Background: Child maltreatment is a very common problem in the United States; over 702,000 children were victims in 2009. Medical Child Abuse by intentional poisoning, a form of Manchausen Syndrome by Proxy (MSbP), is an extremely rare version of child abuse and often requires multiple health care visits to diagnose. We present a case of MSbP involving intentional poisoning with Syrup of Ipecac.
Case Report: An 8 month-old girl had frequent visits to the emergency department (ED) for episodes of cyclical vomiting and constipation. No cause was found despite upper and lower endoscopies with biopsies, abdominal x-rays, MRIs of the head and lumbar regions, urine studies for infection and drugs, and multiple blood tests. The child was referred to a specialty center and her mother, a paramedic, relocated to be closer to this quaternary center. ED visits increased to every 3 days. The mother reported placing a nasogastric tube for fluid supplementation until the child could be formally evaluated. Further workup included: upper GI with small bowel follow through, abdominal ultrasound, extensive metabolic workup, stool studies, and additional screening blood tests. Providers noted symptoms often completely resolved within 12 hours of hospital admission. With an extensive negative work-up the diagnosis of MSbP was entertained. Poison Control was contacted and emetine and cephaeline levels were sent. The urine emetine level returned at 8.4 ng/mL (lowest limit of detection 5 ng/mL) and cephaeline level was undetectable (0.5 ng/mL). Child Protective Services was contacted and the child was removed from the mother's care, whereupon her symptoms resolved. Criminal charges against the mother have been filed.
Discussion: Intentional poisoning of children is uncommon. A 2-year prospective observational study in the United Kingdom identified only 65 cases with the most common drugs being anticonvulsants and opioids. Documented cases of intentional Ipecac poisoning are rare, particularly with Ipecac use becoming far less common. Our case is even more unique in that only emetine was detected. Emetine and cephaeline are the active alkaloids in Syrup of Ipecac that induce vomiting. Pharmacokinetic studies of both xenobiotics in humans revealed a half-life (t 1/2) of 3.45-9.4 hours for cephaeline, while the t 1/2of emetine was longer at 65.4-163 hours. One explanation for this large difference is emetine's enterohepatic recirculation.
Conclusion: Providers should be aware intentional poisoning with Syrup of Ipecac may be the cause of chronic vomiting. Detection is possible but only with a high level of suspicion and specialized testing. Emetine may be more readily detected than cephaeline given its longer half-life.