Factitious Fever Research Articles

Patients’ right to confidentiality and sharing information with colleagues: The dilemma in managing a patient with Munchausen syndrome – A case report

We report the case of a young woman with a “pyrexia of unknown origin” in the background of a history involving SLE, ocular toxoplasmosis and Ig A nephropathy. The history was narrated by her with precise details but there was no documentary proof of any previous admissions. She had a prolonged hospital stay and repeated hospital admissions for the same illness with extensive investigations including a PET scan. Once evidence for “factitious fever” was overwhelming she got herself discharged from hospital refusing psychiatric help. Close scrutiny revealed that she had got herself admitted to several hospitals in the Western Province subsequently, with the same complaint, with all clinicians investigating her extensively, sometimes including invasive procedures. The ethical dilemma faced by us relating to sharing her clinical details with a wider clinical group is discussed.

Diagnóstico diferencial de la fiebre infecciosa prolongada sin focalidad

Persistent fever of unknown origin (PFUO) refers to processes with temperature increases greater than 38.3°C, checked at least twice, over more than 3 weeks’ duration, undiagnosed after taking the clinical history, physical examination and the appropriate initial diagnostic tests. Most PFUO are due to infections, neoplasms, inflammatory systemic diseases and a miscellany that includes pharmacological fever and factitious fever, leaving an increasingly reduced group with no identified aetiology. Complementary tests must be guided by a detailed clinical history and thorough physical examination, together with periodic reassessment of the patient. In the event of clinical failure and deterioration, empirical treatments should be used depending on the suspected pathology, although, in general, therapeutic trial is not recommended.

Protocolo diagnóstico de las fiebres prolongadas

The term fever of unknown origin (FUO) is reserved for febrile processes with temperatures greater than 38.3°C documented on more than one occasion, lasting longer than 3 weeks, with no determined cause and after a review of the medical record and a complete physical examination followed by appropriate complementary diagnostic tests.FUO is caused by infections, neoplasms, inflammatory diseases and miscellaneous conditions that include drug fever and factitious fever. For a growing proportion of patients, the cause of the fever is not determined.Thorough reviews of the medical record, detailed physical examinations and periodic reassessments are essential in the study of FUO. If an etiological diagnosis is not reached after performing a basic battery of additional tests, more specific diagnostic tests should be considered based on previous findings. In general, therapeutic trials with antibiotics or steroids should be avoided.

A rare case of factitious fever

A rare case of factitious fever

A Roadmap for Fever of Unknown Origin in Children

Fever of unknown origin (FUO) in adults is conventionally defined by the occurrence of body temperatures above 38.3 degrees C (101 degrees F) for a period of 3 weeks without any identified etiology after a period of 1-week hospitalization. The issue of FUO in pediatrics is rather hazy and still represents a challenging diagnostic dilemma. Most of the available data are limited to nationwide cohorts of patients of any age. The major difficulty in establishing a diagnosis is that the characteristic features rendering specific disorders clinically recognizable are absent or subtle, hence only a painstaking questioning on family background may elicit the correct investigative path. No diagnostic algorithms are actually available and clinicians must rely on a very careful step-by-step evaluation of the single patient. The need for invasive diagnostic techniques should be closely taken into consideration when laboratory tests or simple imaging procedures fail to discern the origin of FUO. Fevers with no reasonable explanation and no localizing signs often conceal different common diseases in children, which tend to display an unusual or atypical pattern. The principal causes behind FUO in pediatric age remain infections, followed by collagen vascular diseases and neoplastic disorders, although most children with malignancies present other systemic signs or suggestive laboratory abnormalities. The possibility of autoinflammatory syndromes, drug fever, and factitious fever should also be taken into account.

Childhood Factitious Disorders—A “Hot” Case of Menstruation

Background: Factitious disorders are rarely reported in the pediatric gynecologic literature. We present a case of factitious menstruation in a ten year old prepubertal child. Case: A ten year old girl presented to her pediatrician’s office with an episode of vaginal bleeding. She reports bright red vaginal bleeding that over 4 days changed to an orange colored odorous discharge. The bleeding occured at regular intervals throughout the day. In the pediatrician’s office she was found to have a normal exam. A White Blood Cell count was 5.9 K/uL, Hemoglobin 13.3mg/dl, Hematocrit 38.8%, and the platelet count 276k. Sedimentation rate was 6 mm/hr, Thyroid Stimulating Hormone was 0.777 uIU/ml, Lutenizing Hormone 0.3 mIU/ml, Follicle Stimulating Hormone 9 mIU/ ml, Estradiol 7 pg/ml, and Free Thyroxine 1.15 ng/d. A computerized tomography (CT) scan of the abdomen and pelvis with nonionic contrast was within normal limits. There was no comment on the uterus, ovaries, or vagina. A non-contrast CT scan of the head is normal but with limited evaluation of pituitary gland. The patient was referred to an adolescent medicine specialist for further evaluation. Physical exam revealed a thin, pale prepubescent child. Breasts are prepubescent, SMR 1. Her abdomen was soft but tender to palpation in the left lower quadrant. Pubic Hair was SMR 1. Her external genitalia were normal. The hymen was annular and no discharge or erythema was present. The rectal exam was normal. A pelvic ultrasound demonstrated a prepubescent, anteverted uterus with an endometrial stripe 0.1 cm. There was no evidence of echogenic foreign body. The ovaries are normal. Gonorrhea/Chlamydia Nucleic Acid Amplification testing was negative. A genital culture grows 3+ normal flora. The patient was seen again in conjunction with a pediatric gynecologist. The vagina is irrigated with 20cc of saline. The effluent was clear. Heme testing from pad was negative. A few days later the mother found a vial of hot sauce in the child’s book bag. When confronted, the child confesses to placing the foreign liquid on the pad. A planned exam under anesthesia is thus avoided. Comments: A high index of suspicion is required in diagnosing factitious disorders. Psychosomatic illnesses have a wide spectrum of presentation and are likely more common than realized. There are three distinct mental health disorders in which a patient intentionally produces physical symptoms or illness: Malingering, Factitious Disorder, and Factitious Disorder by proxy. In Factitious Disorder the patient produces symptoms or signs to assume the sick role. Examples include induced infections and factitious fever. Malingering differs from Factitious Disorder in that in Malingering, the individual is consciously motivated by an external incentive, such as missing school or work. In Factitious Disorder the individual is usually not aware of the motivation behind the factitious behavior and external incentives are absent. Recognizing the possibility of factitious illness in patients who present with atypical clinical manifestations is imperative to reduce unnecessary risk to the patient through continued medical evaluations and to avoid long term psychopathology.

Le paradoxe des fièvres prolongées inexpliquées

Fever of unknown origin are defined by a fever greater than 38.3 °C evolving during at least three weeks and without diagnosis despite appropriate explorations. Despite medical advances, they remain unexplained in 20 to 50% of cases after exhaustive explorations and the proportion is increasing in the literature. More than 200 diseases have been reported as a cause. The infectious (viral disease, tuberculosis…) and neoplastic causes (mainly lymphomas) seemed to be reduced to the benefit of noninfectious inflammatory diseases (Still's disease, giant cell arteritis…). Drug fever and factitious fever are also common. Genetic recurrent fevers form a special group, which benefit of recent advances in genetics. Diagnosis of these fevers of unknown origin is based on clinical examination and laboratory and radiologic investigation. Despite prospective protocols, it is difficult today to provide recommendations on the management and to suggest a hierarchy of tests. The role of modern explorations as FDG–PET remains to be clarified. The overall prognosis of these fevers of unknown origin remains good and the use of empirical therapeutic trials must remain exceptional.

Fever of unknown origin in adults: Evaluation of 144 cases in a non-university hospital

The spectrum of diseases found in series of fever of unknown origin shows variation in relation to selection bias; particularly, selection of the most difficult cases in tertiary reference university centres. We present a series of 144 patients presenting to a non-university hospital between 1999 and 2005 (secondary level of the health care system) with a community-acquired fever of unknown origin. In 37 cases (25.7%), the reason for fever could not be explained. Among the 107 patients with a final diagnosis (74.3%), non-infectious inflammatory disorders represented the most prevalent category (35.5%), surpassing infections (30.8%), miscellaneous causes (20.6%) and malignancies (13.5%). 13 entities accounted for over 68% of diagnoses (sinusitis and occult dental infections, Q fever, Epstein-Barr virus and cytomegalovirus infections, lymphoma, colo-rectal adenocarcinoma, adult-onset Still disease, systemic lupus erythematosus, giant cell arteritis and/or polymyalgia rheumatica, rheumatoid arthritis, polyarteritis nodosa, factitious fever and habitual hyperthermia). As demonstrated in other studies, non-infectious inflammatory diseases emerge as the most prevalent diagnostic category. Giant cell arteritis and polymyalgia rheumatica were particularly frequent in the elderly. Epstein-Barr virus and cytomegalovirus infections and habitual hyperthermia were particularly frequent in the youngest patients. There were no major differences in repartition of diagnostic categories between this series and historical university series.

Pyrexia of unknown origin

<h2>Abstract</h2> Fever of unknown origin (FUO) is now often defined as a fever higher than 38.3°C on several occasions during at least 3 weeks with uncertain diagnosis after several obligatory tests. Infection accounts for about one-third of cases of FUO, followed by neoplasm and non-infectious inflammatory diseases. No diagnosis is reached in 25–35% of cases. In patients with periodic fever, this percentage is higher. A diagnostic algorithm is proposed in which the most important steps are history-taking, physical examination and obligatory investigations in a search for potentially diagnostic clues (PDCs). First, factitious fever and drug fever should be excluded. Further diagnostic procedures should be guided by a list of most probable diagnoses. In patients without useful PDCs, certain diagnostic procedures, divided into first-stage and second-stage investigations, should be performed. If no diagnosis is reached and the clinical condition is stable, waiting for new PDCs is recommended. In patients with recurrent fever, diagnosis should comprise only a search for PDCs matching known recurrent syndromes. Scintigraphic methods such as gallium-67 citrate-labelled leucocytes and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are often used in patients with FUO. Because of the favourable characteristics of FDG-PET, conventional scintigraphic techniques may be replaced by FDG-PET in institutions where it is available. If undiagnosed fever persists, supportive treatment with non-steroidal anti-inflammatory drugs can be helpful. Most patients with undiagnosed FUO have benign self-limiting or recurrent fever. Other therapeutic trials should be considered only in patients who deteriorate.

Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge

Factitious disorder, Munchausen’s Syndrome, and deliberate self-harm have recently been conceptualized as different facets of self-destructive behavior. A descriptive typological classification has been presented by Willenberg et al., but has not yet been tested with a clinical sample. The instrument distinguishes between direct self-harm (e.g., self-inflicted wounds), self-induced disease (e.g., factitious fever), and indirect self-harm delegated to medical staff (e.g., repeated operations occasioned by feigned symptoms). All patients referred to the psychosomatic-psychotherapeutic liaison-consultation service or to the outpatients’ department within 14 months ( n=995) and all patients discharged from in-patient psychosomatic-psychotherapeutic treatment within 2 months ( n=62) were assessed. Expert instruction and supervision were provided for the diagnosticians. The assessment was continued for a subsequent year, without special supervision ( n=1,058). Self-destructive behaviors were diagnosed in 7.5% of the cases in the first sample, with certainty (59.5%) or on suspicion (40.5%). In the subsequent sample without supervision, the rate reduced to 3.6%. Referrals had come from almost all clinical departments, including the emergency unit (26%), surgery, internal intensive care, endocrinology (9.5% each), neurology, infectiology, nephrology (7.1% each), dermatology, gastro-enterology, cardiology (4.8% each) and surgical intensive care (2.4%). The occurrence of pathological self-destructive phenomena is underrated when using only the ICD-criteria. The rate is influenced by diagnostic attention.

Fever Adults -In Approach to Diagnosis and Management

Fever is one of the most important and presenting symptoms in family practice. However making the correct diagnoses and selecting the most effectiye therapy poses a challenge to the busy family practitioner. Fever is defined as an elevation of body temperature above the normal daif variation and is found in a number of disease states as a result of the re-setting of the hypothalamic set point by various exogenous and endogenous cytokines and pyrogens. In family practice,fever is much more likely to be a manifestation of a common rather than a rare disease and key concepts, including pyrexia of unknown origin and factitious fever, should be understood, important life threatening conditions, e.g. malaria and meningococcal disease must always be considered when confronted by a patient with acute febrile illness and ill-defined localising signs. Antipyretics and other supportive therapy should be judiciously used, since they may obscure the effect of a specific therapeutic agent on the natural course ofthe disease and the focus of management should remain the underlying condition.

Pyrexia of undetermined origin in patients with human immunodeficiency virus infection and AIDS.

The case records of consecutive patients admitted to a specialist HIV/AIDS inpatient unit between 1989 and 1993 with pyrexia of undetermined origin (PUO) were reviewed in order to determine the eventual diagnosis. Seventy-nine episodes occurred in 75 patients; 52 patients had a prior AIDS defining diagnosis. CD4+ lymphocyte counts ranged widely, 0-0.79 (median = 0.04) x 10(9)/l. Infections were found in 63 episodes (79%), including mycobacterial infection in 41 episodes (53%) and bacterial infection in 12 episodes (15%). Tumours were found in 6 episodes (8%), 5 of these were lymphoma. Factitious fever accounted for 2 episodes (3%) and connective-tissue disease for 1 episode (1%); no definite diagnosis was reached in 7 episodes (9%). PUO in HIV positive patients is commonly due to infection or tumour. Unexplained fever in this patient group should not be ascribed to HIV infection itself and should be vigorously investigated to find a cause.

FACTITIOUS HIV INFECTION.

When clinicians think about factitious illness, fever and hypoglycemia are among the syndromes that come to mind. This report describes seven cases

Children with fever of unknown origin in Argentina: an analysis of 113 cases.

The aim of this study was to determine the causes of fever of unknown origin, to evaluate new diagnostic tests and to elucidate risk factors for chronic or life-threatening disorders. The medical records of 113 children who had undiagnosed fever for at least 3 weeks were reviewed. Infection (N = 41) was the most frequent cause of fever of unknown origin. Respiratory tract infections were the most common causes in infants and endocarditis and tuberculosis were more frequent in older children. Neoplastic disorders (N = 11) occurred in children older than one year. Juvenile rheumatoid arthritis (N = 9) was the most common collagen-vascular disorder (N = 15). Miscellaneous disorders and factitious fever occurred in 21 and 4 cases, respectively. Twenty-two patients remained undiagnosed. History and physical examination led to a final diagnosis in 81% of cases. Abdominal ultrasonography was performed in 71 patients (61%) and was helpful for diagnosis in 15%. Children with life-threatening or chronic disorders (N = 58) were older than those with self-limiting conditions (N = 55; P = 0.017). Cardiovascular and articular signs and symptoms were more frequent in the former group (P = 0.01).

Fever of Unknown Origin in the 1980s

To determine the relative proportions of the diagnostic categories in patients with fever of unknown origin who were examined in the 1980s. Prospective case series. General Internal Medicine Service based at University Hospital, Leuven, Belgium. One hundred ninety-nine consecutive patients meeting the classic criteria of fever of unknown origin who were treated in the 1980s. The final diagnosis established at discharge or during follow-up. Infections were found in 45 patients (22.6%), tumors were found in 14 (7%), multisystem diseases were found in 42 (21.5%), drug-related fever was found in six (3%), factitious fever was found in seven (3.5%), habitual hyperthermia was found in five (2.5%), miscellaneous diseases were found in 29 (14.5%), and no diagnosis was reached in 51 (25.6%). Tumors were a less important cause of fever of unknown origin in the 1980s. The same holds true for some infectious diseases, such as abscesses and hepatobiliary disorders. Multisystem diseases were more frequently found, and the number of undiagnosed cases increased. Although these shifts in the disease spectrum in fever of unknown origin most probably resulted from a constellation of factors, we suspect that these changes are mainly due to easy and early diagnosis by new diagnostic modalities, such as ultrasonography and computed tomography, of previously common causes of fever of unknown origin.

Differential diagnosis in fever of unknown origin: significance of concomitant clinical symptoms

Between 1978 and 1984, 169 patients were admitted to the hospital for fever of unknown origin which was repeatedly above 38.3 degrees C. After a retrospective analysis of their records the patients were divided into two groups on the basis of the following new criteria. The first group (74 patients) was described as having "monosymptomatic fever", i.e. fever without any other physical signs, whereas the second group (95 patients) had "polysymptomatic fever", i.e. fever with additional physical signs. In 56 patients (76%) of the monosymptomatic group fever had lasted longer than 3 weeks prior to admission. In 86% of these patients case history, physical examination, microbiological tests, serological tests for microorganisms and outoimune antibodies, and microscopic inspections of tissue and/or bone marrow led to a diagnosis. Malignancies, factitious fever and fever of unknown origin were found only in this group. The patients with malignancies were generally older than the rest of the patients (p less than 0.05), and eight of ten patients suffering from connective tissue diseases also had monosymptomatic fever. The incidence of infections in this group was 42% (31 cases), in contrast to 88% (84 cases) in the polysymptomatic group (p less than 0.05). Whereas the latter had significantly more bacterial infections (p less than 0.05), viral infections prevailed in the monosymptomatic group (p less than 0.05). Thus, the etiology of polysymptomatic fever distinctly differed from that of monosymptomatic fever. Since the frequency distribution of etiologies in the monosymptomatic group corresponded to that of the cases of fever of unknown origin in the literature, differentiation into monosymptomatic and polysymptomatic fever might be helpful in determining further diagnostic workup of patients with fever of unknown origin.

Psychogenic fever

A review of the literature suggests that body temperature may rise when a person is under emotional stress. The term "psychogenic fever" has been applied to this phenomenon. A study of temperature and pulse rate of psychiatric patients diagnosed predominantly as neurotic in a university teaching hospital was undertaken. Changes in pulse rate indicated that the period before ward rounds was more stressful than other times of the day. However, psychogenic fever in these patients was not found. One case of factitious fever was uncovered during the study.

Factitious Fever Updated

The clinical spectrum of factitious disease is sufficiently complex to make it inevitable that patients with selfinduced illnesses will continue to confound physicians and plague medical institutions. In particular, patients with factitious fever (FF) remain as challenging to clinicians today as they were a century ago. 1 A recent review by Rumans and Vosti 2 once again draws our attention to this fraudulent malady. Consistently running through the FF literature have been two closely linked themes—the mastery of deception and remarkable ingenuity displayed by these troubled patients and the chagrin of their physicians over failing to recognize this disorder more swiftly. Prompt detection not only spares patients prolonged hospitalization and unwarranted treatment and procedures, but more important, it allows appropriate psychiatric care to be offered. 2,3 Since early detection can be viewed as the clinician's primary responsibility and most helpful therapeutic intervention in factitious disease, the answers to the following

Factitious Fever and Self-Induced Infection

We review in detail the syndromes of factitious fever and self-induced infection, with discussion of 32 cases studied at the National Institutes of Health and the extensive English language literature. In addition, we describe the nature of the underlying psychiatric illnesses and present guidelines for the diagnosis and management of these patients.

Factitious and fraudulent fever

The task of elucidating the etiology of fever of undetermined origin remains a major undertaking. Factitious fever is uncommonly considered of major importance in the differential diagnosis of fever of undetermined origin although it is a readily identifiable syndrome and one that is easily excluded once it has been considered. Early identification may reduce the necessity for prolonged, expensive and potentially hazardous hospitalizations for such patients. A retrospective study identified 2.2 per cent (11 of 506) of all patients whose fever on their charts was coded as fever of undetermined origin as having factitious fever. These patients either created factitious fever by manipulation of the thermometer or fraudulent fever by self-induced means. A review of the literature yielded an additional 70 cases in which fever was either the sole factitious sign or part of a larger, more complex factitious illness. Patients were typically young, female and often associated with the medical profession. Patients with factitious fever differ from those with the stereotyped Munchausen's syndrome and may be difficult to recognize. Signs leading to the recognition of this syndrome are emphasized. Since the nature of the psychiatric Illness may vary from patient to patient, early discovery may facilitate psychiatric intervention as such patients may be more amenable to therapy.