Medires Publishers - Article

Abstract

Background: Richard Asher syndrome was first described by Richard Asher in 1951, and he named it “Munchausen syndrome” after a fictionalized German character, Baron von Munchausen who was traveling and telling fantastic tales about his invented deeds. Richard Asher syndrome has not been reported from Iraq before. Patients and methods: The case of a patient complaining of recurrent bleeding per rectum over the previous seven years is described.

Results: A male who was otherwise health was seen at about the age of 30 years because he was complaining of recurrent bleeding per rectum of about seven years. He didn’t have bleeding from another site or any systemic symptom. He said that the last episode of bleeding occurred before about one week. All of the previous investigations including ESR complete blood count, stool examinations, abdominal ultrasound, abdominal X-ray, barium enema radiography and lower endoscopy showed normal findings. He said, previously a doctor diagnosed his illness as ulcerative colitis and prescribed him oral sulfasalazine to be taken during the episodes of bleeding, and another doctor suggested surgical removal of the colon. As it was not possible to identify any pathology, he was advised to wait for the next episode, and to do stool examination on the day of bleeding. However, after few weeks he came again and said that the last episode of bleeding occurred before about one week, and he didn’t do stool examination during the days of bleeding.

Conclusion: As early as 1955, Tyndel rightly criticized naming the syndrome after Baron Munchausen, as this name is not representative of the syndrome, and considered to be misleading because Baron Munchausen was considered as a source of harmful fantastic humor. Therefore, the appropriate name is Richard Asher syndrome. The first case of Richard Asher syndrome from Iraq is reported in this paper.

Introduction

Richard Asher syndrome was first described by Richard Asher (Figure-1) in 1951, and he named it “Munchausen syndrome” after a fictionalized German character, Baron von Munchausen who was traveling and telling fantastic tales about his invented deeds [1].

A clinical syndrome is a combination of signs and symptoms associated with a specific disease or disorder. Clinical syndromes are generally named after the physician or group of physicians who first described or reported the syndrome. Therefore, Richard Asher syndrome is the appropriate name for the syndrome first reported by Richard Asher in 1951[1-5].

Patients and methods

The case of a patient complaining of recurrent bleeding per rectum over the previous seven years is described.

Results

A male who was otherwise health was seen at about the age of 30 years because he was complaining of recurrent bleeding per rectum of about seven years. He didn’t have bleeding from another site or any systemic symptom. He said that the last episode of bleeding occurred before about one week. All of the previous investigations including ESR complete blood count, stool examinations, abdominal ultrasound, abdominal X-ray, barium enema radiography and lower endoscopy showed normal findings.

He said, previously a doctor diagnosed his illness as ulcerative colitis and prescribed him oral sulfasalazine to be taken during the episodes of bleeding, and another doctor suggested surgical removal of the colon. 

As it was not possible to identify any pathology, he was advised to wait for the next episode, and to do stool examination on the day of bleeding. However, after few weeks he came again and said that the last episode of bleeding occurred before about one week, and he didn’t do stool examination during the days of bleeding.

Discussion

The first case of Richard Asher syndrome was first described by Richard Asher in 1951, and further descriptions of the first case were published by several authors during the 1950s including Gatenby in 1951, Gawn and Kauffmann in 1955, and other authors. They reported a man who was presented with a fabricated illness of intermittent bleeding from the ears and nose and other sites.

The patient was most probably simulating bleeding from nose and ears by scratching the nasal and aural orifices, and spreading the blood over his ear and nose. The patient also fabricated hematuria by immersing pieces of blood-stained cotton-wool in his urine [6, 7, 8]. 

In 1955, Richard Asher suggested that there are three main types of the syndrome [8, 9]: The bleeding type (hemorrhagica histrionica): The patients in this group have been called sometimes, the factitious bleeders, and this type is probably the most common form of the syndrome.

The abdominal type (laparotomophilia migrans).

The neurological type (neurologica diabolica) associated with fake faints, fits, palsies, and other unreal neurological symptoms.

In 1955, Tyndel rightly criticized naming the syndrome after Baron Munchausen, as this name is not representative of the syndrome, and considered to be misleading because Baron Munchausen was considered as a source of harmful fantastic humor [10].

In 1960, Peyman reported a rare case of Richard Asher syndrome presenting as a chest pain [11].

Our patient was less sophisticated than most previously reported patients with Richard Asher syndrome as he failed to provide any sign or evidence of real illness. 

In a previous case reported by Anderson and colleagues in 1972, a female nurse fabricated gastrointestinal bleeding in the form of hematemesis and melena and provided evidence of blood loss by making herself lose blood through venesection and traumatic epistaxis, and she was receiving blood transfusions [12]. 

In 1989, McFadden and Roberts, reported a female patient with Richard Asher syndrome who was just like our patient presenting with rectal bleeding and claimed that she had received a diagnosis of ulcerative colitis [13]. 

Appropriate approach to the patient can help in confession and accepting treatment with psychotherapy [14]. 

Conclusion

As early as 1955, Tyndel rightly criticized naming the syndrome after Baron Munchausen, as this name is not representative of the syndrome, and considered to be misleading because Baron Munchausen was considered as a source of harmful fantastic humor. Therefore, the appropriate name is Richard Asher syndrome. The first case of Richard Asher syndrome from Iraq is reported in this paper.

Acknowledgement

The author has the copyright of the sketch included in this paper.

References

1. Asher R. Munchausen's syndrome. Lancet 1951 Feb 10; 1(6650):339-41. Doi: 10.1016/ s0140-6736(51)92313-6.
   View at Publisher | View at Google Scholar
2. Al-Mosawi AJ. Mostyn Embrey syndrome. 1st ed., Saarbrücken; LAP Lambert 3-Academic Publishing: 2016 (ISBN: 978-3-659-88892-2).
   View at Publisher | View at Google Scholar
3. Al-Mosawi AJ. Unilateral Renal Agenesis and the Awareness of Mostyn Embrey Syndrome. Journal of Renal Medicine March 21, 2017; 1(1):1-4. Doi: 10.5281/zenodo. 3875737.
   View at Publisher | View at Google Scholar
4. Al-Mosawi AJ. The case number 506 of Mostyn Embrey syndrome: Imaging studies and ethics of naming syndromes. Progress in Women's Health Care August 2021; 2(1) 10-28. Doi: 10.5281/zenodo.5201561.
   View at Publisher | View at Google Scholar
5. Al-Mosawi AJ. Mostyn Embrey syndrome: Awareness and ethics of naming syndromes. Scholars' Press, June 2021 (ISBN-13: 978-3-659-83722-7, ISBN-10: 3659837229).
   View at Publisher | View at Google Scholar
6. Gatenby PB. A case of Munchausen's syndrome. J Ir Med Assoc 1952 Apr; 30(178):102-3.
   View at Publisher | View at Google Scholar
7. Gawn RA, Kauffmann EA. Munchausen syndrome. Br Med J. 1955 Oct 29; 2 (4947): 1068. Doi: 10.1136/bmj.2.4947.1068.
   View at Publisher | View at Google Scholar
8. Asher R. Munchausen Syndrome. Br Med J 1955 Nov 19; 2(4950):1271.
   View at Publisher | View at Google Scholar
9. Shane SJ. Munchausen's Syndrome. Can Med Assoc J 1958 Apr 1; 78(7):532-3.
   View at Publisher | View at Google Scholar
10. Tyndel M. Munchausen Syndrome. Can Med Assoc J 1958 Jun 1; 78(11):891.
    View at Publisher | View at Google Scholar
11. Peyman MA. Development of chest pain in Munchausen's syndrome. Br Med J 1960 Mar 5; 1(5174):699-701. Doi: 10.1136/bmj.1.5174.699.
    View at Publisher | View at Google Scholar
12. Anderson JC, Ewan PW, Compston ND. Haemorrhage and fever in the Munchausen syndrome. Postgrad Med J. 1972 Jul; 48(561):445-7. Doi: 10.1136/pgmj.48.561.445.
    View at Publisher | View at Google Scholar
13. In 1989, McFadden and Roberts, reported a rare case of Richard Asher syndrome presenting
    View at Publisher | View at Google Scholar
14. McFadden JP, Roberts C. Munchausen's syndrome diagnosed by radiological examination. Postgrad Med J 1989 Jun; 65(764):429-30. Doi: 10.1136/pgmj.65.764.429.
    View at Publisher | View at Google Scholar
15. Tucker LE, Hayes JR, Viteri AL, Liebermann TR. Factitial bleeding: successful management with psychotherapy. Dig Dis Sci 1979 Jul; 24(7):570-2. Doi: 10.1007/BF01 489328.
    View at Publisher | View at Google Scholar