To the Editor: I read with interest the case report by Drs. Aleem and Ajarim,¹ who described a genuine case of chronic physical factitious disorder, also known as Munchausen's syndrome. However, the doubt could be cast whether or not the patient artifactually induced acquired immunodeficiency syndrome (AIDS). An in-depth analysis of the report revealed that besides other presentations of chameleon-like characteristics, this patient on multiple occasions self-induced swellings and abscesses involving different anatomical parts of the body, in particular, groin, abdomen and both breasts. The present author speculated that psychodynamically, she was repeatedly enacting by self-producing the surgical illnesses with the most approximation of the scenes which reflected the features of the breast cancer from which her mother had suffered. If the patient has herself communicated or disclosed to the referral physicians or the authors that she has AIDS, the controversy regarding which disease she fakingly induced would be over automatically on a temporary basis. Because once their factitious illnesses are identified, such patients tend to take flight from the hospital and present themselves with old or new symptoms in other hospitals. Notably, a majority of patients with Munchausen's syndrome present with life-threatening symptoms rather than diseases, depending on clinicians to formulate a diagnosis, until the feigned nature of the most probable illnesses is determined. With special reference to the fact that peregrination was not observed in this patient could be explained by either she fits into the classification of wandering versus nonwandering² or sociocultural variables. In Saudi culture, the female needs mehram for traveling, who is not available all the time.

If the present commentator accepted that this patient was self-inducing AIDS, the reviewed literature appears to be rather uncontextual. In fact, the authors must have reviewed the pertinent literature on Munchausen's syndrome presenting as AIDS.^3-14 A medline computer search up to February 1992 revealed these 12 references and thereafter there will certainly be more published case reports of Munchausen's syndrome with factitious AIDS. For the information of the authors, this is not the first case report of Munchausen's syndrome from Saudi Arabia. Earlier we reported a case of Munchausen's syndrome and review of world literature which was not published in the Annals (unpublished case report 10 May 1992). Recently, we have reported a Saudi divorced female who presented with salient features of Munchausen's syndrome with trihexyphenidyl dependence.¹⁵ In this report, we have discussed in detail the relationship between factitious disorders and drug abuse.

There are some errors in this paper which could be due to multiple reasons. For example, Carney and Brown is written in the text, but in the reference list, only Carney is mentioned. In some places, the words "associates" (Nanji and associates) and "colleagues" (Reich and colleagues) are mentioned when there are only two authors. My philosophy is that the authors must try their best to minimize the occurrence of such errors before submitting their papers to the Annals and, moreover, that proofreading provides another opportunity to reduce such errors. Besides other reflections and interpretations, these mistakes are a constant irritant for readers.

Naseem Akular Qureshi, MD

Medical Director Buraidah Mental Health Hospital P.O. Box 2292 Buraidah, Saudi Arabia