Munchausen syndrome by proxy (MSBP) or factitious disorder imposed on another (FDIA) is a bizarre psychiatric entity, consisting in fabrication of symptoms and alteration of laboratory tests by a caregiver. It is considered a serious form of child abuse. Alarm signs are frequent medical visits, strange symptoms which are never objectified during hospitalization. 3 years 8 months old boy first presented to our department in October 2022 for prolonged fever. We ruled out infections, malignancies, autoimmune diseases. The patient kept coming back once every fortnight for the same reason – fever, every time associating something particular and new - from painful joints to hemorrhagic complaints. Interestingly, with every new visit, the patient’s medical history became more complex. The mother also developed an attachment relationship with the medical staff. During a 4 months period of repeated admissions, child’s symptoms were never objectified throughout hospitalization, never consistent with the declared symptoms and test results. When the physician’s attitude changed from empathic to distant, she never came back for check-ups. A pediatrician work largely depends on a good communication with the parents. When there is no medical explanation for declared symptoms, one might question the merit of the story. This case sets a bright light on how difficult the diagnosis and management of FDIA is and the severe consequences this disease has on a defenseless child.

Background: Omega-3 polyunsaturated fatty acids (PUFAs) are increasingly reported to improve chronic neuroinflammatory diseases in peripheral and central nervous systems. Specifically, docosahexaenoic acid (DHA) protects nerve cells from noxious stimuli in vitro and in vivo. Recent reports link PUFA supplementation to improving painful diabetic neuropathy (pDN) symptoms. However, the molecular mechanism behind omega-3 PUFAs ameliorating pDN symptoms is lacking. Therefore, we sought to determine the distinct cellular pathways that omega-3 PUFAs dietary supplementation promotes in reducing painful neuropathy in type 2 diabetes mellitus (DM2) patients. Methods: Forty volunteers diagnosed with type 2 diabetes were enrolled in the "En Balance-PLUS" diabetes education study. The volunteers participated in weekly lifestyle/nutrition education and daily supplementation with 1,000 mg DHA and 200 mg eicosapentaenoic acid. The Short-Form McGill Pain Questionnaire validated clinical determination of baseline and post-intervention pain complaints. Laboratory and untargeted metabolomics analyses were conducted using blood plasma collected at baseline and after three months of participation in the dietary regimen. The metabolomics data was analyzed using random forest, hierarchical cluster, ingenuity pathway analysis, and metabolic pathway mapping. Results: We found that metabolites involved in oxidative stress and glutathione production shifted significantly to a more anti-inflammatory state post supplementation. Example of these metabolites include cystathionine (+90%), S-methylmethionine (+9%), glycine cysteine-glutathione disulfide (+157%) cysteinylglycine (+19%), glutamate (-11%), glycine (+11%) and arginine (+13.4%). In addition, the levels of phospholipids associated with improved membrane fluidity such as linoleoyl-docosahexaenoyl-glycerol (18:2/22:6) (+253 %) were significantly increased. Ingenuity pathway analysis suggested several key bio functions associated with omega-3 PUFA supplementation such as formation of reactive oxygen species (p = 4.38 × 10-4, z-score = -1.96), peroxidation of lipids (p = 2.24 × 10-5, z-score = -1.944), Ca2+ transport (p = 1.55 × 10-4, z-score = -1.969), excitation of neurons (p = 1.07 ×10-4, z-score = -1.091), and concentration of glutathione (p = 3.06 × 10-4, z-score = 1.974). Conclusion: The reduction of pro-inflammatory and oxidative stress pathways following omega-3 PUFAS supplementation is consistent with using omega-3 PUFAs as a complementary dietary strategy as part of the overall treatment of painful diabetic neuropathy.