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Abstract

Introduction: Diagnosing factitious disorders can be expensive, time consuming, and challenging. We present a clinical conundrum of refractory hypotension that ultimately led to a diagnosis of surreptitious AV-nodal agent abuse. Case: A 41 year-old female with a diagnosis of idiopathic capillary leak syndrome (ICLS), s/p demand pacemaker for intermittent symptomatic bradycardia, was admitted for elective administration of intravenous immunoglobulin (IVIG). Development of hypoalbuminemia, bilateral pleural effusion, and peripheral edema on a background of refractory hypotension during a preceding hospital admission (6 months prior to the index admission) aided the diagnosis of ICLS [1]. A diagnosis of ICLS was made following an extensive 2-year evaluation by multiple specialties for a constellation of symptoms that had escaped clinical diagnosis. She was committed to IVIG, after failure of first line therapy (Terbutaline) [2] by an autonomic dysfunction expert, in consultation with an allergist, pulmonologist, general cardiologist, and electrophysiologist. On evaluation, her physical examination, biochemical profile, echocardiogram, pacemaker evaluation, and radiology were all unremarkable. Within one hour of admission, the patient developed acute refractory hypotension and bradycardia prompting pacemaker activation and vasopressors. Hemodynamic improvement noted during the course of the day was followed by a precipitous decline at night, only to improve dramatically again with short periods of vasopressor therapy. This was the pattern of her clinical course during her admission. Inconsistencies in her clinical presentation (no evidence of hemoconcentration or third spacing - a hallmark of ICLS) and intermittent pacemaker activation for bradycardia, prompted a reevaluation of her clinical diagnosis. The evanescent nature of the symptoms in an otherwise healthy individual was intriguing. Our belief in the medical adage 'All other things being equal the simplest answer is usually the best' prompted us to consider surreptitious AV-nodal blocker abuse. We requested serum beta and calcium-channel blocker levels during the throes of these acute hypotensive episodes while the patient was on norepinephrine. A two year search for a medical dilemma that escaped clinical diagnosis came to fruitition when a Metoprolol level of 95 ng/ml (therapeutic limit 20 to 340 ng/ml) and a Verapamil level of 380 ng/ml (therapeutic limit 70 to 350 ng/ml) was reported. A case for Munchausen's Syndrome - Factitious disorder was thus made. Patient was confronted with the data and reluctantly admitted to surreptitious use of Metoprolol and Verapamil. She elected to have her pacemaker removed and psychiatry services were consulted. Discussion: Factitious Disorder is a mental disorder in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created their symptoms. Idiopathic capillary leak syndrome is a rare disease of unknown cause. It results in reversible plasma extravasation and vascular collapse. Diagnosis is made clinically and by exclusion of other diseases that cause similar signs and symptoms [1]. Factitious disorders must also be considered as part of the differential diagnosis when there are inconsistencies in the patient's history, laboratory tests, and physical examination findings [3]. Conclusion: Factitious disorders could be the simplest explanation for medical conundrums that baffle physicians. "When you hear hoofbeats, think horses, not zebras." Reference #1: Druey KM et al. Narrative review: the systemic capillary leak syndrome. Ann Intern Med 2010; 153-90. Reference #2: Gousseff M, et al. The systemic capillary leak syndrome: a case series of 28 patients from a European registry. Ann Intern Med 2011; 154:464. Reference #3: Krahn LE, Li H, et al. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. Jun 2003;160(6):1163-8