A 32-year-old woman comes to the emergency department due to 2 days of high fever, chills, and generalized weakness. The patient was hospitalized 6 weeks ago due to polymicrobial sepsis and recently finished several weeks of antibiotics. Her blood cultures at diagnosis were positive for Escherichia coli, Bacteroides, and Peptostreptococcus, and repeat cultures after antibiotics were negative. She believes that "the antibiotics were stopped too soon and now the infection has come back." The patient also has a history of chronic abdominal pain and has had an extensive diagnostic workup, which was unrevealing. She does not use tobacco, alcohol, or illicit drugs and works as a nursing assistant. Temperature is 38.9 C (102 F), blood pressure is 110/64 mm Hg, pulse is 102/min, and respirations are 16/min. She has no scleral icterus, and oropharyngeal mucosa is normal. Lungs are clear to auscultation and heart sounds are normal. The abdomen is diffusely tender with superficial palpation, but no guarding or rebound tenderness is present. Bowel sounds are normal. Rectal examination reveals brown stool that is occult blood negative. Blood cultures are obtained, and empiric antibiotics are administered. Blood cultures grow E coli and Enterococcus faecalis within 48 hours. Which of the following is the most likely cause of this patient's recurrent bacteremia?

Question

A 32-year-old woman comes to the emergency department due to 2 days of high fever, chills, and generalized weakness.  The patient was hospitalized 6 weeks ago due to polymicrobial sepsis and recently finished several weeks of antibiotics.  Her blood cultures at diagnosis were positive for Escherichia coli, Bacteroides, and Peptostreptococcus, and repeat cultures after antibiotics were negative.  She believes that "the antibiotics were stopped too soon and now the infection has come back."  The patient also has a history of chronic abdominal pain and has had an extensive diagnostic workup, which was unrevealing.  She does not use tobacco, alcohol, or illicit drugs and works as a nursing assistant.  Temperature is 38.9 C (102 F), blood pressure is 110/64 mm Hg, pulse is 102/min, and respirations are 16/min.  She has no scleral icterus, and oropharyngeal mucosa is normal.  Lungs are clear to auscultation and heart sounds are normal.  The abdomen is diffusely tender with superficial palpation, but no guarding or rebound tenderness is present.  Bowel sounds are normal.  Rectal examination reveals brown stool that is occult blood negative.  Blood cultures are obtained, and empiric antibiotics are administered.  Blood cultures grow E coli and Enterococcus faecalis within 48 hours.  Which of the following is the most likely cause of this patient's recurrent bacteremia?

Quizplus · Accepted Answer

Explanation: This woman who works as a nursing assistant has had 2 episodes of polymicrobial bacteremia in 6 weeks, suggesting factitious disorder due to the self-injection of exogenous material. Factitious disorder is a psychiatric condition characterized by feigning or inducing illness to assume the sick role without obvious external benefit (eg, financial gain, avoiding work). One of the most common ways to induce an infection is to inject exogenous material such as sputum, urine, feces, or milk into the skin or bloodstream. Suspicion should be raised when a patient with no history of malignancy or immunosuppressive condition develops recurrent polymicrobial bacteremia with varying organisms. Factitious disorder is most common in women and healthcare workers. (Choice A) This patient was on antibiotics for several weeks, had negative repeat blood cultures, and then developed bacteremia with a different collection of organisms. This makes antibiotic failure unlikely. (Choice B) A dental abscess could cause polymicrobial sepsis with oropharyngeal flora such as Peptostreptococcus and Streptococcus. Escherichia coli would be an unusual organism for a dental abscess, and a significant dental abscess is likely to be associated with pain. (Choice D) Infective endocarditis is most commonly a monomicrobial infection due to Staphylococci, Streptococci, or Enterococci; a polymicrobial infection with a collection of fecal organisms would be atypical. (Choice E) Intraabdominal abscesses are most commonly due to Bacteroides fragilis and E coli; although an occult abscess can cause polymicrobial sepsis, it is unlikely that a different combination of organisms would be found on repeat blood cultures 6 weeks later. Educational objective: Repeated polymicrobial bacteremia in a patient with no history of malignancy or immunosuppressive condition should raise suspicion for a factitious disorder. Factitious disorder is most common in patients who are women and health care workers.

A 32-Year-Old Woman Comes to the Emergency Department Due to 2