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Bloody Tears: A Rare Presentation of Munchausen Syndrome Case Report and Review

We report a 16-year-old Jordanian female who presented with bleeding from both eyes of sudden onset. Her physical examination was remarkable for blood pouring from both eyes, and normal otherwise examination including eye and nose examination. During hospital stay, it was noted that “bleeding” occurred only when alone in the room. She later was seen to prick her finger tips of the left hand with her right hand using a hair clip. She denied any psychological problems, and later did not show for follow-up. Munchausen syndrome as a cause of bleeding is discussed.


Introduction
Munchausen syndrome should be considered in the differential diagnosis of many disorders. It should thought of when a "difficult to explain" presentation of a patient is noted. Hemolacria is one of these diagnostic difficulties, and we report a case of bloody tears in a young Jordanian patient.

Case Report
A 16-year-old female, school student, presented to Prince Hashem Hospital in Zarq governorate in Jordan in November 2009, with the complaint of blood in the tears of 1-day duration.
Review of the patient's history revealed that she was normal until 1 day prior to her presentation when she started to note blood coming from both eyes admixed with the tears; it was fresh in color with no associated pain or change in vision, or aggravated by itching. Her physical examination showed a normal-looking young girl, with streaks of blood from both fornices. General examination was normal; with no signs of anemia, dilated vessels, or bleeding from other sites, including the nose, gums, or skin; and no hepatosplenomegaly or lymphadenopathy. Ophthalmic examination was also normal, with no evidence of conjunctival injury or obvious site of bleeding. Her investigations, including full blood count, prothrombin time, partial thromboplastin time, and bleeding time were normal, too.
The patient was hospitalized for observation; of note was that, the bleeding occurred mainly, almost only, when there were no people around her. Later, she was moved to a bed nearer to the nurses' station, with instructions to call the on call doctor when bleeding is noted.
When bleeding was noted, the medical team was rushed to the patient's bed; they noticed that blood is streaking from both eyes, and also on her cheeks in a linear pattern; inspection of the patient's hands [ Figure 1] showed puncture sites on the tips of her left hand, but none on the right hand; and a hair clip was beside the patient's bed.
The patient was confronted with these finding; and later she admitted using the hair clip to puncture her left side finger tips using the clip with her right hand. She denied any gain that she was aiming at.
The patient was discharged from hospital the next day, and was scheduled for follow-up in 2 weeks; but failed to attend the appointment. No other episodes of bleeding were reported afterwards as per hospital records.

Discussion
Hemolacria or bloody tears is a very rare entity, that has many causes, including tumors [1] conjunctivitis, trauma, retrograde epistaxis, inflammatory polyps, hemangiomas, [2] and chloromas [3] to mention a few; but Munchausen syndrome can be seen with ophthalmic manifestations [4] and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough evaluation. [5,6] Bleeding from any site in the humans is an alarming symptom, and always attracts the attention of healthcare workers to request further investigations and leading to admission to hospitals; this is a reason why patients with factitious disorders [7,8] present with bleeding from different sites including the gastrointestinal, [9] respiratory, [10] as well as unusual sites; [11] our patient and many others from review of the literature had a similar presentation.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [12] requires that the following three criteria be met for the diagnosis of factitious disorder: (1) Intentional production or feigning of physical or psychological signs or symptoms, (2) motivation for the behavior is to assume the sick role, and (3) absence of external incentives for the behavior (e.g. economic gain, avoiding legal responsibility, and improving physical well-being, as in malingering). [12,13] The DSM-IV-TR recognizes the following three types of factitious disorder: (1) Factitious disorder with predominantly psychological signs and symptoms, (2) factitious disorder with predominantly physical signs and symptoms, and (3) factitious disorder with combined psychological and physical signs and symptoms.
A fourth type, factitious disorder not otherwise specified, includes those disorders with factitious symptoms that do not meet the criteria for factitious disorder. The DSM-IV-TR places factitious disorder by proxy (i.e. Munchausen syndrome by proxy) into this category, defining it as "the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role". [14] It has been estimated that 3-5% of physician-patient encounters involve factitious disease. [15] Patients with factitious diseases are extremely difficult to recognize because they do not appear different from patients with authentic causes of similar symptoms, because their psychiatric abnormalities are not appreciated, and because doctors and nurses have a low index of suspicion. Since patients with factitious disease present a false medical history, their physicians prescribe unnecessary procedures and therapies that may result in iatrogenic disease. In many cases, damage to these patients from doctors' actions exceeds the harm resulting from the patients' self-induced illness. [6,16] Many cases from Jordan [17] and other Arab countries [18][19][20][21][22][23] have been reported; with emphasis on the culture in each country and the influence of sociocultural dynamics, that leads to this behavior, including poverty, movement of population as well as religious and cultural influences.
To help keep factitious disease in clinical perspective, one of the case studies involves the antithesis of factitious disease, where a patient was mistakenly diagnosed as having psychogenic pain when in fact the symptoms were caused by an overlooked physical disease. [24] Better knowledge of the clinical features of factitious disease might have prevented the disastrous outcome.
Further researches across cultures are needed for untangling psychological, social, and cultural perspectives of factitious disorders, which may finally lead to the development of novel culturally sensitive treatment strategies.

Conclusion
Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures, and saves the healthcare facilities' money and resources by sparing hospital beds, resources, and money.