Here we describe Munchausen syndrome by tPA, a phenomenon of patients exhibiting factitious symptoms to assume the role of the sick patient, and desiring and receiving tPA.  To illustrate this phenomenon and its magnitude, we present data from a series of cases of Munchausen syndrome by tPA, prevalence in our stroke center, and highlight one illustrative case. 

In emergency assessment of possible acute stroke, rapid evaluation involves determining whether to intervene with administration of tPA.  Often it isn’t discerned whether a patient is having a stroke mimic in advance of administering tPA, and we’ve observed that sometimes patients exhibit Munchausen syndrome to receive tPA.

Cases were identified by review of departmental logs of acute stroke evaluations and discussion with physicians administering tPA.  Munchausen syndrome by tPA was confirmed if the patient exhibited factitious symptoms to assume the role of the sick patient, the patient desired and received tPA, and no alternative diagnosis or secondary gain better accounted for the presentation.

Of 335 cases with tPA administration over 29 months, 10 were confirmed as Munchausen syndrome by tPA, reflecting a 3.0% prevalence.  Nine of 10 patients had symptom duration less than 70 minutes prior to evaluation, 7 had left-sided symptoms, 7 had multiple prior presentations, 8 reported prior TIAs or strokes, and 8 of 9 who received a brain MRI had no prior infarct.  All patient exams were improved or normal by discharge. 

Munchausen syndrome by tPA is an underappreciated phenomenon encountered in evaluating patients with acute stroke symptoms.  Administering tPA in Munchausen syndrome poses an ethical dilemma as standard of care favors rapid tPA administration but administration can cause harm, adds financial burden to the healthcare system, and does not break the cycle of patients continuing to seek inappropriate healthcare.