HYPOKALEMIA LEADING TO TORSADES-DE-POINTES - MUNCHAUSENS DISORDER OR BULIMIA-NERVOSA

A 45-year-old woman traveled over 1000 miles from a major metropolitan area to obtain another opinion for medically refractory diarrhea. She had an extremely complicated medical history with no outside records or family members accompanying her to give collateral history. She had multiple previous diagnostic evaluations including 13 surgical proced ures and many therapeutic trials of various medications. She acknowled ged a preoccupation with weight and appearance, described previous att empts to diet, and repetitively denied purging, including laxative abu se. During her hospitalization she had two episodes of torsades de poi ntes requiring cardiac defibrillation. Laboratory testing revealed hyp okalemia at the time of these events, and a toxicology screen was posi tive for bisacodyl, confirming laxative abuse. When confronted by a co mbined team of cardiology, gastroenterology, and psychiatry specialist , she admitted her laxative abuse and surrendered her supply of Dulcol ax tablets. The discussion addresses the procedures employed to detect her surreptitious medication use, the near lethal cardiac complicatio ns, and the appropriate psychiatric diagnosis. (C) 1997 Elsevier Scien ce Inc.