Factitial aplastic anemia

A Fatal Case of Factitious Aplastic Anemia

We report the case of a 26-year-old female who intentionally ingested busulfan, an oral chemotherapy agent, to induce severe aplastic anemia. The patient was initially thought to be suffering from idiopathic aplastic anemia, before clues suggesting the diagnosis of a factitious disorder were identified. The patient underwent a bone marrow transplant and ultimately died 5 weeks later following a lengthy admission to the intensive care unit. It is unclear whether confrontation about a patient's self-induction of physical illness is beneficial in the treatment of patients with factitious disorder. Cases such as this pose substantial diagnostic challenges, making early recognition of factitious disorder and initiation of treatment difficult. The patient described in this case report had risk factors for a factitious disorder, including age, gender, professional involvement in health care, recent loss and developmental trauma. Factitious disorder, while rare, can have lethal consequences for the patient. This diagnosis must be considered as part of a full diagnostic assessment.

Haemotoxicity of busulphan, doxorubicin, cisplatin and cyclophosphamide in the female BALB/c mouse using a brief regimen of drug administration

Many anticancer drugs are myelotoxic and cause bone marrow depression; however, generally, the marrow/blood returns to normal after treatment. Nevertheless, after the administration of some anti-neoplastic agents (e.g. busulphan, BU) under conditions as yet undefined, the marrow may begin a return towards normal, but normality may not be achieved, and late-stage/residual marrow injury may be evident. The present studies were conducted to develop a short-term mouse model (a 'screen') to identify late-stage/residual marrow injury using a brief regimen of drug administration. Female BALB/c mice were treated with BU, doxorubicin (DOX), cisplatin (CISPLAT) or cyclophosphamide (CYCLOPHOS) on days 1, 3 and 5. In 'preliminary studies', a maximum tolerated dose (MTD) for each drug was determined for use in 'main studies'. In main studies, mice were treated with vehicle (control), low and high (the MTD) dose levels of each agent. Necropsies were performed, and blood parameters and femoral/humeral nucleated marrow cell counts (FNCC/HNCC) were assessed on six occasions (from days 1 to 60/61 post-dosing). Late-stage/residual changes were apparent in BU-treated mice at day 61 post-dosing: RBC, Hb and haematocrit were reduced, mean cell volume/mean cell haemoglobin were increased and platelet and FNCC counts were decreased. Mice given DOX, CISPLAT and CYCLOPHOS, in general, showed no clear late-stage/residual effects (day 60/61). It was concluded that a brief regimen of drug administration, at an MTD, with assessment at day 60/61 post-dosing was a suitable short-term method/screen in the mouse for detecting late-stage/residual marrow injury for BU, a drug shown to exhibit these effects in man.

A case of factitious aplastic anemia

OBJECTIVE

We report the case of factitiously induced aplastic anemia by the ingestion of busulfan, a bifunctional alkylating chemotherapeutic agent used in the treatment of chronic myelogenous leukemia. The medical consequences and financial costs of this illness are reported. The reader will gain an understanding of the relevant clues to the diagnosis of a factitious hematologic illness, the psychodynamic issues present in this case and the legal, ethical and countertransferential issues raised by the case.

METHOD

A single case review including medical and billing records, patient and staff interviews and literature review.

RESULTS

The covert ingestion of busulfan by this patient resulted in life-threatening bone marrow suppression, bilateral aseptic hip necrosis, transfusion-dependent thrombocytopenia and a chronic pain syndrome. Her treatment was complicated by noncompliance with prescribed treatments and polymicrobial sepsis possibly secondary to the self-injection of feces into her central line. To date, the total cost of care for the treatment of this patient's medical complications secondary to her ingestion of busulfan exceeds $1,100,000.00.

CONCLUSIONS

This case underscores the importance of the early recognition by the primary care physician of the possibility of a factitious etiology of hematologic abnormalities such as aplastic anemia due to the ingestion of bone marrow ablative medications. The index of suspicion is increased when the patient is a young health care provider, usually female, with atypical pancytopenia and an unusual disease course and response to treatment.

Factitious deafblindness: an imperceptible variant of factitious disorder

We describe two women who, over a period of years, feigned the loss of both vision and hearing. Their principal motive appeared to be pursuit of the sick role, though each acquired disability payments as well. A face-saving intervention sharply reduced the alleged hearing deficits in one case; the other patient precipitously left treatment. A broad range of permutations of factitious disorder has been reported, but these appear to be the first published cases of factitious deafblindness.