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HIP Osteonecrosis Secondary to the Administration of Corticosteroids for Feigned Bronchial Asthma.

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Number 1, January 1994, pp 139-141
0 1994, American College of Rheumatology
The Clinical Spectrum of the Factitious Disorders
We describe the case of a woman who developed
hip osteonecrosis after prolonged use of corticosteroids
for feigned bronchial asthma. This type of musculoskeletal manifestation of the factitious disorders has not
been reported previously.
Factitious disorders are characterized by physical and/or psychological symptoms that are either
intentionally produced or feigned. Such patients have
been recognized in the literature as displaying Munchausen’s syndrome; they are predominantly men,
may work in the health field, and often have a long
history of hospitalizations and have undergone invasive diagnostic and surgical procedures (1,2). It is
common for these patients to change residence, and as
they present to each new facility, to give inaccurate
From the Division of Clinical Immunology and Rheumatology and the Division of Pulmonary Medicine, Department of Medicine, the Division of Orthopedics, Department of Surgery, and the
Department of Psychology, The University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
Supported in part by grant 2-60AR-20614 from the National
Institute of Arthritis and Musculoskeletal and Skin Diseases.
Graciela S. A l a r c h , MD, MPH: Professor of Medicine,
Division of Clinical Immunology and Rheumatology; Isis Mikhail,
MD, MPH: Research Coordinator, Division of Clinical Immunology
and Rheumatology; Kenneth A. Jaffe, MD: Assistant Professor of
Surgery, Department of Surgery; Laurence A. Bradley, PhD: Professor of Medicine, Division of Clinical Immunology and Rheumatology and Professor of Psychology, Department of Psychology;
William C. Bailey, MD: Professor of Medicine, Division of Pulmonary Medicine and Associate Chief of StaE for Education, Veterans
Administration Medical Center.
Address reprint requests to Graciela S. A l a r c h , MD,
MPH, The University of Alabama at Birmingham, University Station, MEB 615, Birmingham, AL 35294.
Submitted for publication April 28, 1993; accepted in revised form June 17, 1993.
information about previous hospitalizations, diagnoses, etc. (1-3).
Asthma has been infrequently reported as a
factitious illness (4), and iatrogenic Cushing’s syndrome has been the only reported side effect of steroid
treatment for factitious asthma (5). Musculoskeletal
manifestations of Munchausen’s syndrome have included cellulitis, osteomyelitis, infectious arthritis,
reflex sympathetic dystrophy, and pseudoneuropathic
arthritis (6-11). In the present report, we describe a
patient who developed osteonecrosis as a result of
prolonged use of corticosteroids for the treatment of
feigned asthma. No similar case has been reported in
the literature reviewed.
The patient, a 48-year-old Caucasian woman,
presented to The University of Alabama at Birmingham in August 1990 for evaluation of refractory
asthma. She reported that she had had asthma since
she was 13 years old, but that it was not severe until
she reached age 37, when bronchodilators and parenteral, oral, and inhaled corticosteroids were required.
Previous evaluations performed when the patient was
living elsewhere had failed to demonstrate bronchoconstriction.
The patient claimed to have had a number of
fractures due to “brittle bones.” She had undergone a
total of 1 1 knee surgeries, including 2 total left knee
arthroplasties (the first at age 39, and a revision at age
42), but a clear diagnosis prior to these surgeries could
not be documented. She had been confined to a
wheelchair for a year because of the condition of her
knees. She had had a cholecystectomy, multiple breast
biopsies (the last demonstrating “atypical cells,” according to the patient), and had been diagnosed as
having mitral valve prolapse and esophageal reflux.
She listed 15 medications to which she was “allergic”
(primarily causing gastrointestinal distress). Her current medications included bronchodilators, H-2 blockers, diuretics, potassium, nonsteroidal antiinflammatory drugs, daily oral corticosteroids (prednisone, 15
mglday), narcotic analgesics, cough suppressants, and
tranquilizers. She used nasal 0, on an as-needed basis.
She was a widow, had no children, and her only living
relative was her mother.
Examination findings were remarkable for the
patient’s inability to blow out inspired air, a barely
audible systolic click, a midline abdominal surgical
scar, and multiple well-healed surgical scars in both
knees. Her chest radiograph results were normal, as
were the results of pulmonary function tests. Tapering
of the corticosteroids was advised, but patient was lost
to followup until June 1991, when she presented with
“worsening asthma.” She was in a wheelchair, had a
cast on each leg (because of “recent fractures”), and
was receiving 0, treatment (4 liters per minute). She
had not tapered her medicines and claimed to have
been hospitalized for more than 30 days for control of
her asthma. Her examination results were normal, as
were the findings of a chest radiograph. She was
scheduled to undergo pulmonary function tests, with
methacholine challenge, but again was lost to followup.
In March 1992, she presented to the orthopedic
clinic with pain in the left hip, and the diagnosis of
early osteonecrosis was made. A core decompression
failed to help, and in June 1992, she underwent a hip
arthroplasty. After surgery, she became dyspneic and
demanded bronchodilators and corticosteroids. Of
note, her chest radiograph results remained normal,
and no examiner could document wheezes. The patient reluctantly agreed to be transferred to our rheumatology rehabilitation unit, but indicated that her
goal was to achieve “wheelchair independence”
(transfer from bed or commode to wheelchair and from
wheelchair to bed or commode), and not ambulation.
She cooperated only partially with the therapists, and refused to undergo a psychological evaluation. She agreed to taper her prednisone gradually, and
by the time of discharge, she was taking prednisone at
a dosage of 8 mg every other day. After discharge, she
was able to taper her prednisone to 5 mg every other
day. She continued taking all her other medications. In
October 1992, she presented with persistent pain in her
right thumb and was maneuvering her wheelchair with
difficulty. On examination, she was found to have
subluxation of the carpometacarpal joint; the joint was
injected with corticosteroids and splinted, but she
experienced no improvement. She was now in an
electric wheelchair and expressed the belief that only
surgery could resolve her problem; a carpometacarpal
joint arthroplasty was performed. Studies performed
during 1992 demonstrated decreased bone mineral
density in her axial as well as her peripheral skeleton.
However, no underlying cause, other than the corticosteroid intake, could be demonstrated.
This report demonstrates a rather characteristic
case of factitious disorder with significant physical
manifestations. The patient had assumed a sick role
since very early in her life and had numerous medical
problems, invasive studies, and surgical procedures
(1-3); she exhibited very demanding behavior with the
hospital staff, and was not willing to consider any of
their evaluative or treatment plans (e.g. psychological
evaluation) (3,6).
This patient, in contrast to others who maintain
similar physical manifestations, had several organ
systems affected, requiring involvement of various
medical and surgical subspecialists. Osteonecrosis resulted from the aggressive use of corticosteroids to
treat feigned bronchial asthma. Bronchial asthma has
been infrequently reported in the literature on factitious disorders (43). Refractory bronchial asthma
coupled with negative physical findings led to the
diagnosis of a factitious disorder in a young woman
described previously (4). While Cushing’s syndrome
has been reported in a patient with factitious asthma
(9,osteonecrosis secondary to the administration of
corticosteroids for a feigned ailment has not.
It has been suggested that information on patients with factitious disorders should be entered into a
national database, but such information may negatively bias a physician dealing with these patients. It is
also debatable how extensively one should search for
paraphernalia that may confirm the nature of the
disorder in these patients. Issues such as the patient’s
privacy, the implications of factitious diagnoses in
terms of health care costs, third-party reimbursement,
and disability benefits are also obvious concerns.
Another concern regarding patients with factitious disorders is the confusion experienced by physicians in attempting to develop treatment plans. Treat-
ment is complicated by the fact that, although patients
do play an active and conscious role in either provoking or feigning their clinical manifestations, the impulse leading to these pathologic behaviors appears to
be uncontrollable (3). It is believed that a severe
psychiatric borderline personality disorder, characterized by repetitive self-damaging behavior, lack of
anger control, a chronic pattern of unstable interpersonal relationships, poor self-identity,mood shifts, intolerance to being alone, and chronic feelings of boredom
and emptiness, underlies factitious disorders (3). It is
rather difficult for physicians to help patients with
factitious disorders to seek psychiatric treatment since
they can rarely tolerate confrontation from others.
Patients like the one described herein exemplify
not only the spectrum of the factitious disorders, but
also their severity, chronicity, poor long-term outcome (1-3), and burden to the health system (3). Even
in the best-possible-case scenario, that of early recognition and treatment of the disorder, the therapeutic
success rate is minimal.
W e are grateful to Elizabeth M o r c z e c k , I r e n e Tracy,
and Ella Henderson for their help in t h e preparation of the
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hip, administration, bronchial, secondary, corticosterone, osteonecrosis, asthma, feigned
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