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Feigned HIV in a Malingering Patient

Key Words: AIDS/HIV • Anxiety Disorders (General)

TO THE EDITOR: Malingering occurs in the military, prison, work, and medicolegal environment.¹ It has been defined as the intentional production of symptoms, signs of illness, or disability in order to obtain a secondary gain.² Examples of a secondary gain include avoiding military service, avoiding a jail term, securing living arrangements, and acquiring drugs or money. The authors report a case of malingering with ingestion of HIV medications in a noninfected HIV patient to avoid employment and to obtain free living arrangements.

Case Report

A 26-year-old man, a former emergency medical service worker, was admitted to the hospital for a 3-day history of malaise, productive cough, and fever up to 105°F. His past medical history included claiming to be diagnosed with HIV over 6 years ago. He reported a 10 year history of intravenous (IV) drug abuse, an 8 year history of multiple unprotected sex with males and females, unemployment for the past 7 years, and past housing at several homeless shelters. He presented to the hospital with medications that included zidovudine (300 mg bid), lamivudine (150 mg bid), and ritonavir (600 mg bid). He had a temperature (oral) of 103F. Otherwise, the physical examination, vital signs, and laboratory studies were normal. Chest X-ray demonstrated a right lower lobe infiltrate. Home HIV medications were continued and Bactrim was empirically started for Pneumocystis carinii pneumonia (PCP). Blood, sputum, and urine cultures were done. The patient was found to have Staphylococcus aureus bacteremia on blood cultures, presumably from his history of (IV) drug abuse. Sputum and urine cultures were negative for acid fast, PCP, fungus, and aerobic and anaerobic bacteria. Vancomycin and gentamicin were given initially, but they were both discontinued in favor of an oxacillin sensitivity report. Given the patient's history of fever, IV drug abuse, and Staphylococcus aureus-positive blood cultures, a cardiac transthoracic echocardiography was obtained. The cardiac echocardiography was normal with no vegetations indicative of infective endocarditis. The patient was discharged free of symptoms after several days of hospitalization and was subsequently referred to an HIV intermediate care facility. The patient remained at the facility for 3 months while frequently volunteering at schools, teaching and addressing issues on HIV. While still at this facility, he presented to the local clinic for a routine examination. His CD4 count was found to be 540, viral load undetectable, ELISA negative for HIV-1 and -2, and Western blot negative. Out-of-state documents from previous admissions indicated that the patient had indeed been tested for HIV but with a negative result. The patient was confronted with this information, and all antiviral agents were discontinued. Despite initial anger and denial, the patient subsequently admitted feigned HIV infection for the purpose of free room and board at the HIV intermediate care facility. In addition, the patient admitted to obtaining his antiretroviral medications from an HIV patient at his most recent homeless shelter. He agreed to a psychiatric evaluation, and he was told to follow up with his current physician. The patient never returned for an evaluation and was lost to medical follow-up at our clinic.

Discussion

Even when physicians have presented with evidence suggestive of a genuine organic illness they should be aware of malingering, especially if a secondary gain is suspected. In our patient, the presence of a secondary gain can be identified as feigning HIV infection to obtain HIV support services (i.e., free housing, board, and benefits). Our patient was directly observed and documented to have ingested HIV medications with significant toxicity profiles over a 3-month period.

Interestingly, the patient was educating the public on HIV prevention and the role of safe sex. The patient therefore not only was intentionally feigning physical/psychological signs and symptoms to physicians and HIV intermediate care facility employees, but to the public and society as a whole.

The authors acknowledge that psychiatric treatment of malingering patients is rarely successful. The main objective in identifying these individuals is the avoidance of potentially dangerous, costly, and complicated ethical and diagnostic investigations and treatments.^3–7 The authors suggest that for patients who self-report HIV infection, the physician should obtain previous records and other documents by contacting the hospitals that the patient reports previously attending. If records are inconsistent with the patient's history and indicate that the patient has feigned HIV infection, a careful assessment of the patient's motives, confronting the patient with inconsistencies, and the use of other informants can all help to establish the validity of what the patient reports.

REFERENCES

1. Kaplan HI, Sadock BJ: Comprehensive Textbook of Psychiatry, 5th Ed, Baltimore, MD Williams & Wilkins, 1989 pp. 394-396
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC, American Psychiatric Association, 1994, p 683
3. Zumwalt RE, McFeeley F, Maito J: Fraudulent AIDS (letter). JAMA 1987; 257:3231
4. Tyson ED, Fortenberry JD: Fraudulent AIDS: A variant of Munchausen's syndrome (letter). JAMA 1987; 258:1889-1890
5. Evans GA, Gill MJ, Gerhart S: Factitious AIDS (letter). N Engl J Med 1988; 319:1605-1606[Medline]
6. Sno HN, Storosum JG, Wortel CH: Psychogenic "HIV infection." Int J Psychiatry in Med 1991; 21:93-98[Medline]
7. Sheon AR, Fox HE, Alexander G, Buck A, et al: Misdiagnosed HIV infection in pregnant women: implications or clinical care. Public Health Rep 1994; 109:694-695[Medline]

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