The child was referred to a medical clinic in Wisconsin with hydropneumothorax following several hours of bloody diarrhea, cough, retching, and hematemesis. His two younger siblings were deceased following premature rupture of fetal membranes. After episodes of acute respiratory distress and heart block during the hospital stay, constant surveillance by one-to-one nursing or video monitoring was ordered. A nurse observed abuse; the District Attorney was contacted; the parents were confronted with the diagnosis of Munchausen's Syndrome by Proxy, a form of child abuse; and the child was placed in protective custody. The child has remained in a foster home for 3.5 years, initially demonstrating autistic-like behaviors and experiencing one transient psychotic episode in reaction to lint balls blowing in his face. He also abused a pet and a foster sibling. The parents divorced, the nonabusive father filed for custody, and father and son have had increasing contact. Recently the child began living with his father and began a transitional kindergarten. This case indicates the need to consider Munchausen Syndrome by Proxy when certain physical symptoms are found and when recurrent premature births occur. 28 references (Author abstract modified)