Download “Doc, There`s a Worm in My Stool”: Munchausen Parasitosis in a

"Doc,There’s a Worm in My Stool":
Munchausen Parasitosis in a Returning Traveler
Christopher J. Gill and Davidson H. Hamer
Although delusional parasitosis is frequently diagnosed by travel medicine and infectious disease specialists, factitious illness/Munchausen syndrome is extremely
rare.
Our infectious disease service was consulted regarding a woman patient who claimed to have passed a large
roundworm in her stool that she believed was acquired
during foreign travel. When the parasite was identified
as an earthworm, our presumptive diagnosis of intestinal ascariasis was replaced with the correct diagnosis of
Munchausen parasitosis.
Although our case is quite unusual in the fields of
travel medicine and parasitology, it is typical of Munchausen syndrome in general and is another example of
the spectrum of psychiatric disease encountered in these
disciplines. In contrast with the more commonly encountered condition of delusional parasitosis, which is a form
of monosymptomatic psychotic hypochondriasis, our
patient deliberately manufactured both a compatible
history for her illness, and a corroborative (although
phony) pathologic specimen. As is often the case with
Munchausen patients, we were unable to provide her with
the needed psychological support as she severed all contact with our service prior to being confronted with evidence of her sham illness.
A limited number of helminthic infections exist in
which patients are able to actually observe large roundworms in their stool. The most common of these worldwide is ascariasis, and the typical adult ascarid may attain
a length of greater than 30 cm.1 Infection follows the
ingestion of ascarid eggs that contaminate food. A typical adult worm has a lifespan of 8 to12 months, and it
is the senescent or deceased adults that are passed and seen
by patients. We report a case of a woman who claimed
to have passed a worm in her stool which, based on her
description, was thought most likely to be an adult
Ascaris lumbricoides worm.
Christopher J. Gill, MD, and Davidson H. Hamer, MD, FACP:
Division of Geographic Medicine and Infectious Diseases,
New England Medical Center, Boston, Massachusetts; Tufts
University School of Medicine, Boston, Massachusetts;
Christopher J. Gill, MD: Division of Clinical Care Research,
New England Medical Center, Boston, Massachusetts;
Davidson H. Hamer, MD, FACP: Department of International
Health, Boston University School of Public Health, Boston,
Massachusetts; Department of Medicine, New England
Medical Center, Boston, Massachusetts.
Case Report
In midwinter, our infectious disease service was
asked to consult on a 53-year-old woman presenting to
our emergency department in a panicked state, claiming that she had passed a large worm in her feces. She
submitted the worm in a styrofoam cup atop a fresh stool
sample. The patient informed us she had traveled to an
unspecified island in the Caribbean and to Marseilles,
France, 9 months earlier and asked specifically whether
we thought she might have acquired this infection on her
travels. Other than anxiety at seeing the worm, she had
no other symptoms. She denied abdominal bloating or
colic, diarrhea, nausea, cough, wheezing, weight loss,
fatigue, rashes, or fever. She reported no prior medical
or psychiatric history; her physical examination was
unremarkable. A complete blood count showed a normal hematocrit; she had no leukocytosis or eosinophilia.
Given her travel history, and what was clearly a
species of large roundworm, ascariasis was considered the
most likely diagnosis. She was counseled that in otherwise healthy travelers, these were usually benign self-limited infections. Despite these reassurances, she made
multiple phone calls to the infectious disease clinic and
This work was previously presented by Dr. Gill as an oral
communication at the second International Conference of
Parasitology and Tropical Medicine, Kuala Lumpur, Malaysia,
October 2001.
This work was supported by National Institutes of Health
training grant 5T32AI0738 and NRSA training grant T32
HS00060-09 from the Agency for Healthcare Research and
Quality.
Neither of the authors have financial interests in any
company or drug that relates to or is mentioned in this
article. Support for this project was not provided by any
agency or organization with a financial interest or stake in
the results.
Correspondence: Davidson H. Hamer, MD, FACP, Division of
Geographic Medicine and Infectious Diseases, Box 7010
New England Medical Center, 750 Washington St., Boston
MA 02111.
J Travel Med 2002; 9:330–332.
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G i l l a n d H a m e r, M u n c h a u s e n P a r a s i t o s i s
331
the on-call infectious disease physician requesting additional information, reassurance, and advice about her
condition. At this point, although it was not felt to be
medically essential, she was offered a 3-day course of
albendazole and asked to come to our clinic for additional stool ova and parasite exams.
Our parasitology laboratory subsequently notified
us that the worm was not an ascarid, but was a common
garden earthworm, Allolobophora caliginosa (Fig.). The
patient did not keep her scheduled infectious disease clinic
appointment or submit her stool samples and was lost to
follow up.
Discussion
This patient’s final diagnosis was Munchausen syndrome. It was apparent that she knowingly manufactured
her illness, given her assurances that the worm was present in her feces. In hindsight, we suspect that her history
of travel to France and the Caribbean, “9 months ago”
was provided to suggest a plausible site of acquisition and
to add credibility to what would be our likely diagnosis,
based on the typical ascarid lifespan of 8 to12 months.1
The fact that this event occurred in midwinter, at a time
when the ground was frozen solid and covered with
snow, attests to the efforts she must have undertaken to
even find an earthworm. We can only speculate whether
she ate the worm, which would have passed intact due
to its indigestible chitinous exoskeleton or simply placed
the worm in a sample of stool. We did not think that accidental ingestion of an earthworm was a credible hypothesis in an adult. Nor did we consider the possibility that
the worm may have floated up through the plumbing to
be a credible explanation for this occurrence. This theory would seem to require a situation where the local water
table was saturated due to heavy rains or snow melt.
However, this event occurred in midwinter at a time
when the ambient New England temperatures were well
below freezing,the ground was solid,and the weather characteristically dry for the season.
Factitious illness describes patients who deliberately mimic symptoms of disease or induce illnesses for
secondary gain. The term Munchausen syndrome—
coined by Asher2 after the famed self-aggrandizer and
spinner of tall tales, Baron Karl Friedrich Heironymous
Freiherr von Munchausen—should be viewed as the
extreme manifestation of factitious illness.
Asher described several characteristic features of
Munchausen syndrome.2 Peregrination,a behavior of continually shifting care from one physician or hospital to
another, is classic. Peregrination reflects the need of
Munchausen patients to maximally exploit the patient
experience but is also a practical response to having
their manufactured illnesses unmasked repeatedly. Another
Figure These are the two fragments of earthworm
(Allolobophora caliginosa) as our laboratory received them. The
scale is in centimeters and millimeters. The worm appears pale
due to being preserved in formalin. A section of the worm’s head
was missing. The large arrow indicates the hood, which has
been transected, but is still recognizable. The small arrow
indicates one of the segmentations that is characteristic of
annelids rather than nematodes. Our laboratory did not make
the cuts to the worm. These appear to have been made by a
relatively blunt object, such as a garden spade, as the edges
are uneven and ragged.
characteristic feature is pseudologica fantastica, which
refers to the extraordinary and often convincingly wellresearched histories that Munchausen patients provided
to their physicians. Moreover, these stories are not just
elaborate in detail, but they display a pattern of pathologic storytelling that is itself intriguing to the listener.
Most factitious illnesses fall into one of four groups:
self-induced infections, simulated illnesses (including
both confabulated histories, and faked symptoms), chronic
wounds, and surreptitious self-medication.3 Infectious disease clinicians are most likely to encounter Munchausen
patients in the context of fever of unknown origin consultations.4,5 Several recent reports of sham human
immunodeficiency virus infection have also proven to be
Munchausen syndrome.6
Munchausen syndrome shares important features
with malingering. However, whereas falsified illness is a
central aspect of both, the patient’s underlying motivation is what sharply distinguishes the two diseases.7 In
malingering, the motivation is transparent to the observer:
illness is feigned to avoid work or punishment or to
receive some form of undeserved compensation, such as
disability payments or legal damages. By contrast, in
Munchausen syndrome, the illness behavior is motivated
by the patient’s desire for the psychological rewards they
derive by occupying the patient role.8 Additionally,
patients who successfully deceive their physicians feel
empowered by the fact that at least temporarily, they know
332
something that all the clever doctors do not, namely that
their illness is false. Whereas malingerers are quite aware
of their motivations,Munchausen patients are usually blind
to the deep subconscious drives that compel their actions.
Our patient’s illness should also be distinguished from
the more common disorder delusional parasitosis, wherein
patients labor under a false conviction of parasites infecting their intestines, skin, or other body systems. Delusional parasitosis is properly thought of as a form of
monosymptomatic hypochondriacal psychosis, which
generally responds well to neuroleptics.9
Examples of Munchausen syndrome are rare in the
parasitology literature. One notable example was a German hospital laboratory technician who was treated for
13 apparent relapses of Plasmodium falciparum malaria
after travelling once to Tanzania.10 With each illness, the
parasites were shown via restriction fragment-length
polymorphism analysis to be genetically unrelated and
thus represented sequential infections rather than a relapsing condition. Since this occurred in Germany, it was
suspected and later proven that the patient was autoinoculating blood from travelers and expatriates returning from
the tropics, which she had access to through her laboratory work. Another bizarre case involved a worldtraveling airline engineer who repeatedly sought treatment
for self-reported lymphatic filariasis. The patient possessed
remarkable knowledge about filariasis, including demanding that blood smears be done at 2 am so as to document
nocturnal microfilaremia. Ironically, although no clinical evidence supporting filariasis ever emerged, the
patient had been diagnosed at prior hospitals with an
actual case of chronic myelogenous leukemia.11
Munchausen patients are often difficult to manage,
partly because of damage to the patient-doctor relationship and because Munchausen patients frequently
eschew psychological care.This was certainly the case with
our patient who severed all contact with our clinic and
hospital before an appropriate psychological intervention
could be undertaken. Psychopharmaceutical agents may
be of adjunctive benefit for selected patients displaying
symptoms of depression, anxiety, or psychosis,12 although
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 9 , N u m b e r 6
overall behavioral therapy is the most important intervention.13 Experts in the field debate whether directly
confronting Munchausen patients is beneficial or harmful. If patients are to be confronted, it is recommended
that this be nonpunitive to avoid shaming the patient,
and it should be a segue to further therapy that includes
a partnership with the patient’s attending physician and
a mental health professional.14
References
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6. Zuger A, O'Dowd MA. The baron has AIDS: a case of factitious human immunodeficiency virus infection and review.
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