SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hemoptysis can be a life-threatening condition, and the underlying cause may be difficult to uncover. Rarely, when extensive workup continues to be unrevealing, and the circumstances surrounding the hemoptysis are suspect, factitious hemoptysis should be considered as a potential cause for recurrence. CASE PRESENTATION: A 48yo man with a history of recurrent hemoptysis, gunshot wound, recurrent PE, COPD, and recurrent unexplained bacteremia presented to the ED with hemoptysis. Over 4 years, he was seen at 4 local hospitals, and had 26 CT scans of the chest, 3 bronchoscopies without bleeding source identified, and 3 IR embolization procedures. CT was notable for severe paraseptal emphysema, sequela of previous surgery, tracheomegaly (Figure 1). No episodes of hemopytsis were witnessed by the healthcare team. Samples were noted to be watery (Figure 2) and sent for cell count, but not performable due to cellular degeneration. Room search revealed syringes with old blood products (Figure 3). After a sitter was placed, no further samples of hemoptysis were produced. Psychiatry evaluated the patient and believed this was consistent with a factitious disorder, though the patient denied tampering with his IV and declined psychotherapy. He was discharged home and a flag was placed on his chart to alert future healthcare providers about the need for close monitoring. DISCUSSION: Factitious hemoptysis is a rare diagnosis, with only a few dozen cases reported in the literature [1]. Patients often present to multiple hospitals with similar complaints, though have been reported to use different names and identifiable numbers [2]. Papers report methods such as holding aspirated blood within the mouth to simulate hemoptysis [3]. Suspicious factors in this case included his numerous unrevealing procedures, the watery nature of the samples provided, and the pattern of seeking medical attention at different centers. The concurrent unusual bacteremias without clear source also raised red flags. What made this case challenging was the fact that our patient had underlying structural lung disease and a history of PE on anticoagulation, both increasing risk of hemoptysis. In the literature, there were variable responses to confrontation with evidence, with some patients acknowledging the factitious nature of their presentation, with others continuing to deny manipulation. There is also variability in patients’ agreement to seek psychotherapy for their condition. CONCLUSIONS: Though rare, factitious hemoptysis should be considered when extensive workup for recurrent hemoptysis is unrevealing. Additional invasive testing causes harm in these cases, and treatment should be focused on psychiatric optimization of the patient’s underlying disease. Importantly, at each encounter, a thorough evaluation must be completed before making a diagnosis of factitious hemoptysis, especially in a patient at risk for true bleeding. Reference #1: Baktari, J. B., Tashkin, D. P. & Small, G. W. Factitious hemoptysis. Adding to the differential diagnosis. Chest 105, 943–945 (1994). Reference #2: Serban, J. P. S. K. A., Joseph P Smith Karina & Bosslet, G. T. Factitious Hemoptysis after Right Lower Lobectomy. Internal Medicine: Open Access vol. s12 (2015). Reference #3: Andrade, T. L. E. S. & Pereira-Silva, J. L. Factitious hemoptysis in Munchhausen syndrome: a differential diagnosis to be considered. J. Bras. Pneumol. 31, 265–268 (2005). DISCLOSURES: No relevant relationships by Catherine Gao, source=Web Response No relevant relationships by Clara Schroedl, source=Web Response