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A Woman With Recurrent Back Pain and Fever February 7, 2007 Case Information: History & Physical PMHx: HTN, dyslipidemia, congenital neurogenic bladder, (requiring self-cath), CKD, recurrent UTI, solitary right functioning kidney, (left atrophic kidney), vesicoureteral reflux, (diagnosed in her teens), mitral valve prolapse, schizoaffective disorder, eczema PSHx: appy, lap chole, exploratory lap History & Physical Meds: Triamterene/HCTZ 37.5/25 Lipitor 10 mg ASA 81mg Olanzapine 7.5mg Mirtazapine 30mg Lorazepam 1mg QID Clobetasol .05% cream prn Allergies: PCN (dyspnea) Social Hx Moved to Madison to pursue degree in counseling psychology, former phlebotomist, single, never married, no children, lives with roommate, smokes 1ppd x 30 years, rare ETOH, no exercise Family Hx Parents deceased. Mother died in 60s with MI/HTN. Father died of lung CA/DM. Nine siblings, (second youngest of ten). Sis with Breast CA in 40s, Bro with heart dz NOS ROS (pertinent positives) Irregular menses x 2 yrs, recurrent UTIs, (several a year/none currently), self-caths q 3-4 hrs Physical PE: Well-appearing, middle-aged woman, pleasant, timid, flat affect VS: afebrile, BP 130/84, HR 80, RR 16 ; 5’1, 140# Benign exam RECURRENT BACK PAIN AND FEVER Initial Illness: One week progressive fever, (T Max 101.0), nausea, right low back pain, poor appetite, malaise. Denied dysuria, urgency, frequency PE: T 100.5, BP 160/100, HR 100, RR 16, Right CVA tenderness Pt felt she had a UTI. Urine Cx: pan-sensitive E. Coli Tx with cipro x 14 days. Sx resolved. TWO WEEKS LATER… Same sx, UA not clean catch, Urine cx negative, CT abd without stone. Tx empirically with TMP/Sulfa Sx resolved. TWO WEEKS LATER… Sx of back pain and malaise Tx empirically with levaquin Urine cx pan-sensitive E. Coli Sx resolved. TWO WEEKS LATER… Severe right lower back pain, vomiting, fever 102.0, tachycardia Admitted directly to hospital for presumptive pyelonephritis Urine cx pan-sensitive E. Coli; Blood cx negative CT Abd: left atrophic kidney, (5 cm), right kidney with two renal cysts, (largest 17mm), no evidence of urinary tract obstruction, two small right-sided renal parenchymal calculi, no perinephric abscess Nephrology Consult: Chronic pyelonephritis secondary to longstanding reflux, (resulting in CKD). Theorized that left atrophic kidney was source of infection and was seeding the right kidney via her reflux. Infectious Disease Consult: Source was possibly renal cysts or calculi. Recommended CT-guided aspiration of cyst. (Cystic fluid negative for infection) Urology Consult: Thought above theories all very unlikely. Convinced her recurrent infections were due to poor self-catheter technique. (She was able to demonstrate meticulous technique; they were satisfied. Nothing to add) Disposition: Pt gets better. Discharged on prophylactic bactrim DS one at bedtime. Follow up urine cx was negative. ILLNESS ESCALATION Over the next few months, sx become more frequent and severe, despite antibiotic prophylaxis. Numerous out-pt appointments, urgent care visits, and hospital admissions. (7 admits in 6 months). ILLNESS ESCALATION Each admission pt sicker, requiring longer stays, numerous tests, consults. Final consensus was to proceed with left nephrectomy. (Atrophic kidney as source) Pt extremely relieved that definitive plan and treatment was in place. ILLNESS ESCALATION Urologist remained skeptical—ordered VCUG to prove presence of reflux before scheduling pt for surgery. (Pt had been dx as teen) VCUG cancelled—pt too sick and again admitted with fever and back pain. ILLNESS ESCALATION Hospital Course: pt became hemodynamically unstable, transferred to ICU for tx of septic shock, was intubated and required multiple pressors. Urine cx: citrobacter, enterococcus, candida, klebsiella Blood cx: candida glabratta, (two sets) HISTORY GATHERING ICU nurse informs emergency contact of pt’s change in medical status. Sister visits and raises suspicion of factitious disorder Hx of secretly making herself sick, (beginning in childhood. Never self-cathed as child/adolescent!) TRUTH Pt weaned from vent. Medically recovers. I gently confront pt. Pt reveals medical supplies, (urine-filled syringe, IV tubing, etc…) Dr. Grant strangely relieved. PLAN Assure pt medical care would continue, (prolonged tx for fungemia). I would not abandon her. Protect pt from self-harm and from harmful medical procedures. (24 hour sitter). PLAN Engage psychiatric care, (Tx both factitious disorder and schizoaffective disorder) Resume antipsychotics and psychotherapy while on medical floor Transfer to psychiatric unit when medically stable PLAN Enlist family support. Pt accepts plan. FACTITIOUS DISORDER Form of feigned illness, distinguished from malingering and somatoform disorders. The distinction is based on intentionality and objective. FACTITIOUS DISORDER Malingering—feigning illness has external incentive, (avoiding work). Factitious D/O—No other incentive than to be a patient and experience the sick role. Somatoform D/O-- symptoms are NOT voluntarily produced. FACTITIOUS DISORDER Factitious illnesses have broad spectrum of presentations. Mild form—physical symptoms simply exaggerated. Extreme form—Munchausen’s Syndrome The seeking of multiple invasive procedures and operations, sometimes with serious risk to life. HISTORY “Munchausen’s Syndrome” coined by Sir Richard Asher in a famous paper in the Lancet in 1951. Re Baron Karl Friedrich von Munchausen, (1720-1797), a retired German cavalryman who traveled around entertaining people with his preposterous stories. Feats included riding cannonballs, traveling to the moon, and escaping from a swamp by pulling himself up by his own hair. HISTORY Asher identified and classified the major presenting profiles of most factitious pts: Abdominal: “laparotomophilia migrans” Hemorrhagic: “hemorrhagica histrionica” Neurologic: “neurologica diabolica” Dermatologic: “dermatitis autogenica” Febrile: “hyperpyrexia figmentastica” Hospital hoboes, polysurgery addicts, professional patients Psychiatric Diagnosis: Factitious illness as a formal psychiatric disorder was first added to the DSM in 1952 when it described malingering. “factitious disorder” itself wasn’t added until 1980, with Munchausen’s syndrome being absorbed under the term “fictitious disorder NOS” Factitious Disorder—Defining characteristics: Intentional production of symptoms Illness behavior reflects a wish to assume the sick role Absence of external incentives for the behavior PATHOGENESIS: Conjectural. Research is lacking. Possible explanations found largely in psychiatric and psychoanalytic literature. CLINICAL PRESENTATION: Feigned illness usually very clever & convincing. Pts often have familiarity with med terminology, usually from extensive contact with the health profession, either as pts or employees. Suspicion usually not raised for long periods of time. CLINICAL PRESENTATION Illness is feigned through variety of ways— confabulated history, (neurogenic bladder), faking symptoms, (back pain), creating real illness by artificial means, (ingestion/injection of contaminants), tampering with instruments, (IVs, thermometers, lab specimens). CLINICAL PRESENTATION Transparent forms of self-mutilation are generally avoided. Pts usually appear more comfortable than their “condition” would warrant. Pts generally cooperative/receptive to all recommendations for evaluation—no matter how complicated or risky, (nephrectomy). Requests for consent to contact family members or other hospitals are usually denied. Nursing staff commonly observes lack of visitors, lack of phone calls, (suggesting asocial, isolated, or secretive behavior). DIAGNOSIS: No specific tests. Dx relies on astuteness of clinician First clue usually from checking other sources, (family, hospitals). Source of illness should be questioned when routine tx of illness does not result in improvement. Pt’s readiness to acquiesce to procedures/surgeries that would normally provoke anxiety in other pts raises suspicion. EPIDEMIOLOGY: Prevalence data is lacking. Pts who simulate dz are elusive/secretive by nature. Severe cases adopt aliases and modify their stories. Histories fabricated/unreliable and defy checking against factual accounts. When on the verge of detection, pts often leave AMA. Serious personality disorders often compromise the development of relationships needed to help them. EPIDEMIOLOGY: Extremely difficult to distinguish between naturally occurring dz and dz secondary to fictitious behavior. Laws regulating medical privacy and confidentiality also create barriers to data gathering. All of above result in few opportunities to work with and try to understand these pts. EPIDEMIOLOGY: These roadblocks to accumulating data suggest that the problem, although likely rare, is seriously under recognized and underreported. PREVALENCE DATA: Study at University of Toronto, Published 1990 in Psychosomatics. Study attempted to document the incidence of factitious disorder in a general hospital setting, (Toronto General Hospital). Method: Retrospective study conducted on 1361 referrals to the psychiatric consult service at the hospital. All referrals of medical and surgical inpatients to the consult service were examined over a three year period ending in Feb 1988. Method: Pt information was obtained from database forms that are routinely completed on all inpatients referred to the consult service. The forms were completed by the residents rotating through the psychiatric consult service. Database forms contained info re demographics, reason for referral, DSM-III psychiatric diagnoses, and treatment recommendations. Method: The full hospital charts were reviewed in all the identified cases of factitious disorder. The dx of factitious disorder was rejected when an examination of the medical chart revealed that an organic basis for disease was subsequently discovered. Results: Of the 1361 consults reviewed, 73 patients were seen more than once, thus 1288 different patients were actually seen. Dx of factitious disorder was based on DSM-III criteria. 11 patients met criteria for dx. The dx of factitious d/o was subsequently rejected on one patient when organic basis for disease was later discovered. 10 out of 1288 pts were diagnosed with factitious disorder. (.8%) Results: Age range: 19-64, median age 26 7 of 10 pts female Mean duration of sx prior presentation was 4 years, (range 0 to 11 years) 2 pts worked in health care fields, 1 social worker, 2 factory workers, 2 students, 1 housewife, 2 unemployed. Personality D/O dx in 4 of 10, (3 borderline, 1 atypical) 5 of 10 reported prior suicide attempts 2 of 10 had criminal histories Results: Acknowledgment of the factitious behavior was unusual. (1 of 10 admitted to her role in the illness) Acceptance of psychiatric treatment was unusual. (2 of 10). Follow up available only on one patient who subsequently died of self-induced illness. DISCUSSION: The above study suggests that factitious disorders are not commonly identified in the general hospital setting, but that these cases are associated with considerable morbidity, mortality, and health care expenditure. 3 of 10 patients were involved professionally in health care. Literature review suggests that pts with factitious disorder commonly have backgrounds in medically related fields or caring professions. DISCUSSION: Factitious Disorder is a syndrome that encompasses a heterogeneous group of patients. The patients in this study varied in their choice of symptoms, methods of inducing illness, chronicity of behavior, and associated psychopathology. DISCUSSION: Systematic study of a larger number of cases is needed to determine which characteristics are associated with the acceptance of psychotherapeutic treatment and with favorable outcomes. TREATMENT CONCEPTS: Confrontation is foundation of effective mgmt, when done in non-punitive manner with assurance that care will not be discontinued. Pts who also suffer from anxiety, depression, or psychotic disorders may also respond to the usual kinds of tx for these disorders. Focus on minimizing disruption to the nursing unit, help to lessen the potential for iatrogenic complications, and avoid expensive/dangerous interventions. TREATMENT CONCEPTS: Protect the patient from self-harm. Limit pt care to one physician and one hospital. If any approach is to be therapeutic, it is likely to occur in the context of a continuing pt-physician relationship, preferably with a primary care physician. BIBLIOGRAPHY: Asher, R. Munchausen’s Syndrome. Lancet 1951; 1:339. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987. Bean, W.B.: Munchausen’s Syndrome, Perspect Biol Med 2:347-353, 1959. Chapman, J. Peregrinating Problem Patients—Munchausen’s syndrome. JAMA 1957; 166:927. Kass, F.C. (1985). Identification of persons with Munchausen’s syndrome: ethical problems. General Hospital Psychiatry, 7, 195-200. Raspe, R.E., et al: Singular Travels, Campaigns, and Adventures of Baron Munchausen, New York: Dover Publications, Inc, 1960. Raspe, R.E. (1785). Baron von Munchausen’s Narrative of his Marvelous Travels and Campaigns in Russia. Powell, R., Boast, N. The million dollar man. Resource implications for chronic Munchausen’s syndrome. British Journal of Psychiatry. 1993; 162:253. Spiro, HR. Chronic factitious illness. Munchausen’s syndrome. Archives of General Psychiatry 1968; 18:569. Sutherland, AJ, Rodin, GM. Factitious disorders in a general hospital setting: Clinical features and a review of the literature. Psychosomatics 1990; 31:392.