Case 1 – Forensic Study
To begin with our first case summary, I am presenting a forensic autopsy case. This case is not a real one in all detail but is drawn from one of my cases. I chose a forensic case because people often seem interested in the cases and for the youth of today, CSI is creating a great deal of interest in forensic cases.
J.L. was a twenty-eight month white female who was an 8lb4oz product of a full-term pregnancy born to a GR3PA3AB0 mother after an uneventful thirty nine week gestation. The mother had prenatal care and was twenty-nine. The infant had some early bouts of diarrhea and required hospitalization for mild dehydration. The diarrhea was severe enough that the infant had a gastrointestinal consult who felt that there was some lactose intolerance.
At ten months, the infant developed a seizure disorder. The seizures were not precipitated by fever and were not grand mal. Instead, the infant appeared to be in a non\responsive post-ictal state after the bouts. The mother witnessed these seizures and sought medical care. The infant was sent to a pediatric neurologist at age 19 month and had a CT scan. No mass was identified on the scan. A cerebrospinal fluid was obtained. The glucose was 40 mg.dl, the cell count had 10 mature lymphocytes and no red blood cells, and the total protein was normal. Cultures were negative. The mother stayed with the child throughout the hospitalization. The staff witnessed no seizures. An in-hospital video recorded no seizures over a 72 hour period.
During the stay, the mother called the nurses to say that the child had a seizure. When the nurses responded the infant was lethargic and minimally responsive. She regained awareness in about 10 minutes with stable vital signs throughout this time. The infant was begun on seizure medication; she was discharged home to be followed by her family doctor with a six-month neurology visit. She did well at home for two months until the morning of January 13th at which time the mother entered the room and found her seizing. She called 911. The paramedics said that the child was non-responsive and intubated her. No seizures were witnessed. CPR was begun enroute to the hospital but the child expired.
What is your clinical diagnosis? What would you do next?
1. Sudden infant death syndrome
2. Allergic reaction to medications
3. Viral meningitis
4. Brain tumor
5. Need more information
At autopsy, the child was well developed, well nourished and well cared for. An extensive autopsy revealed no anatomic abnormalities. The electrolytes were normal. The metabolic panel for inherited metabolic diseases was negative. The autopsy was signed out as Undetermined.
What would you do next?
The autopsy slides were referred to a pediatric pathologist. No abnormalities were seen. The medical examiners office sent out an investigator to talk to the immediate family, the extended family, neighbors, physicians, and the paramedics. The only significant fact that was not known was that this child had had an older sibling who had died at the age of 4 years of pneumonia of unknown etiology. The child had some treatment for allergies and a variety of rashes not related to food or viral exposure. The death of this child occurred when the current infant was six months of age. The infant discussed here was not ill at the time of the first child’s death. The mother had changed doctors after the death of the first child and had relocated to a different county in the state. The mother had a history of depression and had studied to be a nurse but had not graduated with a degree.
What is your diagnosis?
The working diagnosis is Munchausen’s By Proxy (MBP). This is an uncommon form of child abuse that can be fatal. The history and medical findings are often puzzling and do not seem cohesive. The diagnosis can only be made if one is alert to the warning signs. Munchausen by proxy is described as the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s are for the purpose of indirectly assuming the sick role. The victims may present with multiple symptoms ranging from unexplained bleeding to seizure disorder to sudden infant death syndrome. Other common presenting symptoms can be fever, rash, gastrointestinal symptoms, and apnea. MBPO is associated with a high morbidity. Death rates range from 9% to 33%. The highest mortality has been seen in cases with recurrent induced apnea. Usually only one child is victimized at a time.