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Endocrine Abstracts (2014) 35 P325 | DOI: 10.1530/endoabs.35.P325


1Department of Endocrinology, Diabetes and Metabolism Department of Centro Hospitalar e Universitário de Coimbra, HUC-CHUC, EPE, Coimbra, Portugal; 2Department of Endocrinology, Diabetes and Nutrition of Centro Hospitalar Baixo Vouga, EPE, Aveiro, Portugal.

Introduction: Factitious hypoglycemia results from surreptitious administration of insulin or insulin secretagogues. It can involve non-diabetic individuals with knowledge of hypoglycemiant drugs, or diabetics manipulating the doses.

Clinical case: A 42-year-old women, type 1 diabetic since the age of 14, on intensive insulin therapy (A1C: 8.5%), was hospitalized for study of recurrent severe hypoglycemia in the last 2 months, despite successive insulin doses reductions. History of depression already treated. Clinical examination: conscious and orientated, refusing inter-personal communication; BP: 144/78 mmHg, HR: 96 bpm, BMI 31.1 kg/m2. Six hours after admission presented severe hypoglycemia (<40 mg/dl), erratic, recurrent, and difficult to revert, needing hypertonic dextrose perfusion (30 and 50%) through central venous catheter for >48 h. Several continuous glucose monitoring(CGM) were performed: first with CGMS (marked discrepancies between interstitial and capillary glucose registered); posteriorly with Guardian RT, that revealed lack of sensor registry in nocturnal periods, coincident with abrupt glucose reductions. Complementary evaluations (during hypoglycemia): sulfonylureas (chlorpropamide, glybenclamide, and tolbutamide): <0.1 μg/ml; insulin: >300 mUI/ml, C-peptide: <0.1 ng/ml, proinsulin: <0.1 pmol/l, β-hydroxybutyrate: 0.17 mmol/l, anti-insulin antibodies: 16.15 UI/ml (<0.4). A prolonged fasting test was performed, without any spontaneous hypoglycemia. It was noticed that severe hypoglycemia was preceded by family visits, absences from the infirmary or after visits to the bathroom. After patient confrontation with laboratorial data and psychiatric therapeutic adjustment, the ambulatory insulin scheme was resumed. She was discharged 2 weeks later, much more communicative, and stabilized clinical situation. The patient was reevaluated, 1 month later, and didn’t report any severe hypoglycemia.

Conclusion: The provided patient information didn’t match with laboratory results, pointing to a factitious disease; CGM records were also discrepant. The triad composed by hypoglycemia, inappropriate high insulin, and low C-peptide, suggested factitious hypoglycemia. The confirmation of this diagnosis requires an exhaustive evaluation and often hospitalization. In diabetics, difficulty is increased and long-term prognosis becomes unpredictable.

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