A case is discussed of the use of medical images from the internet to support claims of injury. There were several inconsistencies in both history and examination even prior to the presentation of the specimen radiograph from the internet. Clinicians are advised to be vigilant, to question histories that do not match with examination findings, to ensure that all radiographs are adequately labelled with patient-specific information and to look for radiographic inconsistencies such as the presence or absence of accessory ossicles.

Factitious disorders are illnesses whose symptoms are either self-induced or falsified by the patient. They are thought to be rare although the actual incidence is unknown due to likely under-reporting.1 Munchausen's syndrome is a type of factitious disorder the aim of which is to elicit sympathy or gain attention which reflects a deep-seated need to be sick. This distinguishes it from other factitious illness in which there is normally a more obvious secondary gain. It was first described by Asher2 in 1951 and originally split into three sub-classes according to presentation – abdominal, haemorrhagic and neurological. It is named after Baron von Munchausen (1720–1797), a German officer who travelled widely and was famous during his life-time for telling exaggerated stories about his life. Patients are more commonly male and incidence peaks in the mid 30s.3 We present a case of a patient who presented to our clinic with an inconsistent history, examination and imaging of her left ankle. She attended with a print-out of her supposed radiograph which we found was down-loaded from the internet. We would like to highlight the internet as a potential aid to those with factitious disorders.

A 40-year-old woman was referred for a second opinion regarding her chronically painful left ankle. According to the patient, she had originally injured her ankle in June 2005 following minimal trauma during a charity walk. She had attended an accident and emergency department where the diagnosis of ‘dislocated ankle’ was made. The ankle was apparently reduced in accident and emergency without films prior to manipulation and then immobilised for 3 months in a full below-knee cast. A few weeks after the removal of the cast, she suffered a further dislocation whilst walking. This was in Australia and, again, the ankle was reduced in a local hospital leading to a further 2 weeks in plaster.

When she presented to us, she complained of recurrent painful dislocations, including one which occurred whilst swimming. She had attended several hospitals in this period of time and was using crutches. The situation was not improving despite physiotherapy.

In 2006, she was assessed at a specialist foot and ankle clinic. Plain radiographs and an medical resonance imaging (MRI) scan were unremarkable. She was further investigated with an examination under anaesthetic and arthroscopy. There were no abnormal findings.

She remained off work, using crutches to mobilise. She was referred by her general practitioner (GP) to the hand clinic because of carpal tunnel symptoms and also referred (at her request) for a second opinion regarding her ankle pain.

She attended another specialist foot and ankle clinic in 2007 and, on this occasion, produced a paper copy of a radiograph she said had been obtained for her (by a relative) from the hospital at which she had been treated in Australia. She said it had then been e-mailed to her (Fig. 1). Examination of the ankle was unremarkable.

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Figure 1 Print-out of radiograph provided by patient.

The printed radiograph showed dislocation of the sub-talar and talo-navicular joints and had no patient identification. Furthermore, there are reflections visible suggesting that the image was a photograph of an X-ray on a light-box. The patient's radiographs taken on the day of her appointment do not show an os trigonum. This accessory bone is clearly visible on the paper printout from the patient. These radiological inconsistencies coupled with the atypical history and paucity of abnormal physical signs raised suspicion. Searching Google© images for ‘ankle dislocation’ yielded an identical image to that provided by the patient.4

Discussion with the patient led to no admission of wrong-doing (although she did admit it seemed to be from the internet) and further insistence of symptoms. The GP was informed of the situation and no further orthopaedic management is planned.

Munchausen's syndrome is a factitious disorder in which a patient intentionally fakes, simulates, worsens, or self-induces a medical problem with the aim of eliciting sympathy or gaining attention. Several features may alert the clinician to this diagnosis: dramatic medical history with inconsistent details; lack of physical signs to corroborate the history; symptoms that change or worsen following treatment; multiple attendances, especially at other hospitals; eagerness to undergo even invasive procedures and reluctance to provide contact details for previous healthcare providers.

The internet is a vast repository of medical information and, as such, can be a very useful tool to both clinicians and patients. It also has a supportive role in healthcare as numerous groups exist to allow patients to compare experiences. However, the disadvantages of such ready access to medical knowledge must be highlighted. The use of on-line support groups by patients with factitious illness has already been described;5 however, to our knowledge, the use of medical images from the internet to support claims of injury has not been reported. In this case, there were several inconsistencies in both history and examination even prior to the presentation of the specimen radiograph from the internet.

The authors would advise all clinicians to be vigilant, to question histories that do not match with examination findings, to ensure that all radiographs are adequately labelled with patient-specific information and to look for radiographic inconsistencies such as the presence or absence of accessory ossicles.

1. Robertson MM, Cervilla JA. Munchausen's syndrome. Br J Hosp Med 1997; 58: 30812. MedlineGoogle Scholar
2. Asher R. Munchausen's syndrome. Lancet 1951; 1: 33941. Crossref, MedlineGoogle Scholar
3. O'shea B, McGennis A, Cahill M, Falvey J. Munchausen's syndrome. Br J Hosp Med 1984; 31: 26974. MedlineGoogle Scholar
4. <http://www.fpc.edu/pages/images/AthleticsImages2/AthleticsImages/Athletic%20Training/ankle-dislocation.jpg> [Accessed 25 July 2007]. Google Scholar
5. Feldman MD. Munchausen by internet: detecting factitious illness and crisis on the internet. South Med J 2000; 93: 66972. Crossref, MedlineGoogle Scholar

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