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Letters

Pancytopenia Secondary to Cyclophosphamide in a Case of Factitious Breast Cancer

Pancytopenia Secondary to Cyclophosphamide in a Case of Factitious Breast Cancer

To the Editor: Reports of factitious symptoms have peppered the clinical literature since Dr Richard Asher’s initial identification and description of Munchausen’s syndrome in 1951.1 However, factitious symptoms may now be potentially groomed through the Internet, which not only offers endless information about medical symptoms but also enables access to non-supervised treatment. The following case demonstrates the ease with which patients can obtain and distort medical information as well as order potent medications online—and the harm that can ensue.

Case report. Ms A, a 29-year-old white woman, was admitted to an acute-care hospital through the emergency department in 2010 for pancytopenia. She reported a history of stage 1, estrogen-positive breast cancer and was receiving cyclophosphamide therapy. The pancytopenia was initially discovered during routine blood work that was obtained prior to a dental procedure for an abscessed tooth. The patient was later directed to our emergency department for further evaluation. At the time of admission to hospital, the patient’s white blood cell count was 0.1 cells/mL, hemoglobin was 6.4 g/dL, hematocrit was 17.9%, and platelets were 2 × 109/L.

Following laboratory confirmation, the patient was admitted to the intensive care unit (ICU) under neutropenic precautions. The cyclophosphamide was discontinued, and the patient was transfused with packed red blood cells and granulocyte colony-stimulating factor. In an attempt to gather additional information through medical records, we asked the patient about her current providers and received the names of several treating physicians as well as contradictory information regarding her treatment. Ultimately, all of the physicians whom the patient named as part of her treatment team denied seeing her as a patient.

When confronted with this conflicting information, the patient admitted that she had diagnosed herself with breast cancer based upon a family history of breast cancer and assessment on an Internet breast-cancer risk-factor calculator. After personally concluding that she had breast cancer, the patient ordered cyclophosphamide online from a Web site based in India. At no time did she provide any reason or goal in attempting to deceive the treating medical team with regard to her alleged cancer.

Further background investigation revealed that the patient had previous hospital admissions for intractable migraine headaches that included evaluation by magnetic resonance imaging, magnetic resonance angiography, magnetic resonance venography, and lumbar puncture—none of which revealed any abnormalities.

Once the patient’s pancytopenia resolved, she was transferred from the ICU to a standard medical floor, where she developed unexplained hematomas on the left arm and right leg. Once the hematomas resolved, a psychiatry consultation was requested and the patient was transferred to the inpatient psychiatry unit with a DSM-IV diagnosis of factitious disorder with predominantly physical signs and symptoms. On the day of her transfer, the patient was sent to the emergency department for self-reported hematuria; urinalysis in the emergency department revealed no abnormalities.

Although there is a previous case in which a patient feigned ovarian cancer by obtaining symptoms through online information2 and a second case in which a patient underwent bilateral mastectomies for self-reported breast cancer,3 there is no previously reported case in which a patient became cytopenic due to self-purchased chemotherapy for self-diagnosed breast cancer. Clearly, factitious medical disorders can take a number of dangerous forms when aided by the Internet.

References

1. Asher R. Munchausen’s syndrome. Lancet. 1951;257(6650):339-341. PubMed doi:10.1016/S0140-6736(51)92313-6

2. Levenson JL, Chafe W, Flanagan P. Factitious ovarian cancer: feigning via resources on the Internet. Psychosomatics. 2007;48(1):71-73. PubMed doi:10.1176/appi.psy.48.1.71

3. Feldman MD, Hamilton JC. Mastectomy resulting from factitious disorder. Psychosomatics. 2007;48(4):361. PubMed doi:10.1176/appi.psy.48.4.361

Michael I. Saiyasombat, MD

mike3560@yahoo.com

Manjula Satyanarayan, MD

Author affiliations: Department of Internal Medicine, Kettering Medical Center, Kettering, Ohio.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Previous presentation: This case was presented as a poster at the 2011 Society for Hospitalist Medicine Annual Meeting; May 10-13, 2011; Grapevine, Texas.

Acknowledgment: The authors thank Dr Randy Sansone for his technical assistance in reviewing our case. Dr Sansone reports no potential conflict of interest relevant to the subject of this letter.

Published online: April 26, 2012.

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