BACKGROUND: Medical Child Abuse (MCA) is a severe form of child abuse. In MCA, the caregiver abuses the child by exaggerating, fabricating, simulating, or inducing symptoms, and unnecessary, potentially harmful medical care harms the child. Bleeding is one of the most common manifestations of MCA. Diagnosis of MCA is challenging, and late diagnosis may increase the severity and complications. Once suspected, it is essential to apply all relevant methods of investigation to support and confirm the diagnosis, as soon as possible, as late diagnosis increases the risks.
METHODS: An 18-month-old boy was referred to the Pediatric Hematology by the Department of the Emergency with multiple admissions in a 2-week period for recurrent said-to-be bleeding episodes from different sites. Previously, he had been investigated for recurrent bleeding episodes in different hospitals for 4 months. In our center, the review of medical history, examination findings, and laboratory results showed some important inconsistencies leading to suspicion of MCA and the mother as the perpetrator. Then he was hospitalized for close observation. During hospitalization, multiple episodes of said-to-be bleeding were reported by the mother, but active bleeding was never observed by any hospital staff. No bleeding foci were detected in the nose or ears, supporting the diagnosis of MCA. After the file was forwarded to the prosecutor\'s office, the child was taken for institutional care, and no further bleeding was observed after separation from the mother. DNA, which was obtained from a so-called nosebleed during hospitalization, was analyzed and was reported to belong to the mother, confirming the diagnosis.
CONCLUSIONS: This case report draws attention to timely diagnoses by focusing on inconsistencies in the history and clinical signs and good clinical practices for the management of MCA, with a special emphasis on collecting evidence, including DNA samples, to confirm the diagnosis and help the legal process.

We report a Munchausen syndrome by proxy (MSBP) case, which presented as pharyngeal dysphagia and an acquired tracheoesophageal fistula (TEF). A six-month-old Saudi male presented with fever, persistent oral ulcers, intermittent bleeding from the ulcers, failure to thrive (FTT), poor appetite, and possible genetic disease. He had a history of recurring admissions due to infections, including those affecting the chest, ear, and bowel. Additionally, he tested positive for vancomycin-resistant enterococcus. There was no history of surgical procedures or blood transfusions. Due to the patient\'s nutritional status, a gastrostomy tube was inserted. The patient had recurrent bleeding from the tracheostomy tube during the hospital stay despite normal coagulation and platelet profile. Consequently, after diagnostic laryngoscopy, the otolaryngologist specialist pointed out that such retropharyngeal injuries are seen in patients with inflicted injuries, which is, in this case, caused by the mother, as she was the only one with the child during the recurrent bleeding episodes. Thus, we describe a clinical instance of MSBP, especially imitating pharyngeal dysphagia, leading to a delayed diagnosis. We advise adding MSBP to the possible diagnoses upon encountering pharyngeal dysphagia and oral ulcers.

BACKGROUND: Inappropriately high levels of insulin secretion can cause the potentially fatal condition of persistent hyperinsulinemic hypoglycemia of infancy. Our paper focuses on another cause of severe hypoglycemia, which can be easily missed.
METHODS: An 18-month-old Saudi female was referred to our hospital for further investigation and management of her recurrent hypoglycemic attacks as a case of persistent hyperinsulinemic hypoglycemia of infancy. During admission, we noticed multiple red flags from the history; the mother was insisting on a pancreatectomy, rather than going for a positron emission tomography scan, and most importantly, all hypoglycemic attacks occurred while the mother was around. Consequently, after further investigation, the case was diagnosed as a caregiver-fabricated illness, and the case was referred to the Child Protection Center.
CONCLUSIONS: One must have a high index of suspicion to diagnose caregiver-fabricated illness. Physicians should be more attentive to prevent such a disease, which could eventually become lethal if left unnoticed.

In palliative care, many end-of-life (EOL) patients are physically dependent on their caregivers. These patients may also have difficulty expressing their needs because of their underlying disease and are vulnerable to abuse. Factitious disorder imposed on another (FDIA) describes a condition in which an individual intentionally feigns physical or psychological signs or symptoms in another person with the intention of deceiving medical providers. Although FDIA is a form of abuse that palliative care workers must be aware of because of its multiple impacts on EOL care, it has never been reported in the palliative care literature. In this case discussion, we highlight a woman with advanced dementia who was subjected to FDIA. We discuss the impact of FDIA on EOL care and the management of FDIA in palliative care.

Factitious disorder (FD) is a condition in which patients fabricate evidence and produce false stories that often subject them to needless medical interventions with no clear benefits. In some instances, it can be imposed on a secondary victim often as a form of abuse. Most often, victims of a factitious disorder imposed on another (FDIA) are children or the elderly. Despite a mortality rate between 6 and 10% among victims, FDIA still remains underdiagnosed. Research on it often fails to address healthcare management initiatives, as well as the legal and ethical challenges physicians must navigate when managing it. In this report, we present a rare case of FDIA in an adult patient with a history of diabetes, substance use disorder, and schizoaffective disorder. This case highlights the importance of appropriate communication and detailed documentation when signs of FDIA are suspected. It also identifies the benefits of implementing a multidisciplinary approach when appropriate to minimize harm and improve outcomes.

Factitious disorder imposed on another, also known as Munchausen Syndrome by Proxy (MSBP), is a serious form of child abuse that is difficult to diagnose. In general, signs and symptoms are fabricated or produced by the mother or the caregiver. Delay in diagnosis may cause serious morbidity and mortality. Here, we present the case of an 18-month-old boy who was admitted to the Paediatric Infection Clinic with a diagnosis of acute gastroenteritis. When on intravenous fluid therapy, he developed high fever and subsequently, polymicrobial growth was determined in his blood. He was later diagnosed with MSBP. Despite being a rare condition, MSBP is a disorder that is often overlooked and may have fatal outcomes. Early diagnosis is very important in this disorder, which is considerably difficult to diagnose. In suspected cases, interdisciplinary team work is necessary to prevent adverse consequences.

Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians\' differential. This case of a 2-year-old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient\'s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child\'s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful caregivers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Munchausen syndrome by proxy (MSBP) is a condition diagnosed when a caregiver knowingly fabricates or inflicts illness on another for his/her own gain. Typical cases of MSBP detected by otolaryngologists involve facial trauma or otologic injury, while descriptions involving the nose are rare. Destructive nasal lesions have a broad differential diagnosis and may require visits to numerous specialists, placing strain on both the patient and the healthcare system. Early recognition of MSBP in patients with chronic nasal destruction may prevent such unnecessary strain. We present a case of MSBP involving two half-brothers with unexplainable nasal destruction and discuss the literature and current recommendations for managing the diagnosis.

BACKGROUND: Medical child abuse is a challenging diagnosis to make, particularly in older children with unusual presenting symptoms.
METHODS: A 7-year-old child with complex medical history presented with anogenital bleeding of unknown origin. Extensive laboratory testing, imaging studies, and diagnostic procedures were negative for any etiology. Forensic testing confirmed the blood in her underwear was a genetic match to the patient. Trial separation from the mother was diagnostic and therapeutic in this case.
CONCLUSIONS: Older children who are victims of medical child abuse might present in a variety of ways, and might even collaborate with the perpetrator in falsifying symptoms. It is important to keep medical child abuse on the differential when the patient\'s symptoms and work-up do not match.

BACKGROUND: Systemic autoinflammatory diseases (SAIDs) represent a growing number of monogenic, polygenic or multifactorial disorders that are often difficult to diagnose.
METHODS: Here we report a patient who was initially erroneously diagnosed and treated for SAID. Symptoms consisted of recurrent fever, erythematous and/or blistering skin lesions, angioedema, susceptibility to bleeding, external ear infections and reversible anisocoria in the absence of laboratory evidence of systemic inflammation. After two and a half years of extensive diagnostic work-up and multiple empirical therapies, a final diagnosis of Munchausen by proxy syndrome (MBPS) was established.
CONCLUSIONS: The diagnosis of SAID needs to be carefully reassessed if measurable systemic inflammation is missing, and MBPS should be included in the differential diagnosis.