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RESUMEN: El trastorno facticio consiste en falsificar, inducir o agravar las enfermedades para recibir atención médica, independientemente si están enfermas o no. El impacto que tiene esta patología va desde altos costos en salud asociado a la policonsulta, hospitalizaciones y tratamientos innecesarios; la funcionalidad y calidad de vida de estos pacientes, hasta el costo de vidas humanas. Este trastorno sigue siendo un desafío para los clínicos, puesto que no hay evidencia suficiente sobre la epidemiología, etiología, clínica y manejo dada su complejidad. En este artículo se presentará un caso clínico enfatizando en la evolución de la enfermedad, manejo inicial y posterior durante su hospitalización, junto con una actualización basada en la literatura, en torno al tratamiento de esta patología, con el fin de proponer intervenciones preventivas o protocolos que permitan evitar hospitalizaciones y tratamientos innecesarios. Luego se finalizará con la resolución del caso, pronóstico de esta enfermedad y una conclusión.

ABSTRACT Factitious disorder consists of falsifying, inducing or aggravating illnesses in order to receive medical attention, regardless of whether they are ill or not. The impact of this pathology ranges from high health costs associated with polyconsultation, hospitalizations and unnecessary treatments, the functionality and quality of life of these patients, up to the cost of human lives. This disorder continues to be a challenge for clinicians, since there is insufficient evidence on the epidemiology, etiology, clinic and management given its complexity. In this article, a clinical case will be presented, emphasizing the evolution of the disease, initial and subsequent management during hospitalization, together with an update based on the literature, on the treatment of this pathology, in order to propose preventive interventions or protocols that allow avoiding hospitalizations and unnecessary treatments. Then it ends with the resolution of the case, prognosis of this disease and a conclusion.

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ABSTRACT The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests. People with this syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. Both syndromes are well-recognized conditions described in the literature since 1951. They are frequently observed by health teams in clinics, hospital wards and emergency rooms. We performed a narrative, nonsystematic review of the literature, including case reports, case series, and review articles indexed in MEDLINE/PubMed from 1951 to 2015. Each study was reviewed by two psychiatry specialists, who selected, by consensus, the studies to be included in the review. Although Munchausen syndrome was first described more than 60 years ago, most of studies in the literature about it are case reports and literature reviews. Literature lacks more consistent studies about this syndrome epidemiology, therapeutic management and prognosis. Undoubtedly, these conditions generate high costs and unnecessary procedures in health care facilities, and their underdiagnose might be for lack of health professional's knowledge about them, and to the high incidence of countertransference to these patients and to others, who are exposed to high morbidity and mortality, is due to symptoms imposed on self or on others.

RESUMO A síndrome de Munchausen e a síndrome de Munchausen por procuração são condições caracterizadas pela invenção ou pela produção intencional de sinais ou sintomas de doenças, bem como alterações de exames laboratoriais. Indivíduos com esta síndrome fingem que estão doentes e tendem a procurar tratamento, sem ganho secundário, em diferentes serviços de saúde. Ambas as síndromes são condições bem descritas na literatura desde 1951. Elas são frequentemente observadas pelas equipes de saúde em clínicas, enfermarias hospitalares e prontos-socorros. Conduziu-se revisão narrativa, não sistemática da literatura, incluindo relatos de caso, séries de relatos de caso, artigos de revisão indexados no MEDLINE/PubMed de 1951 a 2015. Cada estudo foi revisado por dois especialistas em psiquiatria que, por meio de consenso, escolheram quais estudos seriam incluídos nesta revisão. Apesar da síndrome de Munchausen ter sido descrita pela primeira vez há mais de 60 anos, a maioria dos estudos conduzidos sobre esta condição são relatos de caso e revisões da literatura. A literatura é carente de estudos mais consistentes sobre epidemiologia, manejo terapêutico e prognóstico da síndrome. Sem dúvida, tais condições geram altos custos e procedimentos desnecessários nos serviços de saúde. Seu subdiagnóstico pode se dar pela falta de conhecimento das síndromes por parte dos profissionais de saúde, e à alta incidência de contratransferência aos pacientes e a outros que são expostos à alta morbidade e à mortalidade é justificada pelos sintomas impostos em si mesmo ou em terceiros.

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Self-embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty-two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two-thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.

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We present a detailed case report that shows a woman patient who has Factitious Disorder manifested by the coexistence both of: A) typical/direct Munchausen and B) Munchausen by proxy or indirect: being the frst one (A) about the own person and the second one (B) about other people (most cases about their own young children). Furthermore, in the reported case we observed that the patient shown the particularity of having positive biological markers for Myasthenia Gravis (serology markers), and having inconsistent clinical manifestations that are typically observed in the exacerbation phase when she still continued in remission phase. In our own bibliographic research we couldn`t fnd anything about this case of "Mixed Munchausen Syndrome with organic comorbidity". In the same way as we tried to get information about the diagnostic algorithms and the possible therapeutic treatment strategies we found nothing like this reported before. Finally, this clinical presentation constitutes a blind spot for the scientifc community generating a lack of recognition for this diagnostic category and above all of the confusion that this mental disorder can generate in: a) the inadequate use of therapeutic resources, b) the irrational use of drugs, c) the distortion of institutional instances, and d) the medical behaviors that occurred in this case.

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The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests. People with this syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. Both syndromes are well-recognized conditions described in the literature since 1951. They are frequently observed by health teams in clinics, hospital wards and emergency rooms. We performed a narrative, nonsystematic review of the literature, including case reports, case series, and review articles indexed in MEDLINE/PubMed from 1951 to 2015. Each study was reviewed by two psychiatry specialists, who selected, by consensus, the studies to be included in the review. Although Munchausen syndrome was first described more than 60 years ago, most of studies in the literature about it are case reports and literature reviews. Literature lacks more consistent studies about this syndrome epidemiology, therapeutic management and prognosis. Undoubtedly, these conditions generate high costs and unnecessary procedures in health care facilities, and their underdiagnose might be for lack of health professional's knowledge about them, and to the high incidence of countertransference to these patients and to others, who are exposed to high morbidity and mortality, is due to symptoms imposed on self or on others.

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Cardiopathia fantastica é o termo utilizado para a variante cardíaca da síndrome de Munchausen, condição na qual o paciente busca atendimento médico repetidamente por doenças factícias. Relatamos um caso de síncope induzida por administração inadequada de fármacos cronotrópicos negativos, que resultou em implante de marcapasso definitivo, seguido de reações cutâneas sobre a loja do marcapasso. O acompanhamento da paciente mostrou que as alterações cutâneas eram lesões factícias (Dermatitis artefacta). Apresentamos também uma breve revisão sobre as reações alérgicas a dispositivos cardíacos eletrônicos implantáveis, abrangendo sua fisiopatologia e alternativas terapêuticas disponíveis.

Cardiopathia fantastica is the cardiac variant of Munchausen syndrome, a condition where patients repeatedly seek medical consultation for factitious diseases. We report a case of syncope induced by an inadequate administration of negative chronotropic drugs, which resulted in permanent pacemaker implantation, followed by the appearance of cutaneous reactions over the pacemaker pocket. This patient´s follow-up showed that the cutaneous disease consisted of factitious lesions (Dermatitis artefacta). We also present a brief review on allergic reactions to cardiac implantable electronic devices, including its pathophysiology and available therapeutic strategies.

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El Síndrome de Munchausen describe pacientes que fabrican historias clínicas con falsos síntomas y absurdas evidencias sobre enfermedades, se someten a múltiples investigaciones médicas, operaciones y tratamientos innecesarios, en ocasiones peligrosos para sus vidas. El Síndrome está inspirado en la figura del Barón Karl Friedrich Hieronymus Von Munchausen (1720-1797) un soldado germano, aventurero, notorio por los relatos absurdos, exagerados y fantasiosos de sus hazañas guerreras. En nuestro centro se ha presentado con cierta frecuencia la problemática, nos motiva poner al descubierto las razones que conducen a los seropositivos a permanecer ingresados por largos períodos de tiempo, a reingresar en el Centro, y a solicitar varios servicios médicos, cuando aparentemente desde el punto de vista clínico no se tienen alteraciones. Nuestros objetivos son: Caracterizar la situación clínica sugerente de Síndrome de Munchausen., diagnosticarlo y trazar estrategia de intervención efectiva. Presentamos un caso de un hombre de 39 años, de procedencia urbana, que presenta elementos diagnósticos del Síndrome, presenta abigarrada historia de salud, múltiples síntomas y enfermedades referidas. Los exámenes físicos y complementarios no pueden demostrar origen orgánico de todos los síntomas. La situación clínica presentada tiene elementos reales y ficticios, complejos desde el punto de vista diagnóstico y terapéutico que son sugerentes de Síndrome de Munchausen. Como estrategia de intervención sugerimos el diagnóstico adecuado (por exclusión) del Síndrome de Munchausen. Tratamiento de los problemas orgánicos reales y comprobados y combinar la psicoterapia de choque, de apoyo y los psicofármacos. Pensar siempre en la posibilidad de estar frente a un Síndrome de Munchausen ante una historia clínica abigarrada y compleja.(AU)

Munchausen's syndrome describes patients who build health histories with fake symptoms and nonsense evidences about diseases; they submit themselves to several clinic investigations, surgeries and unnecessary treatments that sometimes are dangerous for their lives. The syndrome is inspired on baron Karl Friedrich Hieronymus Von Münchausen (1720-1797) a German adventurer soldier, notorious for his nonsense, exaggerated and fancy stories about his war feats. In our institution it has been presented this situation frequently, which motivates us to reveal the reasons that make VIH seropositives to keep hospitalized during long periods of time, to come back to the centre and ask for medical services when they do not have alterations since the clinical point of view. This research goal is to characterize the clinic situation of Münchausen syndrome, to diagnose it and to establish the effective intervention strategy. It is presented a case report of a 39 year old man who has diagnosis elements of the syndrome: with variegated health history, several symptoms and diseases. The physical examination and complementaries cannot show the organic origen of all the symptoms. The clinical situation presents real and fictitious elements, complex since the diagnosis and therapeutic point of view that come from Münchausen syndrome. As the intervention strategy it is suggested the adequate diagnosis (by exclusion) of the Münchausen syndrome. The treatment for real organic and tested problems and the combination of shock and support therapy and psychopharmacs finally to think carefully on the possibility to face a Münchausen´s Syndrome with a variegated and complex clinical history.(AU)

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Los trastornos facticios son diagnisticados muy excepcionalmente en nuestro medio. Estos pacientes se

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Los trastornos facticios son diagnisticados muy excepcionalmente en nuestro medio. Estos pacientes se

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The authors review the literature on Münchhausen syndrome, and ilustrate the clinical features of the disorder with the description of a characteristic case. Diagnosis and differential diagnosis are discussed with regard to other somatoform disorders such as conversion disorder and somatization disorder as well as to malingering and schizophrenia. The awareness of general practitioners and surgeons regarding this syndrome may avoid the exposure of these patients to serious complications of unnecessary medical and surgical procedures. The management of Müchhausen syndrome is aggravated by the low compliance in these patients. Early diagnosis could to a considerable extent prevent the iatrogenic risks. The authors recommend that patients presenting the psychopathological features of a Münchhausen syndrome should be conservatively observed and an attempt to clarify both the medical and the psychiatric diagnosis should be made before any invasive procedure is undertaken.

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Os autores apresentam uma revisäo da literatura sobre a síndrome de Münchhausen, ilustrada pela descriçäo de um caso clínico bastante característico do transtôrno. Discute-se o diagnóstico e o diagnóstico diferencial com a simulaçäo, a esquizofrenia e transtornos somatoformes tais como somatizaçäo e conversäo. É importante que o clínico e o cirurgiäo estejam alertas para o diagnóstico de Münchhausen, porque esses pacientes se expöem a graves complicações de procedimentos clínicos e cirúrgicos desnecessários. Devido à baixa adesäo ao tratamento, o manejo clínico da síndrome de Münchhausen é difícil. O diagnóstico precoce pode, de maneira considerável, excluir estes riscos iatrogênicos. Recomendamos que os pacientes com as características psicopatológicas da síndrome de Münchhausen sejam observados de forma cautelosa. Deve-se tentar clarificar tanto o diagnóstico clínico quanto psiquiátrico antes de se realizar qualquer procedimento invasivo

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Munchhausen Syndrome can be expressed in many different ways. We report the case of a patient with cutaneous manifestations. Possible differential diagnostics are being analysed in both dermatology and psycopathologic aspects. Although the syndrome appears frequently, its unsuspected ways of presentation make difficult to diagnose it. It is necessary the knowledge of this syndrome because of the morbid-mortality it implies.

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El Síndrome de Munchhausen puede expresarse de muy diversas maneras. Comunicamos el caso de una paciente con manifestaciones cutáneas. Se analizan los posibles diagnósticos diferenciales en sus aspectos dermatológicos y psicopatológicos. Aunque frecuente, las insospechadas formas de presentación dificultan su diagnóstico. La implicancia de morbi-mortalidad hacen necesario el conocimiento de este síndrome

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El Síndrome de Munchhausen puede expresarse de muy diversas maneras. Comunicamos el caso de una paciente con manifestaciones cutáneas. Se analizan los posibles diagnósticos diferenciales en sus aspectos dermatológicos y psicopatológicos. Aunque frecuente, las insospechadas formas de presentación dificultan su diagnóstico. La implicancia de morbi-mortalidad hacen necesario el conocimiento de este síndrome (AU)

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Os autores relatam um caso de transtorno factício(síndrome de Münchausen) em otorrinolaringologia, ressaltando sua raridade. Discutem os Vários aspectos da síndrome e suas dificuldades diagnósticas, aconselhando alto índice de suspeição e serenidade dos médicos frente a esses pacientes

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Se afirmó que en las últimas décadas, y por la creciente medicalización de la sociedad, se ha descrito la aparición de pacientes con enfermedades ficticias ®complejas¼, que durante años son atendidos en diversas instituciones, demandan gran cantidad de recursos e increpan a los profesionales de la salud por no resolver sus quejas y enfermedades. No es posible demostrar las abigarradas entidades que se buscan afanosamente y que la mayoría de los médicos no se atreven a descartar totalmente por diversos motivos. No son histéricos ni simuladores en el sentido clásico, aunque conscientes de sus actos, tal parece como si los realizaran impelidos por razones que ni ellos mismos comprenden. Para ellos se ha introducido la denominación de síndrome de Munchausen. Se hizo un breve recuento sobre los criterios diagnósticos, grupos de riesgo, cuadro clínico, modus operandi, consecuencias adversas, tratamiento y pronóstico de este moderno desafío que pone a prueba la sagacidad clínica del médico contemporáneo (AU)

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