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An interesting case of factitious pseudomembranous conjunctivitis

Murthy, Vinay Ramachandra; Matada, Roopashri; Deshmukh, Ajinkya Vivekrao; Samak, Lakshmi; Kulkarni, Vinay Vasanth1

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Indian Journal of Ophthalmology: October 2019 - Volume 67 - Issue 10 - p 1693-1694
doi: 10.4103/ijo.IJO_223_19
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A 15-year-old boy was referred from a local ophthalmologist with a suspected diagnosis of unilateral chronic pseudomembranous conjunctivitis, unresponsive to topical antibiotic/steroid treatment.

On presentation, his unaided visual acuity was 20/20, N6 OU. The OS was normal and OD showed freely movable, reddish brown–stained cottony/ropy material in inferior fornix. There was no evidence of any intense inflammatory reaction except few follicles and congestion of lower fornix [Fig. 1a]. The rest of the conjunctiva and cornea were clear [Fig. 1b and c].

Figure 1
Figure 1:
(a) Slit lamp documented photograph showing fresh cotton piece reinserted by the patient in the lower fornix. Inferior conjunctival congestion with mild follicular reaction was noted. (b and c) Superior palpebral and bulbar conjunctiva and superior fornix and cornea were clear

Careful inspection of the material under slit-lamp microscope showed a cotton material with red (?kumkum) and brown (?coffee) powders [Fig. 2a]. Therefore, the patient was asked to report back on reappearance of symptoms. However, the patient went to washroom and came out with alleged reappearance of symptoms. While white cotton was noted in right lower fornix [Fig. 2b], a long cotton piece was recovered from his pant pocket [Fig. 2c]. Therefore, a diagnosis of factitious conjunctivitis was confirmed. The patient was referred to psychology counselor where he and his parents were counseled in detail.

Figure 2
Figure 2:
(a) A material removed from lower fornix and dissected with forceps. On microscopic examination, noted to be a cotton piece stained with red (?kumkum) and brown (?coffee) powder. (b) A fresh cotton piece removed from lower fornix second time. (c) A piece of cotton recovered from patient's pants pocket

Factitious disorders are conditions in which symptoms or physical signs are intentionally produced by patient to feign illness.[1]

The diagnosis of such factitious disorders is notoriously difficult due to its integral features such as deception and denial. In our case, the eye was relatively quiet for such a large amount of “membranes” to form. Variable history about duration of reappearance of membranes after removal aroused the suspicion. Moreover, there was involvement of right lower fornix in the right-handed patient. Although various cases of unilateral or bilateral factitious disease are described in ophthalmic literature, to the best of our knowledge, this is the second reported case of factitious conjunctivitis in India.[23]

To conclude, a strong suspicion in cases with inconsistent history and disproportionate signs and symptoms helps to consider a diagnosis of factitious disorder, the definitive treatment of which lies with psychiatric counseling.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

1. American Psychiatric Association. . Factitious disorders American Psychiatric Association, editors. Diagnostic and Statistical Manual of Mental Disorders. 19944th ed Washington DC American Psychiatric Association:471–5
2. Kapoor HK, Jaison SG, Chopra R, Kakkar N. Factitious keratoconjunctivitis Indian J Ophthalmol. 2006;54:282–3
3. Georgiou T, McKibbin M, Doran RM, George ND. Factitious keratoconjunctivitis (not another case of ocular Munchausen's syndrome) Eye. 2003;17:256–8

Conjunctivitis; cotton piece; factitious; pseudomembranous

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