Fatal non-thrombotic pulmonary embolization in a patient with undiagnosed factitious disorder

BACKGROUND: Factitious fever is extremely challenging to diagnose in patients with complicated chronic medical problems, and represents as much as 10% of fevers of unknown origin. Factitious fever caused by self-injecting oral medications through indwelling central catheters is a diagnostic challenge. CASE PRESENTATION: We present a 32-year-old Caucasian female with history of short gut syndrome, malnutrition requiring total parental nutrition, and pancreatic auto-islet transplant with fever of unknown origin. Multiple episodes of bacteremia occurred with atypical pathogens, including α-hemolytic Streptococcus, Achromobacter xylosoxidans, and Mycobacterium mucogenicum. Chest computed tomography was notable for extensive tree-in-bud infiltrates. Sudden cardiac arrest with right-sided heart failure following acute hypoxemia led to her death. Diffuse microcrystalline cellulose emboli with foreign body granulomatosis was found on autopsy. Circumstantial evidence indicated that this patient suffered from factitious disorder, and was self-injecting oral medications through her central catheter. CONCLUSION: A high index of suspicion, early recognition, and multifaceted team support is essential to detect and manage patients with factitious disorders before fatal events occur.