Rosen & Barkin's 5-Minute Emergency Medicine Consult (463 page)

• Seriously ill who require supportive care
  
• Vomiting and dehydration
  
• Encephalitis, meningitis
  
• Severe pancreatitis
  
• Isolate admitted patients
  

• Virtually all patients
  
• Contagious until about a week after onset of symptoms
  

• Mumps virus is the only cause of epidemic parotitis.
  
• Vaccines are highly effective, and when correctly given confer 90% immunity. MMR should not be given to pregnant women or immunosuppressed or immunocompromised individuals.
  
• Mumps virus is endemic to many parts of the world and may pose a risk to travelers without immunity to mumps.
  

• American Academy of Pediatrics. Mumps. In: Pickering LK, ed.
  Red Book 2012: Report of the Committee on Infectious Diseases.
  29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:514–518.
  
• Mumps. In: Atkinson W, et al., eds.
  Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book).
  12th ed. 2012:205–214.
  
• Mason WH. Mumps. In: Kliegman RM, Behrman RE, Jenson HB, et al., eds.
  Nelson Textbook of Pediatrics.
  19th ed. Philadelphia, PA: Saunders Elsevier; 2011:1078–1081.
  

See Also (Topic, Algorithm, Electronic Media Element)

www.cdc.gov/mumps

CODES

• 072.0 Mumps orchitis
  
• 072.3 Mumps pancreatitis
  
• 072.9 Mumps without mention of complication
  

BASICS

• A neurotic disorder in which the patient fakes signs or symptoms without tangible personal benefit other than to experience the sick role.
  
• Most dramatic form of chronic factitious disorder with a predominance of physical findings.
  
• The nature of the disorder resists rigorous study but possible risk factors include:
  
  • Males
    
  • Less severe factitious disorders are more common in women
    
  • Unmarried
    
  • Age in the forties
    
  • Personality disorder
    
  • A history of sadistic and rejecting parents
    
  • A history of chronic childhood illness
    

• Factitious disorder:
  
  • 3 DSM-IV diagnostic criteria:
    
    • Intentional production of physical or psychological signs
      
    • Motivation to assume the sick role
      
    • Absence of external incentives
      
    • Predominance of symptoms rather than physical findings
      
• Classic Munchausen syndrome:
  
  • Most severe and chronic form of factitious disorders
    
  • Predominantly physical findings
    
• Clinical clusters:
  
  • Self-induced infection
    
  • Simulated specific illnesses with no actual disorder
    
  • Chronic wounds
    
  • Self-medication
    

• Munchausen by proxy:
  
  • The patient’s illness is caused by the caregiver, not the patient
    
  • The motivation for the caregiver’s behavior is to assume the sick role by proxy
    
  • The caregiver inflicts injury or induces illness in their charge, usually a child
    
  • Commonly parents (mostly mothers)
    
• May simulate injury and disease in a number of ways:
  
  • Inflicts injury
    
  • Induces Illness
    
  • Fabricates symptoms
    
  • Exaggerates symptoms of the child’s illness causing overaggressive medical interventions
    
• The perpetrator usually refuses to acknowledge the deception
  
• Cessation of the symptoms when the patient and caregiver are separated
  

Caregivers of elderly patients may also be perpetrators in Munchausen by proxy

DIAGNOSIS

• Inappropriate or bizarre use of the ED
  
• Frequent visits
  
• Numerous hospital admissions
  
• Peregrination: Travel from hospital to hospital
  
• Pseudologia fantastica:
  
  • Intricate and colorful stories associated with the presentation
    
• Alteration of biographical information:
  
  • Use of aliases
    
  • Change date of birth by 1 digit
    
• Escalating demands for diagnostic testing and therapeutic interventions
  
• Hostility toward the health care providers when questioned
  
• Evasiveness regarding details of the presenting complaint
  
• The patient provides excessive medical documentation
  
• Masochistic acceptance of painful procedures
  
• The patient appears more comfortable than is likely considering the disease
  
• The patient demonstrates unusually strong medical knowledge
  
• Frequent homelessness and significant wandering between cities and states
  
• An absence of close interpersonal relationships
  
• Self-medication
  
• Abdominal complaints with history of repeated negative laparotomies (laparotomaphilia migrans)
  
• Witnessed intentional acts to fake illness:
  
  • Inappropriate ingestion of medication to reproduce physical findings
    
  • Injection of contaminants (feces, bacteria, sputum, corrosives)
    
  • Self-induced wounds
    
  • Swallowing blood to simulate a GI hemorrhage
    
  • Self-phlebotomy
    
  • Instrument tampering
    

• Fever:
  
  • Factious from manipulation of thermometer
    
  • Induced from injection of contaminants
    
• Self-induced wounds
  
• Chronic wounds
  
• Multiple scars
  
• Foreign bodies in wounds, ear canals, urethra
  

• Diligent detective work is needed:
  
  • Retrieval of records from other hospitals
    
  • Call on family members to discuss past history for inconsistencies and excessive use
    
  • Call personal physician for background and to coordinate information
    
  • Search patient’s room and belongings to establish the method of deception
    
• Conclusive proof of faking disease is needed to make the diagnosis
  

• Direct observation of the patient when obtaining tests to prevent faking results
  
• Commonly faked lab results:
  
  • Hemoccult positive stool
    
  • Hematuria (intentionally dripping blood into urine sample)
    
  • Hypoglycemia (self-administration of insulin)
    
• Abnormal results from self-medication:
  
  • Low hematocrit (ingestion of warfarin or self-phlebotomy)
    
  • Elevated INR (ingestion of warfarin)
    
  • Thyroid function tests (ingestion of thyroxine)
    
  • Low serum glucose (injection of insulin or ingestion of sulfonylurea)
    
• Evidence of intent to fake illness:
  
  • Testing stool for phenolphthalein may detect laxative abuse
    
  • Serum C-peptide with high insulin levels:
    
    • Low C-peptide: Exogenous administration of insulin
      
    • Elevated C-peptide: Endogenous hypoglycemia or sulfonylurea ingestion
      

Do not rely on imaging brought by the patient

Avoid unless clear objective findings indicate the necessity of a procedure

• True illness:
  
  • Primary illness unrelated to a psychiatric disorder
    
• Secondary to a comorbid condition associated with factitious disorders:
  
  • Secondary to self-destructive acts in patients with dementia, psychotic disorders, or mental retardation
    
  • Secondary to diagnostic and therapeutic procedures
    
• Malingering:
  
  • Clear-cut secondary gain
    
• Conversion disorder:
  
  • Deficits of the voluntary motor or sensory neurologic system that are not consciously produced
    
• Somatization disorder (hysteria, Briquet syndrome):
  
  • Symptoms that involve multiple organs, that varies over time, and are not consciously produced
    
• Other neurotic disorders:
  
  • Anxiety
    
  • Depression
    

TREATMENT