title: Clinical and toxicological findings in two young siblings and autopsy findings in one sibling with multiple hospital admissions resulting in death. Evidence suggesting Munchausen syndrome by proxy.
abstract: A 15-month-old girl underwent several emergency department (ED) visits and two admissions for parent-reported histories of ingestions, apnea, and seizures. She was initially admitted following reports of several unusual episodes of syncope accompanied by convulsive movements and was discharged on mephobarbital with a diagnosis of atypical seizure disorder. The day after discharge, she was brought to the ED in cardiopulmonary arrest and was resuscitated after a prolonged period. She was declared brain dead 2 days later. Ante- and postmortem toxicology produced several inconclusive findings, none of which explained death. Autopsy findings, including neuropathology, failed to demonstrate any significant disease processes. Approximately 3 months later, a 4-month-old female sibling was brought to the ED with a parent-reported history of apnea and seizures similar to the deceased child. A stool specimen obtained 2 days after admission contained numerous tiny seeds, which were found by gas chromatography-mass spectrometry analysis to contain lorazepam and temazepam. The role of these benzodiazepines in the apnea episodes in this infant was unknown, but the presence of the seeds in such a young infant coupled with the parent's aberrant behavior, led to the tentative diagnosis of Munchausen syndrome by proxy. This diagnosis was strengthened when results from these studies persuaded legal authorities to remove the surviving sibling from the parents, resulting in an asymptomatic recovery.
authors.affiliation: Section of Clinical Pediatric Pharmacology, University of Arkansas for Medical Sciences, Little Rock 72202, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Valentine
authors.forename: S
authors.initials: S
authors.lastname: Schexnayder
authors.forename: J G
authors.initials: JG
authors.lastname: Jones
authors.forename: W Q
authors.initials: WQ
authors.lastname: Sturner
mesh_terms: D014151:Anti-Anxiety Agents / Q000506:poisoning*; D001049:Apnea / Q000139:chemically induced; D001344:Autopsy; D002649:Child Abuse / Q000401:mortality; D004630:Emergencies; D005243:Feces / Q000737:chemistry; D005260:Female; D006785:Hospitals, University / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008140:Lorazepam / Q000506:poisoning; D008297:Male; D016735:Munchausen Syndrome by Proxy / Q000139:chemically induced / Q000175:diagnosis* / Q000401:mortality*; D009679:Nuclear Family; D010287:Parent-Child Relations; D010343:Patient Admission / Q000706:statistics & numerical data; D012640:Seizures / Q000139:chemically induced; D013693:Temazepam / Q000506:poisoning
chemical_list: D014151:Anti-Anxiety Agents; D013693:Temazepam; D008140:Lorazepam