Review Article

Cardiopathia Fantastica: The Cardiac Variant of Munchausen Syndrome

Authors: Ted A. Park, MD, Mark Andrew Borsch, MD, Allen R. Dyer, MD, PHD, Alan N. Peiris, MD, PHD

Abstract

Munchausen syndrome is a rare condition in which the patient repeatedly seeks medical care for factitious illnesses. Cardiac Munchausen syndrome was first reported in 1953 and later referred to as cardiopathia fantastica. It is characterized by clinical manifestations of acute cardiac disease that are feigned and recurrent. Cardiopathia fantastica can have a variety of presentations similar to true cardiac disease. Most cases have presented with chest pain simulating acute coronary artery disease, but arrhythmias, hypertensive crises, abnormal biochemistry, and electrocardiographic findings have also been noted. These patients are willing to undergo expensive, invasive, and risky procedures to evaluate their simulated illness. This condition is likely to be significantly underreported. In some patients, the presence of abnormal findings that are clinically insignificant may complicate the investigative approach. Patients with this disorder consume a disproportionate amount of health care dollars and sometimes are left with residual deficits as complications of invasive procedures. In this review, we discuss the recognition, manifestations, and treatment of cardiopathia fantastica.


Symptoms or signs that are intentionally produced or feigned by the patient in the absence of apparent external incentives characterize factitious disorders. Richard Asher coined the term Munchausen syndrome (after the fabled Baron Von Munchausen) in 1951 1 to describe a group of patients with factitious disease. The classic modes of presentation were neurologic (neurologic diabolica), abdominal (laparotomia migrans), and hemorrhagic (hemorrhagica histrionica). Many other presentations have been since described, including lithiasis nephrologica. 2


Cardiac Munchausen syndrome was first reported in 1953 3 and later was dubbed cardiopathia fantastica. Chest pain, arrhythmias, hypertensive crises, and other manifestations of cardiac dysfunction are among the most prevalent conditions presenting to the emergency room. Up to 20% of patients attending an emergency department complain of chest pain, but only approximately 25% of those patients are proven to have myocardial infarction (MI). 4 The majority of these people undergo an extensive and costly workup, which is not without risk. It is likely that some of these patients may have cardiopathia fantastica. Cardiologic manifestations are particularly attractive to patients with Munchausen syndrome because of the prompt and intensive interventions associated with this specialty. Factitious cardiac disease may increase as the public becomes more knowledgeable regarding manifestations of cardiac disease through multiple sources, including the Internet. Moreover, the ability to detect factitious disease may become harder with increasing sophistication of patients mimicking cardiac symptoms. Patients may use alternative medicine remedies with cardiac effects to induce disease. Awareness of the possibility of factitious cardiac disease may prevent unnecessary, recurrent, costly, and hazardous investigations.


Key Points


* Cardiologic manifestations are particularly attractive to patients with Munchausen syndrome because of the prompt and intensive interventions associated with this specialty.


* The cost for negative inpatient cardiac evaluations has been estimated to be $6 billion in the United States each year. How many of these patients are represented by factitious cardiac disease is undetermined, but the cost savings of identifying these patients has a large potential impact.


* Patients with cardiopathia fantastica are willing to undergo incredible hardship, limb amputation, organ loss, and even death to perpetuate the masquerade.


* Routine, brief, supportive office visits should be scheduled at regular intervals to provide reassurance and prevent patients from “needing to develop” symptoms to obtain care and attention.


* Cases involving factitious disorders may enter the civil legal system in a number of ways and cause incorrect judgments, financial costs, and inappropriate medical care if these disorders are not identified.

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References

1. Asher R. Munchausen’s syndrome. Lancet 1951; 1: 339–341.
 
2. Kounis NG. Munchausen syndrome with cardiac symptoms: Cardiopathia fantastica. Br J Clin Pract 1979; 33: 67–72, 79. |
 
3. Dickinson EJ, Evans TR. Cardiac Munchausen’s syndrome. J R Soc Med 1987; 80: 630–633.
 
4. Harvey CJ, Johnston JD. Cardiopathia fantastica exposed by rapid sequential serum creatine kinase analysis. J Intern Med 1998; 243: 323–326.
 
5. Cavenar JO Jr, Maltbie AA, Hillard JR, et al. Cardiac presentation of Munchausen’s syndrome. Psychosomatics 1980; 21: 946–948.
 
6. Manolis AS, Sanjana VM. Cardiopathia fantastica and arteritis factitia as manifestations of Munchausen syndrome. Crit Care Med 1987; 15: 526–529.
 
7. Mumford M, Tobis J. A case of Munchausen syndrome masquerading as unstable angina. J Natl Med Assoc 1981; 73: 661–664.
 
8. Bergethon PR. Factitious ventricular tachycardia. Ann Intern Med 1987; 107: 593–594(letter).
 
9. Boon D, Kraaijenhagen RA, van Montfrans GA. Factitious pheochromocytoma-like hypertensive bouts caused by the valsalva maneuver. Ann Intern Med 2001; 135: 304–305(letter).
 
10. Kailasam MT, Parmer RJ, Stone RA, et al. Factitious pheochromocytoma: Novel mimickry by Valsalva maneuver and clues to diagnosis. Am J Hypertens 1995; 8: 651–655.
 
11. Dimsdale JE, O’Connor D, Ziegler M, et al. Does chromogranin A respond to short-term mild physiologic challenge? Neuropsychopharmacology 1989; 2: 237–240.
 
12. Spitzer D, Bongartz D, Ittel TH, et al. Simulation of a pheochromocytoma: Munchausen syndrome. Eur J Med Res 1998; 3: 549–553.
13. Flaherty ML, Infante M, Tinsley JA, et al. Factitious hypertension by pseudoephedrine. Psychosomatics 2001; 42: 150–152.
 
14. Sturmann K, Shoen T, Filiberti AW. Factitious arrhythmia. Ann Emerg Med 1985; 14: 829–830(letter).
 
15. Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1995 emergency department summary. Adv Data 1997 Apr 15; 285: 1–19.
 
16. Storrow AB, Gibler WB. Chest pain centers: Diagnosis of acute coronary syndromes. Ann Emerg Med 2000; 35: 449–461.
 
17. Shimada T, Ishibashi Y, Murakami Y, et al. Myocardial ischemia due to vasospasm of small coronary arteries detected by methylergometrine maleate stress myocardial scintigraphy. Clin Cardiol 1999; 22: 795–802.
 
18. Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99: 240–247.
 
19. Purcell TB. Factitious disorders and malingering, in Marx J, Hockberger RS, Walls R (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice. St. Louis, Mosby, 2002, vol 2, ed 5, p 1572.
 
20. Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder: A randomized controlled study. N Engl J Med 1986; 314: 1407–1413.
 
21. Martin RL, Yutzy SH. Somatoform disorders, in Tasman A, Kay J, Lieberman JA. Psychiatry. Philadelphia, W.B. Saunders Co., 1997, pp 1119–1152.
 
22. Wheatley D. Evaluation of psychotherapeutic drugs in general practice. Psychopharmacol Bull 1962; 2: 25–32.
 
23. Mydlo JH, Macchia RJ, Kanter JL. Munchausen’s syndrome: A medicolegal dilemma. Med Sci Law 1997; 37: 198–201.