A 56 year old man presented with a 10 day history of fevers, cough, sore throat, and loose stools. Two days after onset he developed an acute polyarthritis affecting the right wrist, left thumb, both feet, and the right ankle. This was followed by a rash over elbows, fingers, and feet. He had no rheumatological history, drank little alcohol and apart from antihypertensive treatment with atenolol and nifedipine, was fit and well.On admission he was apyrexial with normal cardiorespiratory and abdominal examination. A maculopapular, nonblanching rash with pustules and necrosis was evident over the extensor surfaces of both elbows and left calf. In the web space of the index and middle finger of the right hand was a small crusted, healing lesion. Acute, erythematous synovitis affected his right elbow, wrist, and shoulder, left thumb metacarpophalangeal (MCP) joint, both mid-tarsal joints, and right ankle.Laboratory investigations showed his haemoglobin was 112 g/l, white cell count 12.6×10 9 /l, neutrophils 11.4×10 9 /l, urea 17.7 mmol/l, and creatinine 169 µmol/l. The erythrocyte sedimentation rate was 79 mm/1st h and C reactive protein 225 mg/l. Chest radiograph, urine dipstick, blood cultures, abdominal ultrasound, and echocardiogram were normal. In view of his systemic symptoms, polyarthritis and rash, a provisional diagnosis of reactive arthritis or vasculitis was made. A test for autoantibodies, including antineutrophil cytoplasmic antibodies, was requested and subsequently proved negative.With rehydration and analgesia the patient felt better and his renal function returned to normal. Eighteen hours after admission his right hand rapidly developed critical ischaemia from the mid-palm distally. Pulses were present and arterial Doppler results normal. Atenolol was stopped and intravenous methylprednisolone and cyclophosphamide were given for presumed medium vessel vasculitis. The ischaemia resolved. After 24 hours, the hand again became painfully ischaemic and further intravenous methylprednisolone was given, again with improvement.

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Self-induced disease can be difficult to diagnose and costly of time and money to investigate. The key is to think of the possibility. Five patients in whom the evidence for factitious rheumatological illness was strong are discussed and their histories, physical signs and family backgrounds are explored in relationship to factitious disease presenting in other fields. Young immature individuals seem most at risk and the discrepancy between physical signs and understandable pathological mechanisms may suggest the diagnosis. The outlook seems frequently poor.

Hyperlipidaemia advances and retreats Dr A LEWIS (London WlN 1FJ) writes: How long will it be before the hazards of eating dairy foods (23 August, p 564) are remembered with amusement like those of eating meat. This dangerous stuff (especially red meat) "caused" kidney disease, hypertension, rheumatism, and gout because it was a source of uric acid and urea, with which these conditions were thought to be associated.

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