a 34-year-old man who was admitted
with symptoms of epigastric pain, vomiting and
peri-umbilical ecchymosis. Physical examination
showed signs of inflammation in the abdominal
wall with tenderness and guarding in the upper
abdomen. However, various blood test s were un-
remarkable. Computed Tomography and demon-
strated anterior abdominal wall panniculitis. Af-
ter many investigations looking into various ae-
tiological factors that could lead to fat necrosis,
a diagnosi s of Munc hausen’ s sy ndrome was made
and the p atie nt was discharged to the care of the
local general doctor practice following psychi-
atric input.
Keyw ords: Munchausen Syndro me ; Abdominal
Lying to receive attention is not a new concept. This
disorder was formally recognized for the first time in the
far 1800s, and evidence of malingering dates back as far
as Roman times [1]. The first description of this syn-
drome was made by Richard Asher in 1951 [2], and he
coined the term “Munchausen’s Syndrome to describe an
extreme form of factitious disorder, where the patient
moved often to several hospitals with plausible symp-
toms apparently requiring urgent treatment. Later in 1977
Roy Meadow coined the term “Munchausen Syndrom by
proxy” to describe the intentional false reporting of
symptoms in another person who is under the individ-
ual’s care for the purpose of indirectly assuming the sick
role [3]. Nowadays the increasing use of the internet to
provide support for illnesses an d o ther medical issues has
introduced the concept of “health-related online identity
deception-Munchausen by internet” (identified in 2000)
A 34 years old man, usually fit and well, moderate al-
cohol abu se with 20 units a week , presented to the surgi-
cal department with vomiting and severe epigastric pain
radiating to his back. Acute pancreatitis was hypothe-
sised based on his alcoholic habit and on his clinical
examination findings that were suggestive of abdominal
wall inflammation with inspection demonstrating peri-
umbilical ecchymosis consistent with likely Cullen’s sign
and guarding in epigastrium (Figures 1 and 2).
Blood tests failed to demonstrate a serum Amylase rise
and his inflammatory markers (C-Reactive Protein and
White Cell Counts) were within the normal range for our
population. This soft presentation ruled out the diagnosis
of acute pancreatitis. His Glasgow score at presentation
and at day two was zero.
There was no relevant past medical history. A conser-
vative management was considered but the pain and its
clinical severity was actually increasing along with the
extension and worsening of the abdominal wall ecchy-
In day five of his h ospitalization because of un settling
but progressive pain a computed tomography (CT scan)
was requested. The procedure was reported as normal for
any intra-abdominal pathology including a normal pan-
creas, however, a significant anterior abdominal wall
panniculitis was reported (Figure 3).
Clinically, his ecchymosis then developed, over sev-
eral days, to include both flanks and his lower back (Fig-
ure 4). Microbiologist and Plastic Surgeons ruled out
Copyright © 2013 SciRes. OPEN ACCESS
C. Damas et al. / Case Reports in Clinical Medicine 2 (2013) 322-325 323
Figure 1. Ecchymosis—peri-umbilical
and flanks.
Figure 2. Ecchymosis—flanks.
Figure 3. Reconstructed CT demon-
strating anterior abdominal wall pan-
Figure 4. Ecchymosis in both flanks
and lower back.
a diagnosis of necrotising fasciitis. A punch biopsy was
performed by Dermatologist and demonstrated neutron-
phillic invasion of fat but no other pathology.
Unexpectedly, during his stay in hospital, he was al-
legedly witnessed to severely punch himself in the above
mentioned areas several and repeated ly times with strong
force in 4 separate episodes.
A Psychiatrist review was requested and a Mun-
chausen’s syndrome was diagnosed. This was based on
his clinical presentation, past medical history and ac-
cording with the patient notes collected from different
local hospitals and local GP surgery where he had prev i-
ous admission or attended with similar episodes of self
The patient was discharged home advising him that the
areas of induration and swelling over the ecchymosis due
to the panniculitis will take several weeks to reduce in
size and pain.
The psychiatric assessment before discharge did not
recommend any further psychiatry input as he was
deemed to be of low risk to his life and of others.
We presented a clinical case of a patient whose initial
presentation was interpreted and initially managed as
probable acute pancreatitis but after thorough investiga-
tions a diagnosis of Munchausen’s Syndrome was made.
Münchausen syndrome is a psychiatric factitious dis-
order where in those affected feign disease, illness, or
psychological trauma to draw attention or sympathy to
themselves. It is also sometimes known as hospital ad-
diction syndrome or hospital hopper syndrome. Nurses
and doctors sometimes refer to them as frequent flyers,
because they return to the hospital just as frequent flyers
return to the airport. However, there is discussion to re-
classify them as somatoform disorder in the DSM-5 as it
is unclear whether or not people are conscious of draw-
ing attention to themselves [5].
People with Münchausen syndromes deliberately pro-
duce or exaggerate symptoms in several ways. They
might lie about or fake symptoms, hurt themselves to
bring on symptoms, or alter diagnostic tests to draw at-
tention or sympathy to themselves [6,7].
The exact cause of Munchausen syndrome is not
known, but researchers believe both biological and psy-
chological factors play a role in the development of this
In this context, admittin g a patient in the hospital with
past medical history and a clinical sign of a specific con-
dition clearly leads the investigations and the manage-
ment toward a clinical direction rather than a psychiatric
review and this represent a significant loss in the general
economy of a hospital.
Doherty and JD Sheehan described patient with global
Copyright © 2013 SciRes. OPEN ACCESS
C. Damas et al. / Case Reports in Clinical Medicine 2 (2013) 322-325
amnesia, the media publicized his story and printed his
picture, also interpol were involved. After two weeks
another man came to the same hospital with same symp-
toms but clinicians referred there were no symptoms of
psychosis elicited and no evidence of cognitive impair-
ment. After three days a teleph one number was found on
his person, this transpired to be his father’s number that
said the patient was waiting for admission to the local
psychiat r ic hospital because of paran oid schizop hrenia.
After two weeks the same patient was admitted to the
orthopaedic ward with multiple fractures having fallen
from scaffolding. He described delusion of persecution
and passivity and a diagnosis of Munchausen Syndrome
was referred [8].
Faida, Smith et al. described a rare case of Lobular
Panniculitis, a 40-year-old female was hospitalized to in-
vestigate numerous painful unilateral ecchymoses found
on her right low er leg. She denied any h istory of trauma.
During hospitalization new ecchymoses were noted and
also a worsening of the patient’s pre existing lesion. Af-
ter more exams and days on charge all the symptoms
resolved spontaneously. A late X-ray of the leg showed
the presence of a sewing needle into her calf. After this,
the patient became aggressive and attempted to jump out
of the hospital window, fortun ately the staff were able to
stop her. The patient refused any further medical assis-
tance or psychiatric follow up so she discharged herself
from hospital, and the psychiatric team referred a severe
Munchausen Syndrome [9].
Goto and Sasajima described a 64-year-old man ad-
mitted to the hospital after head injury. Ct and Mr imag-
ing revealed a mass with edema in the right frontal lobe.
This mass was surgically removed and the authors no-
ticed a small bone defect in the frontal bone above the
brain abscess. The patient presented atypical seizures
several times, and after the discharged of the patient he
was hospitalized again because the wound had reop ened.
After the second surgery he stabbed a nail into his head
where the bone had been removed due to the previous
surgery, and presented intraventricular hemorrhage that
decreased in size with non-surgical treatment. So the
patient was referred to the psychiatry department with a
diagnosis of Munchausen Syndrome [10].
In particular, consider this patient as affected by an at-
tack of acute pancreatitis was clinically reasonable. How-
ever, is commonly known that serum amylase is insuffi-
ciently sensitive in severe pancreatitis, but also needs to
be aware that a normal serum amylase does not exclude
severe forms of acute pancreatitis, which are associated
with a high morbidity and mortality [11-13] this is main-
ly due to the fact that amylase is rapidly cleared from the
kidneys, and this, along with other factors, may lead to a
normal serum amylase level even in the presence of ne-
crotising pancreatitis [14-16]. Acute pancreatitis may o c-
casionally be complicated by panniculitis as a result of
the release of pancreatic enzymes, occurring in 2% - 3%
of all patients with pancreatic disorders [17-19].
In our case, the peri-umbilical ecchymosis which were
thought to be Cullen’s sign helped actually to rule out the
diagnosis of pancreatitis as this sign is associated with
severe pancreatitis and was not compatible with the soft
clinical presentation of our patient [20].
In conclusion, this brief report describes an atypical
presentation of Munchausen Syndrome which misleads
the clinicians producing a false diagnosis of acute pan-
creatitis [21]. This resulted in 10 days of investigations
and hospitalization that incurred a considerable waste of
professional time at huge economic and financial costs. A
high index of suspicion for mental illness is urged in pa-
tients who present with this picture.
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