A clinical case of factitious hypoglycemia in a patient with type 1 diabetes mellitus

Artificial hypoglycemia (Munchausen syndrome) is a condition caused by low blood glucose due to the deliberate taking of insulin or oral hypoglycemic drugs. Artificial hypoglycemia remains one of the problems that endocrinologists face in their practice; a diagnostic search for its etiological factor can lead to expensive and unnecessary studies. Diagnosis of artificial hypoglycemia in patients with diabetes mellitus on insulin therapy seems to be a labor-intensive task, since unlike most factitious disorders, which may be indicated by atypical manifestations of the disease or conflicting medical information about the patient, in patients with diabetes mellitus hypoglycemic syndrome is an expected unwanted event due to insulin therapy. Therefore, deliberate insulin administration is often not diagnosed until self-induced hypoglycemia becomes recurrent and/or severe. If artificial hypoglycemia is suspected, a number of authors currently recommend testing С peptide and a combination of two methods for quantitative determination of insulin in the blood using different analyzer systems. Active collaboration between clinical and laboratory specialists is the key to successfully solving such a diagnostic problem.

This article presents a clinical case of Munchausen syndrome in a 28-year-old patient with type 1 diabetes mellitus with recurrent hypoglycemia during 21 years, repeated severe hypoglycemia, including loss of consciousness, and proven intentional administration of an insulin analog drug during hospital stay; the complex diagnostic path passed before making the correct diagnosis is described.

1. Bauman V, Sturkey AC, Sherafat-Kazemzadeh R, et al. Factitious hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2018;19(4):823-831. doi:10.1111/pedi.12650

2. Kittah NE, Vella A. MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia. Eur J Endocrinol. 2017;177(1):R37-R47. doi:10.1530/EJE-16-1062

3. Kyriacou H, Duggleby W, Hatoum A, Khan T, Manley G, Filippidou M. Factitious Hypoglycaemia: A Case Report and Literature Review. Psychiatr Danub. 2020;32(Suppl 1):121-129.

4. Yukina M, Nuralieva N, Zelenkova-Zakharchuk T, Troshina E, Melnichenko G. Factitious hypoglycemia: psychosocial characteristics of patients. Endocrine Abstracts. 2023;90:EP1119. DOI: 10.1530/endoabs.90.EP1119

5. Leung KC, Doyle N, Ballesteros M, et al. Insulin Regulation of Human Hepatic Growth Hormone Receptors: Divergent Effects on Biosynthesis and Surface Translocation1. J Clin Endocrinol Metab.

6. ;85(12):4712-4720. doi: https://doi.org/10.1210/jcem.85.12.7017;

7. Kamenický P, Mazziotti G, Lombès M, et al. Growth hormone, insulin-like growth factor-1, and the kidney: Pathophysiological and clinical implications. Endocr Rev. 2014;35(2):234-281. doi: https://doi.org/10.1210/er.2013-1071

8. Galvez T, Lotierzo M, Conquet G, et al. Factitious hypoglycemia in insulin-treated diabetic patients. Ann Endocrinol (Paris). 2023;84(3):364-366. doi:10.1016/j.ando.2023.03.015

9. Lotierzo M, Galvez T, Conquet G, et al. Accurate selection of insulin immunoassay to discern factitious hypoglycemia: a case report. Acta Diabetol. 2023;60(2):315-317. doi:10.1007/s00592-022-01995-9

10. Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in the professional literature. Gen Hosp Psychiatry. 2016;41:20-28. doi:10.1016/j.genhosppsych.2016.05.002

11. Nalbantoğlu Elmas Ö, Demir K, Soylu N, Çelik N, Özkan B. Importance of insulin immunoassays in the diagnosis of factitious hypoglycemia. J Clin Res Pediatr Endocrinol. 2014;6(4):258-261. doi:10.4274/Jcrpe.1492

12. Pa Parfitt C, Church D, Armston A, et al. Commercial insulin immunoassays fail to detect commonly prescribed insulin analogues. Clin Biochem. 2015;48(18):1354-1357. doi:10.1016/j.clinbiochem.2015.07.017

13. Awad DH, Gokarakonda SB, Ilahi M. Factitious Hypoglycemia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 4, 2023.

14. Grunberger G, Weiner JL, Silverman R, Taylor S, Gorden P. Factitious hypoglycemia due to surreptitious administration of insulin. Diagnosis, treatment, and long-term follow-up. Ann Intern Med. 1988;108(2):252-257. doi:10.7326/0003-4819-108-2-252

15. Yukina MYu, Nuralieva NF, Troshina EA, Malysheva NM, Nikankina LV. Difficulties in diagnosing of artificial hypoglycemia: Insulin analogues. Endocrine Abstracts. 2020;70:AEP272. DOI: 10.1530/endoabs.70.AEP272;

16. Yukina M, Katsobashvili I, Platonova N, Troshina E, Mel'nichenko G. Munchausen syndrome with factitious hypoglycemia due to deliberate insulin analog administration and factitious hyperglycemia in a patient with hypothyroidism. Clin Diabetes Endocrinol. 2022. – Т.8. - №1:8. doi: 10.1186/s40842-022-00145-y;

17. Yukina M, Avsievich E, Sakkaeva A, Usoltseva L, Ioutsi V, Troshina E. HPLC-MS/MS in the diagnosis of factitious hypoglycemia: A case report // Endocrine Abstracts. – 2023. –№90. – EP284