Factitious Fever

A 14-year-old boy, studying in Class 9 in a residential school, was brought to the outpatient department with a history of recurrent episodes of fever for 3 months. The fever episodes usually started abruptly with a maximum recorded temperature of 104.4 °F and lasted for 1 to 2 days. He was having two to three such episodes every month. He had been investigated in the school clinic previously, and the reports were found to be normal. The episodes had been treated symptomatically as viral fever. They were sometimes associated with headache but no respiratory, urinary, or gastrointestinal symptoms. There was a history of weight gain of 2 kg in the previous 4 months. On examination, he was overweight, alert, and had normal vital signs. His axillary temperature was 98.2 °F. General physical examination and systemic examinations were normal. The child was investigated. His hemoglobin, total and differential leucocyte counts, and platelet counts were normal, and ESR was 7 mm first hour. The chest X-ray, urine routine reports, and blood and urine cultures were also normal. The parents were asked to maintain a temperature record at home and return when the fever recurred. Six days later, the boy was brought back to the emergency room at 7.15 a.m. with a reported fever of 105.4 °F since 6 a.m. He had been afebrile for the last 5 days, and the parents planned to take him back to school that morning. In the ER, the temperature documented by the nurse was normal. There was no history of intake of any antipyretic drugs and no sweating. His physical examination was once again normal and he seemed comfortable. In view of the previously normal reports, the dramatic drop in his body temperature within an hour with no sweating, and the overall demeanor of the child, the possibility of factitious fever was considered. The child was hospitalized for close observation. After hospitalization, the boy kept showing thermometer recordings to be between 101 and 104 °F, but the temperature recorded by the nurses was always found to be normal. During his stay, the nurses also noticed that he always spent sometime in the bathroom before coming out and recording his axillary temperature. He was subsequently noted to often have hot towels under his arms beneath his shirt which he said was to help control shivering. A family meeting was held during which the observations made in the hospital were shared. The family also shared long-held suspicions that he was manipulating his body temperature and psychiatrist consultation was ordered. The patient revealed feeling homesick in his residential school but also feeling unloved and neglected at home. He felt his parents were busy with their careers and that they loved his sister more as she was scoring better marks at school. He was discharged with referrals for outpatient mental health follow-up and family counseling.