Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 11

11 - FACTITIOUS HYPOGLYCEMIA: DIAGNOSTIC HURDLES IN PATIENTS WITHOUT PREVIOUS MENTAL HEALTH DISORDERS OR HISTORY OF KNOWN INSULIN MISUSE

Friday, Apr 26
12:00 PM – 12:30 PM

Objective :

A case of Factitious Hypoglycemia.


Methods : Clinical and laboratory data.


Results : A 69 year old female with a history of T2DM presented from an outside hospital (OSH) after many episodes of symptomatic hypoglycemia. She was diagnosed at the OSH with adrenal insufficiency of unclear etiology and transferred to our hospital after starting hydrocortisone 20 mg po bid. While hospitalized for two weeks, she continued to have multiple episodes of hypoglycemia (serum glucoses to 38, 42 and 46 mg/dL), despite receiving IV D50, IV 10% Dextrose and glucagon. Lab work included: simultaneous serum glucose 42 mg/dL, insulin 53.7 mU/mL (nl: <24.6), proinsulin 3.6 pmol/L (nl: <8.0), C-peptide 4.05 ng/mL (nl: 0.78-5.19), and beta-hydroxybutyrate <0.2 (nl: <0.3 mmol/L). Serum sulfonylurea screen was negative. A1C was 6.3%. The patient stated that the last time she used insulin was three months previously when her insulin was stopped, due to good DM control. Based on her denial of exogenous insulin use, our team continued to explore other causes for hypoglycemia, and concern was high for an insulinoma. The patient had a bladder stimulator that prevented her from having a MRI. She had a CAT scan of the abdomen that showed intraductal papillary mucinous neoplasm (IPMN). EUS showed IPMN as well.  An Octreotide scan was negative. Plans were for arterial calcium stimulation. However, a nurse found vials of Novolin Regular insulin with many used syringes in a cosmetic bag being sent home with patient’s husband. When patient retrieved the bag, the nurse became suspicious, looked inside the bag and found vials of insulin and syringes. After removing the insulin from the patient’s room, the patient had no further hypoglycemia. Psychiatry evaluated the patient, who diagnosed her with a presumed dissociative disorder. She was diagnosed with factitious hypoglycemia and discharged to home.


Discussion : Factitious hypoglycemia presentation may be difficult to differentiate from insulinoma by history only. The finding of an elevated serum insulin level while having a low c-peptide level is supportive of factitious hypoglycemia. Nonetheless, insulinoma should always be considered until a firm diagnosis is established. It is challenging to diagnose factitious hypoglycemia in a patient without previous mental health disorders or history of known insulin misuse. Psychiatry involvement is critical to making the diagnosis.


Conclusion :

There are many hurdles in diagnosing factitious hypoglycemia without physical evidence of insulin use. This could be overcome by laboratory evaluation, the involvement of Psychiatry, and by monitoring the patient and their belongings more closely.

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Faisal Aljehani

Fellow
Division of Endocrinology, Diabetes & Medical Genetics, Medical University of South Carolina, Charleston-SC, and Jeddah University, Saudi Arabia.
Mount Pleasant, South Carolina

Faisal Aljehani has completed his medical school degree and received His M.B.B.S from King Abdul Aziz University Faculty of Medicine in Saudi Arabia. He is a board-certified internist who did his residency training in University of Utah, Salt Lake City. Now, he is a fellow in the division of Endocrinology, Diabetes & Medical Genetics at the Medical University of South Carolina (MUSC) in Charleston, South Carolina since July 2018.

Kathie Hermayer

Professor
Division of Endocrinology, Diabetes & Medical Genetics, Medical University of South Carolina and Ralph H. Johnson VA Hospital.

Kathie L. Hermayer, M.D., MS, is an associate professor of medicine and endocrinology in the Division of Endocrinology, Diabetes, and Medical Genetics at the Medical University of South Carolina (MUSC), Charleston, South Carolina. She is also the director for the diabetes management service and medical director of hospital diabetes services at MUSC.
Dr. Hermayer completed a master’s degree in biochemical nutrition at the University of Connecticut, Storrs, Connecticut. After receiving her medical degree from Albany Medical College, Albany, New York, she served an internship, a residency, and a fellowship, all at MUSC. She served a two­year national public health scholarship in primary care medicine in St. George, South Carolina from 1984 to 1986. She has been on faculty at MUSC since the completion of her endocrine fellowship in 1992.
Dr. Hermayer has received grants for research on the treatment of diabetes, bone diseases and other endocrine diseases. She has written numerous articles, chapters and abstracts relating to diabetes, thyroid and other endocrine disorders.

Faisal Aljehani

Fellow
Division of Endocrinology, Diabetes & Medical Genetics, Medical University of South Carolina, Charleston-SC, and Jeddah University, Saudi Arabia.
Mount Pleasant, South Carolina

Faisal Aljehani has completed his medical school degree and received His M.B.B.S from King Abdul Aziz University Faculty of Medicine in Saudi Arabia. He is a board-certified internist who did his residency training in University of Utah, Salt Lake City. Now, he is a fellow in the division of Endocrinology, Diabetes & Medical Genetics at the Medical University of South Carolina (MUSC) in Charleston, South Carolina since July 2018.