A 20–year–old woman with a history of Crohn’s disease and a Mallory Weiss tear presented with hematemesis. One month prior to presentation she was admitted to another institution with black, tarry stools. She received multiple blood transfusions; a peripherally inserted central catheter was placed and parenteral nutrition started. Subsequently, hematemesis with left upper quadrant pain developed occurring every other day. Blood cultures were positive for Staphylococcus aureus and Veillonella; antibiotics were started. Hematemesis became more frequent and her abdominal pain worsened, prompting transfer to our institution. Her pain was treated with meperidine due to intolerance to other agents. On exam, vital signs were within normal limits; she had a diffusely tender abdomen and no rebound or guarding; dried blood was noted in her oropharynx. An urgent upper endoscopy was performed with general anesthesia, as the patient could not tolerate conscious sedation due to pain and anxiety; this revealed a Dieulafoy lesion that was injected with epinephrine and a non–bleeding ateriovenous malformation. Hematemesis persisted, requiring additional blood transfusions. She developed acute hypotension and tachycardia in the setting of hematemesis but refused angiography due to lack of general anesthesia. Bleeding persisted and she agreed to angiography, which was normal. Two days later, repeat upper endoscopy revealed no source of bleeding. Repeat blood cultures grew Candida albicans; the venous catheter was removed. Hematemesis resolved and repeat blood cultures revealed no growth. A third venous catheter was placed and hematemesis promptly recurred. Subsequently, several blood–filled syringes were found in her room. A diagnosis of factitious disorder was made; psychiatry was consulted. The venous catheter was removed, hematemesis resolved, and she was discharged home in stable condition.
Factitious disorder, an under–recognized condition in which a patient consciously produces symptoms to assume the sick role, can mimic nearly any organic illness. As such, it presents a diagnostic dilemma. Unlike malingering, the secondary gain is to assume the sick role. Patients presenting with factitious disorder, as in this case, often go to great lengths to mimic illness and receive medical care. Patients typically have a history of hospitalizations at multiple institutions, frequently providing an incomplete history. Involvement of psychiatry is imperative to assist in diagnosis and treatment of coexisting psychiatric illness. It is critical that hospitalists be diligent in excluding organic causes prior to making the diagnosis; this can be time–consuming and often impairs the physician–patient relationship but is necessary to avoid potentially harmful misdiagnoses.
Hospitalists must be familiar with the presentation of factitious disorder. If missed, factitious disorder can expose patients to iatrogenic harm from medical therapy.