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"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. 330 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 1. Hamer DH. Intestinal nematodes. Infect Dis Clin Practice 1996; 5:473–481. 2. Asher R. Munchausen’s syndrome. Lancet 1951; 1:339–341. 3. Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99:240–247. 4. Rumans LW, Vosti KL. Factitious and fraudulent fever. Am J Med 1978; 65:745–755. 5. Aduan RP, Fauci AS, Dale DC, et al. Factitious fever and selfinduced infection: a report of 32 cases and review of the literature. Ann Intern Med 1979; 90:230–242. 6. Zuger A, O'Dowd MA. The baron has AIDS: a case of factitious human immunodeficiency virus infection and review. Clin Infect Dis 1992; 14:211–216. 7. Gorman WF. Defining malingering. J Forensic Sci 1982; 27:401–407. 8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association; 1994. 9. Safer DL, Wenegrat B, Roth WT. Risperidone in the treatment of delusional parasitosis: a case report. J Clin Psychopharmacol 1997; 17:131–132. 10. Kun JF, Kremsner PG, Kretschmer H. Malaria acquired 13 times in two years in Germany. N Engl J Med 1997; 337:1636. 11. Justus PG, Kitchens CS. Secondary leukemia with munchausen filariasis. Ann Intern Med 1976; 85:685. 12. Mayo JP Jr, Haggerty JJ Jr. Long-term psychotherapy of Munchausen syndrome. Am J Psychother 1984; 38:571–578. 13. Klonoff EA, Youngner SJ, Moore DJ, Hershey LA. Chronic factitious illness: a behavioral approach. Int J Psychiatry Med 1983; 13:173–183. 14. Eisendrath SJ. Factitious physical disorders: treatment without confrontation. Psychosomatics 1989; 30:383–387.