factitious disorder ( fd ) is defined in the 5th edition of the diagnostic and statistical manual for mental disorders as the falsification of physical or psychological signs or symptoms , or induction of injury or disease , associated with identified deception . in the spectrum of feigned illness in contrast , malingering is the intentional induction or falsification of illness for the acquisition of secondary gain . existing reports in the gastroenterology literature have been characteristically limited to factitious abdominal pain , diarrhea and gastrointestinal bleeding ( gib ) [ 3 , 4 , 5 ] . conversely , non - gastrointestinal presenting manifestations of fd in the setting of gastrointestinal disorders , such as inflammatory bowel disease ( ibd ) , have been infrequently reported . we report a case of recurrent pancytopenia in a patient with crohn 's disease surreptitiously ingesting 6-mercaptopurine ( 6-mp ) . a 50-year - old female with an 8-year history of fistulizing crohn 's disease and active recurrent perirectal abscesses presented to the outpatient clinic for initial consultation . she had undergone a diverting colostomy elsewhere 2 years prior to consultation and reported a history of greater than 30 perianal surgical procedures . her medical history also consisted of vitamin d deficiency , peripheral neuropathy , osteopenia and obstructive lung disease related to ongoing tobacco use . she reported unsuccessful treatment with 5-aminosalicylic acid agents , methotrexate , infliximab , adalimumab and certolizumab pegol . the patient was started on 75 mg of 6-mp daily , however severe abdominal pain and active perianal disease persisted . thiopurine metabolite testing for thioguanine nucleotide ( tgn ) and methyl mercaptopurine nucleotide ( mmpn ) revealed low levels and the dose was increased to 100 mg daily . laboratory testing demonstrated elevated lipase levels ( 4 times upper limit of normal ) and the patient was told to discontinue 6-mp indefinitely , both by telephone and at a face - to - face follow - up visit , because of probable drug - induced pancreatitis two months later , the patient presented to the emergency department with a 3-day history of progressive headache , fatigue and a spreading erythematous rash . laboratory studies demonstrated pancytopenia , with hemoglobin of 8.3 , mean corpuscular volume of 112 , leukocyte count of 1.7 , absolute neutrophil count of 0.42 and platelet count of 90 . a hematology consultation was obtained and her prior use of 6-mp dosing , followed by cessation , was specifically noted . the pancytopenia was attributed to residual effect of long - term 6-mp use and she was closely monitored , with counts progressively recovering throughout the remainder of her hospitalization . infliximab was reintroduced , and laboratory tests showed normalization of blood counts through the 4-month follow - up visit . however , she subsequently returned to the emergency department 8 days later with abdominal pain and increased ostomy output . pancytopenia was again present with hemoglobin , leukocyte count and platelet count of 7.2 , 2.1 and 42 , respectively . long - term immune - suppressive therapy was suspected as the etiology of the pancytopenia . further analysis demonstrated diploid xx cytogenetics and normal flow cytometric analysis , with no clonal or aberrant leukocyte population identified and no blast proliferation . again , she was transfused and given colony - stimulating factors as well as a prednisone taper and her counts improved . several months later , she was readmitted for pancytopenia , oral ulcers and increased ostomy output . out of concern for her repeated admissions with no identified cause , thiopurine metabolite testing was repeated and demonstrated tgn and mmpn levels of 385 ( therapeutic window 230400 pmol ) and 12,417 ( target < 5,700 pmol to minimize toxicity ) , respectively , consistent with drug being present in the body and with mmpn levels predisposing toward toxicity . in the course of her evaluation , her community pharmacist contacted her outpatient providers and indicated that a refill of 6-mp had been dispensed 1 month prior to admission . the patient denied refilling the old prescription and indicated she did not take the 6-mp . the difficult situation was directly discussed with the patient and she again denied taking the 6-mp . she was specifically advised to not use this medication as it was likely responsible for prior pancreatitis and recurrent pancytopenia . the patient subsequently canceled appointments at our institution and has been out of contact for 6 months . after the pancreatitis attributed to 6-mp in january 2013 , the patient was hospitalized 8 times during the time of this report extending to june 2014 . she had multiple consultations with gastroenterology , hematology , colorectal surgery and single consultations with infectious disease , rheumatology , dermatology , endocrinology and pulmonary medicine . at each hospital discharge , a written list of prescriptions was specifically reviewed with and provided to the patient . medication reconciliation was performed at each outpatient visit , and her list , from which 6-mp was absent , was confirmed on every occasion . fd was first described in the second century by claudius galen , a roman physician who reported feigned medical illness , including factitious gib . factitious disorder in 1843 when he published a systematic account of feigned illness in soldiers and seamen . munchausen syndrome for the most severe variety , in which the deceptive induction of illness becomes the central preoccupation of the patient . a large retrospective cohort study of fd patients spanning 21 years showed a caucasian female preponderance , with an average age of 30.7 years . however , given the central role of deception in the classification of the disorder , it is likely grossly underdiagnosed and therefore underestimated . to our knowledge , this is the first reported case of fd presenting without gastrointestinal manifestations in a patient with ibd . outside of the gastroenterology literature , pancytopenia is a relatively common presenting manifestation of fd . in contrast , the existing gastroenterology literature regarding fd has been limited to several case reports of factitious gib , diarrhea and abdominal pain . the mode of disease induction in cases of gib varied greatly and included autophlebotomy and oral ingestion of blood , administration of blood enemas and injection of blood into the abdomen to simulate extravasation , swallowing razor blades , and disconnection and infusion of radioisotope - tagged red blood cells directly into the rectum during a scintigraphy study . all reported patients had undergone extensive diagnostic testing without identified cause , including conventional radiography , endoscopy and scintigraphy . factitious diarrhea is also well described and often occurs in the setting of surreptitious laxative ingestion , whether for obtaining medical care or other secondary purposes , such as weight loss . in some instances of gastrointestinal fd , patients attributed their symptoms to exacerbations of ibd , either diagnosed by themselves or by other physicians whose identities could not be verified [ 4 , 12 ] . a high prevalence of chronic abdominal pain amongst patients with gastrointestinal disorders , including ibd , has led to anecdotal reports of factitious pain leading to hospitalization . narcotic drug dependence is also noted to be highly prevalent in ibd , however feigned illness for obtaining medication would be classified as malingering for secondary gain . while no systematic analysis of fd in ibd has been undertaken , studies of pediatric ibd patients have demonstrated marked difficulty with social assimilation and resulting isolation , leading to increased absenteeism and refusal to participate in extracurricular activities . examinations of the connection between psychiatric illness and ibd have been fraught with controversy due to methodological heterogeneity . however , they have consistently demonstrated high rates of concurrent depression and anxiety at all ages , beyond what is seen in healthy controls and demographically matched patients with other chronic diseases . concomitant psychiatric illness may also place patients at risk of poor outcomes , as they experience more frequent disease relapse . examinations of the connection between self - perceived stress , irrespective of psychiatric illness , and ibd disease activity have yielded contradictory findings . the diagnosis of fd is notoriously difficult and requires both a high index of suspicion and a systematic approach to exclusion of medical etiology . while not diagnostic , there are several characteristics that suggest the presence of feigned illness when medical causes have been sufficiently evaluated . these include treatment at multiple hospitals and/or clinics , an inordinate number of diagnostic tests without disease identification , eager agreement for invasive testing , unwillingness to provide prior medical records , history of employment or studies within health - related fields , symptom magnitude inconsistent with objective findings , opposition to psychiatric assessment and atypical disease course . of these , the atypical intermittent nature of our patient 's disease course and the similarity to thioguanine toxicity was the aspect which drew suspicion and led to her diagnosis . patients with ibd often have comorbidities that include psychiatric illness , and frequently possess an in - depth knowledge of the medical system by virtue of their life experiences . for an inappropriately motivated patient , access to potent immunomodulatory agents provides an opportunity to experience problems unexpected by a treating team . clinical suspicion of factitious illness is critical to management , as significant morbidity and even mortality may ensue . early identification may ultimately improve patient outcomes . in spite of examination by multiple providers with elaborate processes to ensure reconciliation of medications prescribed and medications being actually taken , unfortunately , as was seen in this case , patients confronted with evidence of their deception may disconnect entirely from their providers and seek a new health care system .
factitious disorder is a rare psychiatric illness characterized by the willful and deceptive induction of illness for the purpose of assuming the sick role . 
 it presents a substantial diagnostic challenge , as patients often go to great lengths to conceal their deception . 
 accordingly , its presence in the full spectrum of gastrointestinal diseases is likely underappreciated . 
 while factitious gastrointestinal bleeding , abdominal pain and diarrhea are relatively common , factitious non - gastrointestinal symptoms in the setting of gastrointestinal illness have been infrequently reported . 
 we present the case of a patient with crohn 's disease with recurrent pancytopenia attributed to the surreptitious ingestion of 6-mercaptopurine . in patients with possible 
 access to immunomodulatory drugs , a high suspicion for and early identification of factitious disorder may improve patient outcomes and avoid invasive and costly diagnostic evaluations .