Transcript A WOMAN WITH RECURRENT BACK PAIN AND FEVER …

A Woman With
Recurrent Back Pain
and Fever
February 7, 2007
Case Information:
History & Physical
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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
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Meds:
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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
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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
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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)
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Irregular menses x 2 yrs, recurrent UTIs,
(several a year/none currently), self-caths
q 3-4 hrs
Physical
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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
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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…
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Same sx, UA not clean catch, Urine cx
negative, CT abd without stone.
Tx empirically with TMP/Sulfa
Sx resolved.
TWO WEEKS LATER…
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Sx of back pain and malaise
Tx empirically with levaquin
Urine cx pan-sensitive E. Coli
Sx resolved.
TWO WEEKS LATER…
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Severe right lower back pain, vomiting, fever
102.0, tachycardia
Admitted directly to hospital for presumptive
pyelonephritis
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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:
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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:
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Source was possibly renal cysts or calculi.
Recommended CT-guided aspiration of
cyst. (Cystic fluid negative for infection)
Urology Consult:
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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:
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Pt gets better.
Discharged on prophylactic bactrim DS
one at bedtime.
Follow up urine cx was negative.
ILLNESS ESCALATION
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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
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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
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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
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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
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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
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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
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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
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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
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Enlist family support.
Pt accepts plan.
FACTITIOUS DISORDER
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Form of feigned illness, distinguished from
malingering and somatoform disorders.
The distinction is based on intentionality
and objective.
FACTITIOUS DISORDER
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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
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Factitious illnesses have broad spectrum
of presentations.
Mild form—physical symptoms simply
exaggerated.
 Extreme form—Munchausen’s Syndrome
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The seeking of multiple invasive procedures and
operations, sometimes with serious risk to life.
HISTORY
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“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
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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
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Psychiatric Diagnosis:
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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:
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Intentional production of symptoms
Illness behavior reflects a wish to assume the sick
role
Absence of external incentives for the behavior
PATHOGENESIS:
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Conjectural.
Research is lacking.
Possible explanations found largely in
psychiatric and psychoanalytic literature.
CLINICAL PRESENTATION:
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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
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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
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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:
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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:
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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:
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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:
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These roadblocks to accumulating data
suggest that the problem, although likely
rare, is seriously under recognized and
underreported.
PREVALENCE DATA:
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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:
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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:
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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:
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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:
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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.
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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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.