Introduction Case Summary Discussion Conclusion

Case Report - A Case of Factitious Fever KS Bhandari#, A Singhal*, R Ramasethu** # Dr KS Bhandari, Resident (Med), MUHS Nasik

*Surgeon Cdr A Singhal MD DNB MNAMS PDCC(Rheumat), Asst Prof( Med), INHS Asvini, MUHS Nasik

** Brig R Ramasethu DM (Nephro), Prof &HoD (Med &Nephro), INHS Asvini, MUHS Nasik

Introduction Factitious Fever refers to factitious disorder imposed on self refers to psychiatric condition in which patients deliberately produce or falsify symptoms and/or signs of illness for the principal purpose of assuming the sick role. Many authorities believe that this factitious disorder is under diagnosed because patient’s wilful deceptions are commonly missed by medical staff (1). Patients are typically young, female and often associated with medical profession. Early identification may reduce the necessity of prolong hospitalization and exposure to various potentially hazardous drugs. Since nature of this illness varies early discovery may help in timely intervention of Psychiatrist as such patients may be more amenable to therapy (2).

Case Summary Our patient is a 24 years old serving soldier in known case of suspected mental and behavioural disorder was transferred from peripheral hospital on 25 Dec 2013 with complaints of fever since 9 Dec 2013 which was intermediate grade initially and later high grade, continuous with no diurnal variation and associated with chills. He had no complaints of poor appetite or weight loss. There were no features suggestive of URTI/ LRTI/ UTI/ Meningitis or other localizing signs. He has history of family dispute as he was married to Doctor who belongs to higher economic strata and he was mere Sepoy in Army. On examination he was febrile with Temp (102.4 F) and his Pulse- 84/ min. BMI-23.3 kg/ m2. His other general and systemic examination was within normal limit. On investigations his Haemogram, Biochemical, metabolic parameters, urine analysis and coagulation parameters were normal. His body fluid cultures including urine, blood and CSF were negative. His peripheral blood smear and Bonemarrow aspirationwere essentially normal. His serological work- up for Malaria, Dengue, Leptospira, Enteric, Leishmania, Ricketssia and Brucella were negative. His work- up for common viral diseases including Hepatitis B, C and HIV was negative. His Pan- fungal culture was negative. The possibility of connective tissue disorder presenting as PUO was thought and his work- up for same including ANA, CRP’s, ACE levelsand thyroid profile were found normal. His radioimaging for possibility of any hidden focus of infection on CECT Head, chest, abdomen and pelvis were also normal. He had normal ECG, ECHO and UGIE. His whole body PET- scan was also normal. He was managed initially with broad spectrum antibiotics, antimalarials and antipyretics but he continued to have intermittent fever with daily spiking upto 103 F. However there was no set pattern of fever and it was also not associated with any diaphoresis or tachycardia. Only after two months of hospital stay he has shown signs of defervescence and after 80 days of in-hospitalization he became normal. Presently he is under follow up for last 3 months with no recurrence of fever.

Discussion Factitious Fever refers to factitious disorder imposed on self refers to psychiatric condition in which patient deliberately produce or falsify symptoms and/or signs of illness for the principal purpose of assuming the sick role. Many authorities believe that this factitious disorder is under diagnosed because patient’s wilful deceptions are commonly missed by medical staff. Patients are typically young, female and often associated with medical profession [1]. There is no hand to hand data available on incidence of this condition is mostly underdiagnosed. Out of various small studies done in America, Europe, Asia the incidence is between 1.5-2.3 in patients who were diagnosed as / presented as Pyrexia of Unknown origin.[2] PUO is the common presentation in tertiary care centre. It is uncommon to think about factitious fever at the first instance to be a causative agent for PUO. Therefore a meticulous approach is required to deal with PUO,s and every possible effort is required to identify the exact aetiology. This approach requires exclusion of common infections including bacterial, parasitic, fungal and viral. Subsequently hidden infectious focus like perineal abscesses, infective endocarditis, and otitis media also needs to be excluded. Other common conditions like solid malignancy, connective tissue diseases and bone marrow diseases needs further exclusion. On after excluding above conditions the diagnosis of Factitious Fever may be entertained.

Conclusion The aim of this case presentation was to report a rare case of Factitious fever. This is not very commonin clinical practice and is further rarer to have such cases at tertiary care centre. Usually this fever last for onetwo weeks but in our case this fever has lasted for three months.

References 1. Lois E. Krahn, M.D.; Hongzhe Li, Ph.D, M. Kevin O’Connor, M.D : Patients Who Strive to Be Ill: Factitious Disorder With Physical Symptoms. Am J Psychiatry 2003;160:1163-1168. 2 Rumans LW, Vosti KL: Factitious and fraudulent fever.Am J Med. Nov; 65(5):745-55, 1978.