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(139) The Perfect Mimic: Factitious Disorder Posing as Type III Hereditary Angioedema


Authors:

Ranjit Chacko, MD – Psychiatrist,Professor of Psychiatry, Houston Methodist Hospital

Connie Hsiao – Medical Student, Texas A&M College of Medicine

Emma Welch – Medical Student, Texas A&M College of Medicine

Marissa Witt-Doerring, MD – Psychiatry Resident, PGY-4, Baylor College of Medicine


Co-Authors:

Presenting Author: Ranjit Chacko, MD, Houston Methodist Hospital
Co-Author: Connie Hsiao, Texas A&M College of Medicine
Co-Author: Emma Welch, Texas A&M College of Medicine
Co-Author: Marissa Witt-Doerring, MD, Baylor College of Medicine

Abstract:

Background

In this case report, we reflect on the challenge of recognizing factitious disorder, the consequences of delayed recognition, and the need for interdisciplinary education regarding diagnosis and management of factitious disorder.

Case

A 36-year-old Caucasian female is undergoing treatment for angioedema crisis on an internal medicine service. She reported a history of type III Hereditary Angioedema (HAE) in 2009 followed by recurrent angioedema crises resulting in frequent hospitalizations, intubations with ventilator requirements, and eventual tracheostomy placement. She also carries a history of deep vein thromboses and pulmonary embolisms resulting in chronic anticoagulation. She currently has a permanent pacemaker after several unsuccessful cardiac ablations for atrial fibrillation in the setting of frequent episodes of endocarditis and bacteremia. The psychiatry consult-liaison service was consulted to explore the possibility of feigned symptoms when her reported angioedema crises persisted in an atypical pattern (only during night shift, beyond expected duration) despite treatment. Confirmation of the primary team’s suspicion of factitious disorder was made through a review of medical records combined with discussions with patient’s past and current treatment providers.

Discussion

HAE is a rare condition that presents with recurrent episodes of angioedema affecting the skin, gastrointestinal tract, and upper airways without associated urticaria or pruritus. Type III HAE, unlike the more common types I and II, is not associated with any diagnostic biomarkers. It is a clinical diagnosis; the only objective signs such as bowel wall inflammation and/or laryngeal edema can be identified during acute crises. This patient made repeated complaints of upper airway tightness and chronic epigastric pain leading to her original diagnosis. Despite multiple upper airway scopes and gastrointestinal imaging, no signs of angioedema were ever found. It is challenging to differentiate true type III HAE from those seeking to falsify symptoms. The inability to make this distinction can unnecessarily expose the patient to invasive procedures and treatments with significant side effects.

Conclusion

This case report highlights the challenges faced in diagnosing factitious disorder that may lead patients to undergo unnecessary procedures. Furthermore, similar case reports have been described, underscoring a consideration of factitious angioedema for any case of refractory type III HAE.

References


  1. Caselli I et al. Epidemiology and evolution of the diagnostic classification of factitious disorders in DSM-5. Psychol Res Behav Manag.2017 Dec 11;10:387-394.

  2. Feldman MF et al. Factitious angioedema: a mimic of refractory “angioedema”. J Allergy Clin Immunology. 2014 Nov-Dec;2(6):795-7.

  3. Miranda AR et al. Hereditary angioedema tyoe III (estrogen-dependent) report of three cases and literature review. An Bras Dermatol. 2013 Jul-Aug; 88(4): 578–584.

  4. Zuraw BL. Hereditary angioedema with normal C1 inhibitor: Four types and counting. J Allergy Clin Immunology. 2018 Mar;141(3):884-885.


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