munchausen syndrome is characterized by feigning physical symptoms to seek attention ; it was first reported by asher in 1951 .
we report a case of cutaneous munchausen syndrome in a patient who self - inflicted trauma to a postoperative wound .
a 50-year - old japanese woman consulted the emergency department of our hospital in august 2015 for bleeding due to an intractable postoperative wound on the lower abdomen ; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis .
the wound was sutured and the patient consulted with the dermatology department 3 days later ( fig .
, she presented with a painful ulcer ( diameter 6 cm ) on her right lower abdomen , and its suture had disappeared ( fig .
she also presented with multiple scars , skin grafts on the extremities , and a missing left lower leg , the causes for all of which were unexplained ( fig .
2 ) . her white blood cell count , neutrophil number , platelet count , renal and liver functions , c - reactive protein level , and ch50 level were normal , except for the hemoglobin level ( 9.2 g / dl ; normal range 12.015.0 g / dl ) .
negative results were obtained for cytoplasmic antineutrophil cytoplasmic antibodies , myeloperoxidase antineutrophil cytoplasmic antibodies , and anti - ss - a antibodies .
a histology of the skin biopsy specimen from the margin of the abdominal ulcer did not show any specific findings such as pyoderma gangrenosum or vasculitis , although we had considered these as differential diagnoses .
she had been presenting with repeated intractable wounds since she was a child , which resulted in the amputation of her left lower leg .
although we asked her about the scar and amputation , she did not reveal any details .
the previous surgeon who had performed the laparoscopic cholecystectomy 1 year before revealed that surgical wound dehiscence had occurred during her admission . after
her medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer 10 years before . during that admission
, she refused to consult with the department of psychiatry , although the staff suspected mental disorders .
therefore , we diagnosed her with cutaneous munchausen syndrome , although we could not determine how she had traumatized the postoperative wound .
after vacuum - assisted closure ( vac ) therapy had been performed to prevent her from traumatizing the ulcer again , it rapidly became granulated and reepithelialized ( fig .
soon after we had told her that we had diagnosed her with cutaneous munchausen syndrome , she discharged herself .
munchausen syndrome is a disorder characterized by a triad of features : simulated illness , pathological lying , and nomadic living .
people with this syndrome self - inflict numerous lesions , keep getting admitted to different hospitals , and feign acute illness , usually spectacular diseases ; and they willingly undergo invasive diagnostic procedures and risky therapies [ 3 , 4 ] .
typical findings in cutaneous munchausen syndrome caused by the intracutaneous presence of foreign material are erythema , swelling , necrosis , and tissue breakdown , which present as ulcerations , abscesses , nodular panniculitis , and pyoderma gangrenosum [ 2 , 5 ] .
most patients with cutaneous munchausen syndrome inject foreign materials into their skin and soft tissue ; however , our patient traumatized her postoperative wound .
the diagnosis of munchausen syndrome , which can sometimes be fatal , is often difficult to make .
also , hospital room and personal - belonging searches can provide evidence of methods for faking symptoms , and video monitoring or a bedside sitter can be helpful , as these techniques often reduce or eliminate symptom frequency during observation .
however , searches and monitoring should be performed after approval has been granted from the institution 's legal counsel .
diagnostic clues include cultured organisms from cutaneous wounds that are uncommonly found on the skin , usually on the nondominant side of the body [ 1 , 2 ] .
cutaneous munchausen syndrome should be considered as a differential diagnosis when a patient 's skin lesions do not heal or when they repeatedly recur despite appropriate treatment , and if routine detailed examinations show negative or normal results .
 a 50-year - old japanese woman consulted the emergency department of our hospital for bleeding due to an intractable postoperative wound on the lower abdomen ; the postoperative wound was owing to a laparoscopic cholecystectomy performed 1 year previously for acute cholecystitis . 
 she presented with a painful ulcer on her right lower abdomen . 
 she also presented with multiple scars , skin grafts on the extremities , and a missing left lower leg , the causes for all of which were unexplained . 
 the results of her blood test were normal , except for the hemoglobin level . 
 histology of the skin biopsy specimen from the ulcer did not show any specific findings . 
 the previous surgeon who had performed the laparoscopic cholecystectomy revealed that surgical wound dehiscence had occurred during her admission . 
 after a body restraint had been applied , the ulcer improved . 
 medical records indicated that she had been admitted to the department of plastic surgery at our hospital for skin grafting of a leg ulcer . during that admission 
 , she refused to consult with the department of psychiatry , al - though the staff suspected mental disorders . 
 therefore , we diagnosed her with cutaneous munchausen syndrome . 
 after vacuum - assisted closure ( vac ) therapy had been performed to prevent her from traumatizing the ulcer again , it rapidly became granulated and reepithelialized . munchausen syndrome is characterized by feigning physical symptoms to seek attention . 
 patients self - inflict numerous lesions , keep getting admitted to different hospitals , and feign acute illness , usually spectacular diseases . 
 vac therapy may be effective for preventing patients with cutaneous munchausen syndrome from traumatizing their wounds . 
Introduction
Case Report
Discussion
Statement of Ethics
Disclosure Statement