Factitious Disorder Manifesting as Acute Tetanus

Factitious disorder is rare, difficult to diagnose, and a unique challenge for the emergency physician.

A patient with factitious disorder intentionally manifests physical symptoms of disease without clear gain and often is willing to undergo invasive procedures.¹ Unrecognized factitious disorder is harmful to our patients and places a large burden on hospital systems, in addition to contributing to physician burnout.² The electronic medical record (EMR) may create a misplaced sense of security in health care providers as it engenders the false belief of completeness of information and infallibility.

We present a case of factitious disorder manifesting as acute tetanus, which to the authors’ knowledge has not been previously described in English publications but may be more recognized in other countries.^3,4

Case
A young male in his early 30s presented to the emergency department unaccompanied, complaining of severe muscle spasms. The patient reported that approximately seven days ago he had stepped on a rusty nail in a horse barn. Several days after that incident, he developed severe cramping and spasms in his bilateral lower extremities that progressed to include his upper extremities and face. He reported that he had been drinking from a straw for the past three days due to being unable to open his mouth fully. He stated that he received no vaccinations as a child due to his parents’ religious beliefs and, specifically, that he was unvaccinated against tetanus.

On initial exam, the patient was in acute distress, exhibiting significant flexion of his toes and lower extremities. He was tachycardic to 130, frequently grimacing and arching his back. He had a healed laceration to the bottom of his left foot. Our patient appeared to exhibit risus sardonicus and severe muscle spasms concerning for acute tetanus. Toxicology was consulted in the emergency department. The patient was given tetanus immunoglobulin, TdaP, and IV metronidazole. He was given high doses of diazepam and opioids and admitted to the intensive care unit (ICU).

While in the ICU, the patient underwent central line placement and received escalating doses of opioids and benzodiazepines, as well as a magnesium infusion. His foot was debrided in the operating room by podiatry. Our patient continued to receive patient-controlled analgesia and scheduled benzodiazepines. He was visited by caseworkers multiple times; they were never able to reach the patient’s significant other or verify the financial information he provided.

Conflicting documentation began to emerge during the patient’s hospitalization. A nutrition consult noted him to be eating a steak dinner brought from outside the hospital. A resident note from later that same day recorded him unable to speak clearly due to muscle spasms in his back and trismus. He was also found to be somnolent at several points during his hospitalization.

The patient’s care was downgraded after 48 hours in the ICU.

On hospital day 8, a code stroke was called due to a new left facial droop. Neurology evaluated the patient and did not appreciate any focal neurologic deficits. Following this code stroke, the patient experienced worsening spasms that were refractory to benzodiazepines. Neurosurgery was consulted and offered the patient a lumbar drain for intrathecal baclofen. Critical care was consulted to offer the patient paralysis and intubation. The patient declined intubation. Despite nothing by mouth (NPO) status, the patient was found eating and laughing with a friend in the room and threatened to leave against medical advice (AMA) when confronted.

On hospital day 9, toxicology discovered that the patient had checked in to multiple regional hospitals and another hospital in a different state under a different alias, also complaining of spasms concerning for acute tetanus. On discovery of the patient’s accurate identity, we were able to see in the EMR that the patient had been seen twice in 2015 (once at our hospital) and once in 2016 at another institution for “acute tetanus.” He had been intubated for tetanus in the past. He had also presented to multiple hospitals in the past six years complaining of headache, fever, and neck pain and had undergone lumbar punctures and prolonged antibiotics due to concern for meningitis. When the inpatient team discussed this with the patient, he left AMA despite the inpatient team strongly recommending he stay in the hospital to be weaned off his high doses of benzodiazepines and opioids.

Discussion
Our patient exhibited several symptoms and signs that have been associated with factitious disorder.⁵ He presented to the ED alone and did not provide reliable contact information for friends or family for collateral information. He had a variable severity of symptoms documented by different members of his care team. When our toxicologist eventually uncovered the patient’s identity through collaboration with regional toxicologists, it became clear our patient had a severe case of factitious disorder. He demonstrated a willingness to undergo invasive procedures, including intubation and central line placement for factitious tetanus as well as lumbar puncture and multiple weeks of antibiotics for factitious meningitis.

Conclusion
Our case highlights the importance of recognizing factitious disorder as early as possible and connecting these patients with appropriate resources, as even specialists have difficulty diagnosing and managing this condition.^5-7 Our patient had nine different subspecialty consultations while admitted during this course of factitious tetanus. Undiagnosed factitious disorder is a tremendous burden on our already strained health care system and exposes our patients to unnecessary invasive procedures fraught with risk. This case also demonstrates the fallibility of the EMR — something rarely considered in this era as the EMR becomes more prevalent and our systems more connected.

A high index of suspicion and repetitive examination of assumptions are critical to successful diagnosis and management of factitious disorder.

References

1. Jafferany M, Khalid Z, McDonald KA, Shelley AJ. Psychological Aspects of Factitious Disorder. Prim Care Companion CNS Disord. 2018;20(1):17nr02229. Published 2018 Feb 22. doi:10.4088/PCC.17nr02229
2. Yates GP, Feldman MD. Factitious disorder: A systematic review of 455 cases in the professional literature. General Hospital Psychiatry. https://www.sciencedirect.com/science/article/pii/S016383431630072X. Published May 12, 2016. Accessed October 24, 2022.
3. Storr-Paulsen A, Troëng T. Rabies, tetanus och meningit--Münchhausens syndrom [Rabies, tetanus and meningitis--Munchausen syndrome]. Lakartidningen. 1978;75(7):563.
4. Effersoe P. Stivkrampe, hundegalskab og anden galskab--igen. En advarsel [Tetanus, rabies and other madness--again. A warning]. Ugeskr Laeger. 1977;139(32):1910-1911.
5. Carnahan KT, Jha A. Factitious Disorder. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 1, 2022.
6. Galli S, Tatu L, Bogousslavsky J, Aybek S. Conversion, Factitious Disorder and Malingering: A Distinct Pattern or a Continuum?. Front Neurol Neurosci. 2018;42:72-80. doi:10.1159/000475699
7. Bass C, Wade DT. Malingering and factitious disorder. Pract Neurol. 2019;19(2):96-105. doi:10.1136/practneurol-2018-001950
8. Marchant B, Brown J. Munchausen Meningitis. Journal of the Royal Society of Medicine. 1990;83:532-533.
9. Kanaan R, Wessley S. The origins of factitious disorder. History of the Human Sciences. https://journals.sagepub.com/doi/10.1177/0952695109357128. Published April 26, 2010. Accessed October 24, 2022.