Factitious Disorder Presenting with Attempted Simulation of Fournier’s Gangrene

Posted By Joseph Tseng
Factitious Disorder Presenting with Attempted Simulation of Fournier’s Gangrene

ABSTRACT: Fournier’s gangrene is a severe polymicrobial necrotizing fascitis of the perineal, genital, or perianal regions. The classic presentation is severe pain and swelling with systemic signs. Crepitus and cutaneous necrosis are often seen. Characteristic CT findings include subcutaneous gas and inflammatory stranding. Unless treated aggressively, patients can rapidly become septic and die. Factitious Disorder is the deceptive falsification of medical or psychological signs and symptoms in oneself. Many deceptive methods have been described, from falsely reporting physical or psychological symptoms, to manipulating lab tests, or even injecting or ingesting foreign substances in order to induce illness. We present a case of a 35-year-old man with factitious disorder who attempted to simulate Fournier’s gangrene by injecting his scrotum with air and fluid. CASE REPORT: History: A 35-year-old male with reported history of right orchiectomy two years ago for Non-Hodgkin’s Lymphoma (NHL) presented to the ED with 3 days of testicular pain and scrotal swelling with fevers and chills. Physical exam: On physical exam, he was distressed, hypertensive at 156/100 mmHg, tachycardic at 122 bpm, but afebrile at 37.6˚C. His penis was normal. His right hemiscrotum was empty, and the scrotal skin was light pink with some induration, but no blanching erythema, crepitus or fluctuance. There were multiple scars on the scrotal skin. His tenderness to palpation was out of proportion to exam. Laboratory studies: Laboratory studies demonstrated a normal white blood cell count of 6.7 K/µL (within normal limits). Other laboratory values were within normal limits. Imaging: Testicular ultrasound demonstrated marked thickening of the scrotal skin with shadowing echogenic foci within the deep subcutaneous tissues, concerning for gas-forming infection (Figure 1). Contrast-enhanced CT of the abdomen and pelvis also demonstrated scrotal skin thickening, as well as air within the inguinal canal and scrotum. The right testicle and spermatic cord were absent (Figures 2 and 3). This was judged highly concerning for a necrotizing infection. There were little or no inflammatory changes in the pelvic or perineal fat, but this was not initially appreciated. Clinical course: He was seen by urologic surgery in the ED who administered broad-spectrum antibiotics and took him emergently to the OR. Upon incising and entering the left scrotum, the surgeons were surprised to note that there was no evidence of any infection. The urology team was understandably confused by the clinical situation, and suspected malingering or factitious disorder. Outside hospital (OSH) records revealed that the patient presented 1 year ago to an OSH under very similar circumstances, with scrotal and retroperitoneal gas on imaging, and was treated for sepsis and Fournier’s gangrene. Testicular exploration there was also negative for infection. He was admitted for o

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