Intelligent Diagnosis, Unexpected Complication in a Munchausen Case of Warfarin Abuse

A 25-year-old man with 10 years history of a migraine headache noticed ecchymotic lesions involving anterior chest wall, both upper and lower limbs that were unrelated to trauma. His laboratory data revealed prothrombin time (PT) 32 seconds, partial thromboplastin time (PTT) 44 seconds, international normalized ratio 6, and normal bleeding time. Mixing study was performed and normalized PT to 13 seconds and PTT to 38 seconds. Factor activity assay revealed a low level of Factors II, VII, IX, and X but normal level of Factor V. Factitious disorders were in high priority in our differential diagnosis. Thus, we evaluated serum warfarin level which was positive. There were no doubts that we encountered Munchausen case that abused warfarin compounds. We decided to use factor eight inhibitor bypassing activity for rapid correction of coagulation disorder. He suddenly complained of chest pain and dyspnea. We encountered to pulmonary embolism.