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.


METHODS
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.
Bright
R
R
Department of Psychiatry, UNC School of Medicine, 27599-7160, USA.
Eisendrath
S
S
Damon
L
L
D000328:Adult; D000741:Anemia, Aplastic / Q000139:chemically induced* / Q000188:drug therapy; D000961:Antilymphocyte Serum / Q000627:therapeutic use; D018906:Antineoplastic Agents, Alkylating / Q000009:adverse effects*; D002066:Busulfan / Q000009:adverse effects*; D016572:Cyclosporine / Q000627:therapeutic use; D005162:Factitious Disorders / Q000150:complications* / Q000523:psychology; D005260:Female; D016179:Granulocyte Colony-Stimulating Factor / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D010198:Pancytopenia / Q000139:chemically induced; D016728:Self-Injurious Behavior / Q000523:psychology; D016312:Treatment Refusal / Q000523:psychology
D000961:Antilymphocyte Serum; D018906:Antineoplastic Agents, Alkylating; D007166:Immunosuppressive Agents; D016179:Granulocyte Colony-Stimulating Factor; D016572:Cyclosporine; D002066:Busulfan