Letter to the Editor
Resistant hypertension and no organ damage: A new case of Munchausen syndrome
Hipertensión arterial resistente sin lesión de órgano diana: un nuevo caso de síndrome de Munchausen
Paola H. Ponte
, Laia Matas, Josep Cadafalch, Juan A. Arroyo
Corresponding author
Departamento de Medicina Interna, Hospital Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Cataluña, Spain
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Ponte, Laia Matas, Josep Cadafalch, Juan A. Arroyo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Paola H." "apellidos" => "Ponte" "email" => array:1 [ 0 => "pponte@santpau.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Laia" "apellidos" => "Matas" ] 2 => array:2 [ "nombre" => "Josep" "apellidos" => "Cadafalch" ] 3 => array:2 [ "nombre" => "Juan A." "apellidos" => "Arroyo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Medicina Interna, Hospital Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Cataluña, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipertensión arterial resistente sin lesión de órgano diana: un nuevo caso de síndrome de Munchausen" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of resistant hypertension ranges from 5 to 30% of the hypertensive population.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Multiple cross-sectional studies have shown that these patients have a 50% increased risk to present cardiovascular complications such as myocardial infarction, stroke, congestive heart failure and chronic kidney disease.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Before a patient is diagnosed of resistant hypertension, however, possible causes such as pheochromocytoma, renal artery stenosis and medications should be ruled out. Munchausen syndrome is a disease in which a patient deliberately simulates symptoms of a disease in order to gain admission to the hospital and get the sick role. The term was first used in 1951 by Asher.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Typically these patients are characterized by a history of repeated simulated or feigned illness, great pseudologia (pathological lying) and pilgrimage (going from a hospital to another).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> The present case illustrates how determining the cause of resistance to hypertension can be abnormally challenging.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 36- year-old woman who was 32 weeks pregnant presented at the obstetric emergency unit in April 2010 with blood pressure of 190/110<span class="elsevierStyleHsp" style=""></span>mmHg despite treatment with labetalol, alfa-methydopa and nifedipine. Blood and urine tests were normal, and fetal development correlated with gestational age. She had no known allergies or toxic habits. She was administered intravenous antihypertensive drugs but the lack of response led to a cesarean section at 36 weeks and she gave birth to a healthy infant. Records from another center showed a history of an untreated attention deficit and an attempted suicide at 17 years of age. At age 31 years, she had been diagnosed with hypertension, coinciding with her first pregnancy. After delivery at our center, she was scheduled for a follow up visit three months later at the hypertension unit but she did not come. She was admitted after confirming persistently high BP (195/147<span class="elsevierStyleHsp" style=""></span>mmHg) and tachycardia (123–143 beats per minute) with 24-h ambulatory BP monitoring. All routine laboratory tests and autoimmunity tests were negative, plasma rennin activity, plasma aldosterone and 24-h urine catecholamines were measured and found to be normal. No microalbuminuria was found. A renal ultrasound with Doppler showed normal renal perfusion, and an echocardiogram and ECG showed no abnormalities. Central aortic pressure was assessed by catheterization and showed high values (191<span class="elsevierStyleHsp" style=""></span>mmHg/106<span class="elsevierStyleHsp" style=""></span>mmHg). A computed tomography angiography was normal. Sleep apnea was ruled out after performing a night pulsiosimetry. To discard autonomic dysfunction an electromyography was performed and showed normality values.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Between 05/2011 and 09/2011, the patient was admitted several times to different hospitals for hypertensive crises. After an extensive study and observing that the patient was taking the medication correctly, with the consent of the patient, we decided to perform a transcatheter renal denervation. While under the effect of the general anesthesia, BP and HR were within normal limits (135/76 and 88<span class="elsevierStyleHsp" style=""></span>bpm). However, after the procedure, her blood pressure rose again. Given the persistence of refractory hypertension and the onset of severe headache and major insomnia that did not respond to standard analgesics or to opioids, we referred her to the psychiatry department. Over the following months, the patient continued follow-up visits at the hypertension unit. With the suspicion of opioid dependence and having ruled out organic disease, we referred her to the drug dependence unit. Little by little, she admitted to inducing high blood pressure readings by performing Valsalva maneuvers and regularly consuming high quantities of caffeine and protein. Munchausen syndrome was finally diagnosed. Munchausen syndrome is considered an extreme form of factitious disease.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Patients with Munchausen syndrome often have co-morbid severe personality disorders,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> but the link with the primary syndrome is unclear. Clinically, these patients have an insatiable compulsion to mimic the severe and potentially fatal disease in the absence of organic disease.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In the case presented here, multiple additional clinical and laboratory studies were performed over a period of several years to exclude secondary causes of hypertension. The discrepancy between blood pressure levels and lack of organ damage could arouse suspicion about substances or maneuvers used by a patient to increase blood pressure. After multiple hospital admissions and ensuring “proper” medication compliance with requirements of intravenous drugs,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–10</span></a> despite the absence of organic lesions, the patient fulfilled criteria for resistant hypertension and underwent renal artery denervation by radiofrequency. Munchausen syndrome in our patient may have been triggered at first pregnancy as the result of a long-term, untreated personality disorder. Since the birth of her first child, she showed signs of anxiety and depressive traits.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ponte PH, Matas L, Cadafalch J, Arroyo JA. Hipertensión arterial resistente sin lesión de órgano diana: un nuevo caso de síndrome de Munchausen. Med Clin (Barc). 2016;146:e51–e52.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ESH/ESC Guidelines for the management of arterial hypertension. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Mancia" 1 => "R. Fagard" 2 => "K. Narkiewicz" 3 => "J. Redón" 4 => "A. Zanchetti" 5 => "M. 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