Abstract

Background: Bleeding from the nose or mouth is a common reason for seeking care in otorhinolaryngology. It often raises fear of serious local disease, systemic illness, or cancer. In most patients, an organic cause can be found. Rarely, however, is the bleeding self-produced. In factitious disorder, symptoms are created deliberately, not for money or legal benefit, but to occupy the role of a patient. These cases are difficult to recognize. They lead to repeated procedures, unnecessary tests, patient harm, distress within families, and wasted medical resources. Recurrent nasal or oral bleeding usually warrants urgent evaluation to exclude vascular lesions, hematologic abnormalities, or malignancy of the upper aerodigestive tract. In rare instances, however, symptoms may be intentionally fabricated, as seen in factitious disorder. Such cases are diagnostically challenging and may lead to repeated invasive procedures before recognition. Case presentation: A 30-year-old woman presented 11 months after delivery of twins with a three-month history of recurrent epistaxis and oral bleeding associated with dysphagia. Multiple prior evaluations, including nasal endoscopy, nasopharyngeal biopsy, upper gastrointestinal endoscopy, and coagulation studies, were unremarkable. Her haemoglobin remained stable despite frequent reports of bleeding. The discrepancy between symptoms and objective findings prompted supervised inpatient observation. During 48-hour continuous monitoring, no spontaneous bleeding occurred. The patient was subsequently observed applying dissolved orange-coloured multivitamin capsule contents to the nasal and oral mucosa to simulate haemorrhage. Psychiatric evaluation confirmed factitious disorder imposed on self, based on DSM-5 criteria. Supportive psychotherapy was initiated. Conclusion: Factitious disorder should be considered in persistent unexplained ENT bleeding when clinical findings are inconsistent with reported severity. Early recognition through structured observation can prevent unnecessary procedures and facilitate appropriate psychiatric care. Close observation, gentle communication, and teamwork across specialities are essential to prevent harm and to ease the burden on patients, families, and clinicians.

Keywords

factitious disorder, epistaxis; oral bleeding, postpartum, diagnostic challenge, munchausen syndrome