A rare cause of hemoptysis: factitious disorder.

Abstract: Hemoptysis is an important symptom that requires broad evaluation, including invasive procedures. Nevertheless, in a considerable number of patients, the cause of hemoptysis may not be adequately determined despite extensive investigations. Factitious hemoptysis is a manifiestation of Munchausen syndrome that describes a group of patients who intentionally produce or feign symptoms or disabilities. Although the disorder is rare, it is believed to be under recognized and under reported. Therefore, there is an urgent need for increased awareness of the disease in order to avoid unnecessary, expensive and sometimes dangerous medical treatment and manipulations. We report a case of Munchausen hemoptysis as a reminder that factitious origins should be added in the differential diagnosis of hemoptysis of unclear etiology.

Keywords: factitious hemoptysis, Munchausen syndrome

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Factitious disorder, also known as Munchausen syndrome, is an extreme condition that defines patients who intentionally produce or feign symptoms or disabilities, either physical or psychological. (1) The manifestations of factitious disorders vary, depending on the patients' medical knowledge, imagination and courage. Pulmonary manifestations of the disorder range from hemoptysis to cystic fibrosis. (2) So far, factitious hemoptysis has been reported in approximately 20 cases. (3-5)

A 26-year-old unemployed woman was admitted with a 6-month history of recurrent hemoptysis and fatigue. She denied high fever, sputum production, or dyspnea, but complained of a 3-month weight loss of 17.5 kilograms. The patient had a 7-year history of tobacco use, but no drug use or alcohol addiction, and her only current diagnoses included depression and gastritis. Medications included levothyroxine, oral contraceptives and [H.sub.2] receptor blockers. Family history included pulmonary tuberculosis in an uncle, and her nephew had recently died due to a massive bleeding episode one month before presentation.

The patient had recently been admitted to two other institutions for evaluation of her hemoptysis, and diagnostic workup included three bronchoscopies, esophagogastroscopy, nasopharyngeal and thorax tomographic scans, as well as pulmonary angiography. No source of bleeding had been found, and the patient was referred to our hospital for further evaluation. On presentation, vital signs were normal and physical examination revealed only pale conjunctivae. Laboratory results were normal, including routine biochemistry and coagulation panels, arterial blood gas, C-reactive protein, and sedimentation rate. Hemoglobin and hematocrit were 10.4 and 31%, respectively. Chest radiography and electrocardiogram were normal. An extensive investigation, including nasal endoscopy, abdominal ultrasonography, and technetium-99m-labeled RBC scan, failed to show any evidence of bleeding. Hemosiderin-laden macrophages were absent in the expectorated blood on several occasions. An extensive infectious disease workup, including tuberculosis, was negative and cytologic analysis of expectorated blood showed no evidence of malignancy. Ophthalmological, dermatological and neurologic evaluations for the suspected diagnosis of vasculitis, including Behcet disease and bleeding disorders, were unremarkable.

During the hospital course, the patient expectorated almost a cup of bright red blood on a daily basis, even in front of medical staff. However, when she was informed that she would need to undergo bronchoscopic evaluation during a bleeding episode, the bleedings ceased during the day time, and began to occur after hours. At this point, factitious hemoptysis was highly suspected as the diagnosis, and the patient was transferred to the psychiatry department. Shortly following the transfer, syringes were found in the patient's cabinet. During six weeks of hospitalization, the patient underwent interpersonal and group psychotherapy with explorative elements. Finally, during the third week of inpatient group therapy, the patient confessed that she had drawn the blood by self-induced phlebotomy. This self-disclosure helped the patient evaluate and change her behavior, and three weeks later, she was discharged and placed in an outpatient program.

Patients with factitious disorders repeatedly present with symptoms that have no organic basis. According to the DSM-IV (Diagnostical and Statistical Manual of Mental Disorders) diagnostic criteria, the motivation for the behavior is to assume the sick role. External incentives for the behavior should be absent for the correct diagnosis. (1,6) Since most patients have been employed in the health care professions, they generally have a somewhat reasonable medical history, but discrepancies are detectable upon careful evaluation. They typically present at multiple hospitals carrying all of their medical records, (7) are usually young in age, and readily provide consent for all invasive procedures, including thoracotomy. (8) In addition, physical examination and laboratory workup generally return within normal limits.

Although it is extremely rare, hemoptysis is the most common symptom of pulmonary Munchausen syndrome. Bleeding is often produced in a crude and tortuous manner, sometimes involving objects such as glass, pins, scissors, and razor blades. (8) Self-inflicted wounds are the most common means of producing blood. (5,8) Although the definite prevalence is not known in this disorder, a large teaching hospital in Toronto found that factitious disorders were diagnosed in 10 of 1,288 (0.8%) patients referred consecutively to the psychiatric consultation-liaison service. (9) Although previous experience with patients with factitious disorders suggests that psychotherapeutic interventions are unsuccessful, (8) our patient benefited from this intervention. While uncommon, factitious disorders are probably underdiagnosed and underreported. (8) The leading cause of failure to correctly diagnose this disorder is the rarity of the disease. Factitious disorder should be kept in mind in the treatment of patients exhibiting symptoms of pulmonary hemoptysis with normal physical and laboratory data.

References

1. Fliege H, Scholler G, Rose M, et al. Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge. Gen Hosp Psychiatry 2002;24:164-171.

2. Kitchens CS. Pulmonary Munchausen Syndrome. Chest 2002;121:1392-1393.

3. Saed G, Potalivo S, Panzini L, et al. Munchausen's Syndrome. A Case of Factitious Hemoptysis. Panminerva Med 1999;41:62-67.

4. Bjornson CL, Kirk VG. Munchausen's syndrome presenting as hemoptysis in a 12-year-old girl. Can Respir J 2001;8:439-442.

5. Gurkan OU, Karacan O, Ozdemir O, et al. Factitious haemoptysis. Aust NZ J Med 2000;30:729.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994.

7. Highland KB, Flume PA. A "Story" of a Woman With Cystic Fibrosis. Chest 2002;121:1704-1707.

8. Baktari JB, Tashkin DP, Small GW. Factitious Hemoptysis Adding To The Differential Diagnosis. Chest 1994;105:943-945.

9. Feldman MD, Ford CV. Factitious Disorders. In: Sadock BJ, Sadock VA (eds). Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Philadelphia, Lippincott William and Wilkins, 2000, pp 1533-1544.</p> <pre> Life without music would be an intolerable insult. --Edward Abbey </pre> <p>Nurdan Kokturk, MD, Numan Ekim, PROF, Selcuk Aslan, MD, Asiye Kanbay, MD, and Aysegul Tetik Acar, MD

From the Departments of Pulmonary Medicine and Psychiatry, Gazi University School of Medicine, Ankara, Turkey.

Reprint requests to Asiye Kanbay, MD, Gazi University School Of Medicine Department of Pulmonary Medicine, Besevler, Ankara, Turkey 06510. Email: [e-mail]

Accepted September 20, 2005.

RELATED ARTICLE: Key Points

* Hemoptysis might be a symptom of factitious disorder.

* Munchausen syndrome should be kept in mind in the differential diagnosis of hemoptysis.

* In Munchausen syndrome the physical examination and laboratory workup are generally normal.