(009) Fool Me Once… A Case of Severe Factitious Disorder Complicated by Cardiopathia Fantastica and False Positive Troponin Levels

Abstract:

Background: Chronic factitious disorder, or Munchausen syndrome, includes deliberate fabrication of physical symptoms without obvious secondary gain (Yates, 2016). Severe presentations can be complicated by elements of sociopathy, dramatic and false personal histories (pseudologica fantastica), and travel from hospital to hospital (peregrination) (Steel, 2009). A subset of patients report cardiac-specific complaints, risking exposure to unnecessary and potentially harmful diagnostic studies (Park, 2004). We present the case of an individual with an extensive history of factitious behavior and heightened danger of invasive procedures exacerbated by false positive troponin levels.

Case: A 50-year-old male presented to the emergency department with severe chest pain not remitting to oral nitroglycerin. He reported an extensive cardiac history including several myocardial infarctions, stent placements, bypass surgery, heart failure, and reported heart transplant candidacy. In addition, he shared an extensive family cardiac history but refused to provide and family or emergency contacts. He consistently reported he worked as a veterinarian but would not share additional personal or relationship details.
Pain complaints appeared disproportional to unremarkable examination findings. Electrocardiogram was unremarkable. However, high-sensitivity troponin I peaked at 530 ng/L (normal is < 53 ng/L), down-trending to 404 ng/L the following day. Subsequent cardiac catheterization revealed non-obstructive disease of native coronary arteries and previously placed patent grafts and stents without other acute or actionable findings. Providers concluded that the troponin elevation represented a false positive result.
Later, a physician recognized him from performing a recent procedure at a nearby community hospital, noting the patient was now admitted under a different name. Psychiatric consultation affirmed the diagnosis of factitious disorder given his pattern of treatment engagement, identification with the sick role, and absence of clear secondary gain. Additional chart review revealed 49 emergency department visits (some within the same day) across 11 states while using 3 different aliases during the previous two years and other episodes of unexplained hypertroponinemia. A therapeutic discharge was conducted to prevent further misuse of medical resources.

Discussion: This case highlights the cumulative hazards of severe cardiac factitious disorder complicated by misleading laboratory results. Among numerous potential causes of false positive troponin levels, his previous work with animals (if accurate) could generate assay-interfering heterophilic antibodies (Chaulin, 2022). Compared to other physical symptoms, factitious chest pain can accelerate exposure to interventional procedures and hospital admission.

Conclusion: CL psychiatrists should be aware of the role of false positive laboratory findings in obfuscating signs and symptoms of fabricated illness. EMR platforms could be leveraged to alert future providers to consider procedural restraint and augment patient safety.

References:
 
Steel RM. Factitious disorder (Munchausen's syndrome). The Journal of the Royal College of Physicians of Edinburgh, 2019, 39(4), 343–347.
 
Yates, GP, Feldman, MD. Factitious disorder: a systematic review of 455 cases in the professional literature. General Hospital Psychiatry, 2016, 41, 20–28.
 
Park TA, Borsch MA, Dyer AR, Peiris AN. Cardiopathia fantastica: the cardiac variant of Munchausen syndrome. Southern Medical Journal, 2004, 97(1):48-52.
Chaulin AM. False-Positive Causes in Serum Cardiac Troponin Levels. Journal of Clinical Medicine Research, 2022, 14(2):80-87.

Presentation Eligibility: This abstract has not been submitted for presentation or for a journal previously.

Diversity, Equity, and Inclusion: CL psychiatrists play a key role in guiding the delivery of equitable and safe care delivery to all patients. Individuals suffering from chronic factitious disorder are exposed to procedural interventions that yield more harm than benefit, while simultaneously consuming resources that limits access by others in need. Unfortunately, this can persist without the opportunity to gain more meaningful insight into patterns of treatment seeking behavior. Targeted liaison education and consulting with health systems privacy officers could reinforce clinical and EMR-based approaches to proactive identification, clinical restraint, and judicious resource access in these situations.