Apotemnophilia Masquerading as Medical Morbidity

J. Mike Bensler, MD, Douglas S. Paauw, MD, FACP


South Med J. 2003;96(7) 

In This Article

Case Report

The patient was a 24-year-old man who presented to a campus health clinic with a 2-week history of bilateral lower-extremity foot weakness and numbness. He was subsequently referred to the neurology service for further workup of his symptoms. His physical examination was remarkable for 2/5 strength with dorsiflexion and plantarflexion of the feet bilaterally, along with decreased sensation to light touch bilaterally over the lower extremities up to the level of the midcalf. It was also noted that the distal phalanges of the patient's feet were missing, which the patient reported was secondary to "frostbite" sustained during a mountain-climbing accident in 1999. After cerebrospinal fluid and blood chemistry were found to be normal, the patient underwent nerve conduction studies, which revealed absent sural sensory nerve action potentials bilaterally, increased bilateral F-wave latency along the distal portion of the tibial nerves, and moderate slowing of nerve conduction velocity in the peroneal nerves and tibial nerves bilaterally. His nerve conduction studies were consistent with a diagnosis of Guillain-Barré syndrome (GBS). A 5-day course of outpatient intravenous immunoglobulin was administered, and the patient was instructed to follow up at the clinic if his symptoms progressed.

One week later, the patient presented to the emergency department with bilateral lower-extremity pain, weakness, and swelling, along with 39.6°C fever and tachycardia. A repeat physical examination demonstrated 0/5 strength with dorsiflexion and plantarflexion of the feet bilaterally, along with bilateral, symmetrical erythema and edema of the lower extremities. Minor excoriations were noted on the patient's ankles, but no noticeable lacerations, ecchymoses, or puncture wounds were found. The patient was diagnosed with bilateral lower-extremity cellulitis as a complication of GBS, and he was admitted to the neurology service for administration of intravenous antibiotics.

During the next 2 days in the hospital, the patient continued to spike high fevers as his legs remained erythematous and swollen despite the administration of intravenous antibiotics. After consultation with the general surgery service, it was determined that bilateral incisions and drainage of the lower extremities were indicated to prevent necrotizing fasciitis. At the surgeon's request to take the patient to the operating room, the patient requested bilateral below-the-knee amputations (BKAs) of his lower extremities. An orthopedic surgeon was consulted, and it was determined that amputation was not indicated, so the patient agreed to undergo bilateral incision and drainage of his lower extremities.

Additional history was obtained from the patient's spouse, and she revealed that the patient's distal phalanges of the feet were missing because he had performed self-amputation with a tourniquet in 1999. The patient's spouse further confessed that the patient had had a past "fascination with amputations," and she had previously discovered him placing tourniquets around his lower extremities at various times. It was concluded that his bilateral neuropathy and cellulitis of the lower extremities were due to self-induced ischemia with tourniquets. The patient was diagnosed with apotemnophilia and transferred to the psychiatric service for further evaluation and treatment.

The patient's medical history was remarkable for previous injuries to the lower extremities. He had a foreign body needle fragment removed from his right knee in 1992 and had sustained a fracture of the third left toe after shooting himself with a pellet gun. In 1995, he had presented to a children's hospital with right lower-extremity cellulitis and compartment syndrome. He had undergone surgical fasciotomy/exploration that revealed no necrosis or evidence of significant infection of the extremity at that time. The patient's medical charts also revealed that his biologic father had paranoid schizophrenia and had committed suicide 2 years earlier.

The patient's stay in the psychiatric ward was brief, consisting of 2 weeks of daily psychotherapy, rehabilitation therapy, and physical therapy. During discussions with the inpatient psychiatric team, he described himself as a world-class athlete and artist and stated that he was extremely intelligent. At the time of his discharge from the psychiatric ward, the patient maintained his desire to undergo bilateral BKAs in the future, stating, "It is likely that my infections will come back." His final wound cultures from incision and drainage grew 3+ -hemolytic Streptococcus (not A, B, C, F, or G species), 3+ Gram-positive cocci consistent with oral anaerobes, 3+ mixed skin flora, and 2+ yeast. By the end of the patient's hospitalization, he was walking slowly without discomfort. He was discharged on no medications and instructed to follow up for outpatient counseling.