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The patient described by Duffy in the same issue of the Journal was a 33-year-old man who presented with hemoptysis and hematuria and who claimed to be a Navy pilot. He also reported a history of Goodpasture's syndrome2.
The July 1992 issue of the New York State Journal of Medicine included a clinical conference on Munchausen's syndrome. This conference centered on the case of a 33-year-old black man who was admitted to the New York Infirmary Beekman Downtown Hospital because of hemoptysis, hematuria, severe low back pain, and a history of Goodpasture's syndrome. The patient also claimed to have been a Navy pilot who served in the Gulf war3.
In an editor's note to the Duffy article, readers were alerted to the possibility that the patients described in the two Journal articles were one and the same2. Indeed, a comparison of the medical and personal histories, signs, and laboratory-test results supports the probability that the two articles in the Journal as well as the clinical conference in the New York State Journal of Medicine describe the same man. There is one important characteristic, however, that is not identical -- that of race. Flynn described the man as being black,3 Ifudu et al. described him as being white, and Duffy did not say. Can the discrepancy be resolved? It is difficult to believe there are two men operating under the same guise.
Pascal James Imperato, M.D.
New York State Journal of Medicine
Lake Success, NY 11042
References
Both Patient 3 and the Red Baron had some evidence of iron deficiency anemia. Were they (or was he, if the patients are the same person) bleeding themselves?
George F. Krakowka, M.D.
Wenatchee Valley Clinic
Wenatchee, WA 98807
The prudent clinician should be aware that Goodpasture's syndrome can occur without the typical appearance of nodular shadowing or confluent consolidation on chest films. The existence of this rare, or perhaps unique, patient with Munchausen's syndrome who had signs and symptoms of pulmonary hemorrhage and renal disease should not distract the clinician from carrying out a thorough workup to confirm or deny the diagnosis of Goodpasture's syndrome.
Edmund J. Lewis, M.D.
Rush-Presbyterian-St. Luke's Medical Center
Chicago, IL 60612
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I suggest that a preferable approach would have been to discuss frankly with the patient the inconsistencies in his presentation and seek his permission to obtain information from other hospitals. If the patient had refused to sign requests for medical records, there would have been sufficient grounds to discontinue potentially harmful medical interventions and pursue a psychiatric diagnosis. This strategy would have resulted, at worst, in a similar outcome, and perhaps the physician's frank, respectful manner would have enhanced the patient's willingness to consider psychiatric treatment. In any case, no law or ethical principle would have been breached.
Richard L. Brown, M.D., M.P.H.
University of Wisconsin School of Medicine
Madison, WI 53715
Medical authors are strongly discouraged from presenting identical information in more than one published article. This does not prevent multiple articles from describing different encounters with the same patient. Surely this patient, besides endangering his life and wasting resources (including physicians' time), has used up his quota of academic articles. One hopes that he will be recognized in the future. In one unique sense, he is to be envied: he has appeared in the Journal, albeit as a patient, more times than many authors dream of.
Are there other patients who keep reappearing in the medical literature? Ifudu and colleagues suggest that the establishment of a registry of patients with Munchausen's syndrome might help prevent extensive invasive procedures in these patients. Perhaps medical authors and editors should also consult such a registry.
Andre Weltman, M.D.
Mount Sinai Medical Center
New York, NY 10029
References
To the Editor: We wish to correct the discrepancy noted by Dr. Imperato in our report. Our Patient 3 was a black man whom we erroneously described as being white. Dr. Krakowka's observation about the difference in weight between Patient 3 in our report and the patient described by Duffy can be explained by the differences in the time of evaluation. We saw Patient 3 in 1988, whereas Dr. Duffy saw him in 1992. We agree with Dr. Krakowka that the hematologic data are consistent with iron deficiency anemia. It is conceivable that self-induced trauma to his buccal mucosa was the source of the patient's "hemoptysis."
Dr. Lewis' point is well taken. We agree that the diagnosis of Munchausen's syndrome should not be made in haste, to avoid missing an authentic illness.1 With regard to Dr. Brown's comments, we are amused at the extent to which political liberalism has been interjected into patient care. It is interesting that Dr. Brown thinks that helping patients avoid potentially lethal and unnecessary invasive procedures by whatever methods are applicable is not justifiable. By extension of his logic, we must obtain consent from patients who require urgent psychiatric intervention.
Onyekachi Ifudu, M.D.
Eli A. Friedman, M.D.
State University of New York Health Science Center at Brooklyn
Brooklyn, NY 11203
References
My point in using this case was not to describe yet another patient with Munchausen's syndrome but to demonstrate the difficulties in clinical reasoning that such a case represents. For their proper diagnosis these cases require of the physician a blend of belief and disbelief, a stance that is nearly impossible for physicians to assume, since trust must remain the basis of the doctor-patient relationship. It is hoped that my article demonstrated the complexity of this diagnostic challenge, in which real psychopathology masquerades as an organic illness.
The ethical considerations surrounding the care of patients with Munchausen's syndrome have been addressed by many parties1,2,3,4. It has been their conclusion that a patient's right to confidentiality is not inviolate when the doctor-patient relationsip is distorted by the patient and the patient constitutes a risk to himself or herself or to other doctors or hospitals. Our patient might have received chemotherapy or undergone another renal biopsy if his ruse had not been promptly uncovered. This consideration did not necessarily justify our approach completely, and it is important to consider Dr. Brown's suggestion as a better alternative. His choice of management might have been more successful in permitting a therapeutic alliance to be established for subsequent psychiatric intervention. To superimpose deceit by the physician on a patient's deceit is to guarantee failure in the doctor-patient relationship.
Perhaps the Red Baron's next landing will not be managed as Goodpasture's syndrome but as the psychiatric disorder he actually has. This hope was the purpose of the exercise.
Thomas P. Duffy, M.D.
Yale University School of Medicine
New Haven, CT 06510
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