LETTER TO THE EDITOR
A case of intractable recurrent abdominal cutaneous
ulceration caused by self-injection of menstrual blood
Received: 3 August 2007 / Accepted: 26 November 2007 / Published online: 5 January 2008
Abstract The causes of recalcitrant cutaneous ulcerations
are various and complex. Self-injury is one of them, and
self-injected substances have also been reported. In our
case, autologous menstrual blood was used, resulting in
incurable cutaneous ulcerations and inappropriate opera-
tions being performed several times by plastic surgeons.
Meticulous care is indispensable for treatment of patients
with Munchausen’s syndrome.
The causes of recalcitrant cutaneous ulcerations are various
and complex. If the lesions are clinically atypical and
morphologically bizarre, self-injury should be considered.
Munchausen’s syndrome is characterized by the feigning of
the symptoms of a disease or injury to draw attention or
sympathy. We report a patient who underwent surgical
operations ten times for treatment of incurable cutaneous
ulcerations caused by Munchausen’s syndrome.
A 38-year-old woman presented with the complaint of
refractory cutaneous ulceration on the lower abdomen and
intermittent abdominal pain. She had undergone abdominal
operations several times for peritonitis and intestinal
obstruction. After exploratory laparotomy by an obstetri-
cian 1 year previously, wound dehiscence occurred on the
lower abdomen, resulting in intractable cutaneous ulcera-
tion. Because of failure to cure, the obstetrician consulted a
plastic surgeon, and the patient underwent surgical oper-
ations ten times within a year. However, the ulcerations
failed to heal. The patient was admitted into our hospital.
Figure 1 shows the ulcers at admission. A culture test of the
ulcerations revealed Pseudomonas aeruginosa. Laboratory
investigations did not show any sign of infection.
Surgery was performed in the standard way under
general anesthesia. The cutaneous ulceration over the
superficial fascia was removed, and neither a subcutaneous
pocket nor an abscess was found. Postoperatively, the
physical examination did not show any abnormal findings.
On postoperative day (POD) 5, the gauze was suddenly
stained by profuse, dark-red-colored, serous exudates
around the drainage tube insertion site. Exudate culture
revealed Pseudomonas aeruginosa. However, the wound
showed no dehiscence and was almost cured without
inflammation. The source of the exudate was not clear. At
that time, we suspected and warned the patient against self-
injury. Then, the exudate disappeared. On POD 11, a
similar exudate suddenly appeared. Meticulous inspection
revealed pinholes on the surface of clear film, covering the
gauze and the abdominal skin (Fig. 2). The wound was
already healed. She denied self-injury, but checking her
home with her permission revealed that she had needles, a
syringe, and tampons stained with dark-red-colored fluid
(Fig. 3). No laboratory tests were done to prove the type of
fluid used. But, it is presumed that the fluid used was her
menstrual blood from tampons, infected with Pseudomonas
aeruginosa. She did not admit self-injection to the end.
Self-induced disease is rare and was first reported in
1951 in patients with factitious disorders and exclusively
physical symptoms; this was termed as Munchausen’s
Eur J Plast Surg (2008) 30:303–304
Department of Plastic Surgery,
Osaka University Graduate School of Medicine,
T. Fujiwara (*)
2-2 C11, Yamadaoka, Suita-shi,
Osaka 565-0871, Japan