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Factitious Hypoglycemia


Presentation

  • The patient presented with symptoms of hypoglycemia, consistently low fasting plasma glucose values and a reversal of symptoms with glucose administration.[ncbi.nlm.nih.gov]
  • Average age was 13.5   2.0 years with the youngest patient presenting at the age 9.5 years. Blood glucose control was poor (hemoglobin A1c: 12.1   4.0%). In 35%, psychiatric disorders were mentioned as contributing factors.[ncbi.nlm.nih.gov]
  • Factitious hypoglycemia is similar in presentation to insulinoma and occurs most commonly in persons with ready access to insulin.[scholars.opb.msu.edu]
Splenomegaly
  • Computed tomography (CT) of the abdomen and pelvis, which was performed without contrast due to renal failure, showed a non-specific nodular lesion some millimeters in size in the pancreatic tail, homogeneous splenomegaly, and lytic lesion at the T11[elsevier.es]
Fatigue
  • A 36-year-old woman without significant medical history complained of "spells" of diplopia, fatigue, and dizziness.[ncbi.nlm.nih.gov]
  • The patient was recently dismissed from his job at a major retail chain because of frequent absences related to weakness and fatigue. The patient underwent a second supervised fast.[academic.oup.com]
  • Hypoglycemia is characterized by blood sugar less than 70mg/dL.[1] Hypoglycemia is associated with neuroglycopenic symptoms, such as impaired mentation, irritability, fatigue, visual changes, slurred speech, and motor deficits.[2] Post-gastric bypass[bariatrictimes.com]
  • .  They include behavioral changes, confusion, fatigue, loss of consciousness, cognitive impairment, somnolence, dizziness, slurred speech .  If these signs and symptoms are not recognized and treated and the plasma glucose level continues to decrease[slideshare.net]
  • […] thinking, impaired judgment Nonspecific dysphoria, moodiness, depression, crying, exaggerated concerns Feeling of numbness, pins and needles (paresthesia) Negativism, irritability, belligerence, combativeness, rage Personality change, emotional lability Fatigue[en.wikipedia.org]
Pallor
  • Hypoglycemia causes adrenergic symptoms such as tachycardia, palpitations, tremor, sweating, pallor and anxiety, and non-adrenergic or neuroglycopenic symptoms including hunger, headache, weakness, visual disturbances, confusion, lethargy, seizures, and[elsevier.es]
  • Signs and Symptoms of Hypoglycemia in Infants and Children Adrenergic Neuroglycopenic Other Infants: Tachycardia Poor feeding Hypothermia Tachypnea Lethargy Pallor Irritability Cyanosis Hypotonia Jitteriness Seizure Coma Apnea Children: Nausea Visual[ahcmedia.com]
  • Signs of hypoglycemia • Common signs of hypoglycemia include : 1. diaphoresis and pallor. 2.[slideshare.net]
  • Shakiness, anxiety, nervousness Palpitations, tachycardia Sweating, feeling of warmth (sympathetic muscarinic rather than adrenergic) Pallor, coldness, clamminess Dilated pupils (mydriasis) Hunger, borborygmus Nausea, vomiting, abdominal discomfort Headache[en.wikipedia.org]
Hypothermia
  • It may also present with transient hemiplegia, hypothermia or hyperthermia, convulsions, diplopia and strabismus [ 9 ]. If untreated, it can progress to stupor, coma and, exceptionally, death.[patient.info]
  • Signs and Symptoms of Hypoglycemia in Infants and Children Adrenergic Neuroglycopenic Other Infants: Tachycardia Poor feeding Hypothermia Tachypnea Lethargy Pallor Irritability Cyanosis Hypotonia Jitteriness Seizure Coma Apnea Children: Nausea Visual[ahcmedia.com]
  • In newborns, hypoglycemia can produce irritability, jitters, myoclonic jerks, cyanosis, respiratory distress, apneic episodes, sweating, hypothermia, somnolence, hypotonia, refusal to feed, and seizures or "spells."[en.wikipedia.org]
Diplopia
  • A 36-year-old woman without significant medical history complained of "spells" of diplopia, fatigue, and dizziness.[ncbi.nlm.nih.gov]
  • It may also present with transient hemiplegia, hypothermia or hyperthermia, convulsions, diplopia and strabismus [ 9 ]. If untreated, it can progress to stupor, coma and, exceptionally, death.[patient.info]
  • SIGNS-SYMPTOMS-Physical-Exam 1) General : confusion, lethargy 2) HEENT: diplopia 3) CVS : tachycardia 4) Neurologic: tremulousness, weakness, paresthesias, stupor, seizure, or coma 5) Mental status: irritability, inability to concentrate, or short-term[slideshare.net]
Suicidal Depression
  • Factitious hypoglycemia is associated with a higher incidence of suicide, depression, and personality disorders. Insulin-induced hypoglycemia can be detected by an insulin to C-peptide ratio that is greater than 1.0.[ncbi.nlm.nih.gov]
Confusion
  • Hypoglycemia causes adrenergic symptoms such as tachycardia, palpitations, tremor, sweating, pallor and anxiety, and non-adrenergic or neuroglycopenic symptoms including hunger, headache, weakness, visual disturbances, confusion, lethargy, seizures, and[elsevier.es]
  • Common presenting symptoms include nausea, confusion, tremor, sweating, palpitations, or hunger. Patients may present with a nonspecific clinical history.[us.bestpractice.bmj.com]
  • They can also be neuroglycopenic along a wide range which includes: confusion, visual disturbances, behavioral changes, seizures or epileptic like movements, confusion or frank coma. [4] Due to the non-specific nature and presentation of signs and symptoms[diapedia.org]
  • Slurring of speech, confusion, change of behaviour, truculence. Stupor, coma. Subacute hypoglycaemia Also known as hypoglycaemia unawareness.[patient.info]
  • This means that some assays will show high insulin concentrations, whereas others may show undetectable levels, which would lead to the results and confusion described above.[aacc.org]
Seizure
  • A few months before her admission at the endocrinology department, she started to have recurrent episodes of severe hypoglycemia resulting in several seizures, and was once in a state of deep coma which lasted about 48 hours.[ijsronline.net]
  • Hypoglycemia causes adrenergic symptoms such as tachycardia, palpitations, tremor, sweating, pallor and anxiety, and non-adrenergic or neuroglycopenic symptoms including hunger, headache, weakness, visual disturbances, confusion, lethargy, seizures, and[elsevier.es]
  • The advised family practitioner observed a generalized seizure. Intravenous application of diazepam terminated the seizure, but the patient remained unconscious.[journal.diabetes.org]
  • On the following night, he developed seizures and returned to the local ER where his plasma glucose was measured at 1 mmol/L (18 mg/dL). The patient denied drinking alcohol recently and admitted drinking only at holiday celebrations.[academic.oup.com]
  • It may take longer to recover from severe hypoglycemia with unconsciousness or seizure even after restoration of normal blood glucose.[en.wikipedia.org]
Dizziness
  • A 36-year-old woman without significant medical history complained of "spells" of diplopia, fatigue, and dizziness.[ncbi.nlm.nih.gov]
  • The 29-year-old man experienced diaphoresis with tremor, chest pain, dizziness, and shortness of breath in the early morning, four days before his admission.[aafp.org]
  • You want to avoid being abruptly awoken in the middle of night because it can increase your risk of injury, due to dizziness, lightheadedness, etc. – especially if you sleep alone.[belmarrahealth.com]
  • Early symptoms include: Confusion Dizziness Feeling shaky Hunger Headaches Irritability Pounding heart ; racing pulse Pale skin Sweating Trembling Weakness Anxiety Without treatment, you might get more severe symptoms, including: Poor coordination Poor[webmd.com]
  • A 63-year-old man with type 2 diabetes mellitus diagnosed in 1989 was admitted to our ward due to a 10-month history of recurrent episodes of dizziness. His diabetes had been treated with 10 mg glyburide since 1994.[journal.diabetes.org]
Headache
  • Hypoglycemia causes adrenergic symptoms such as tachycardia, palpitations, tremor, sweating, pallor and anxiety, and non-adrenergic or neuroglycopenic symptoms including hunger, headache, weakness, visual disturbances, confusion, lethargy, seizures, and[elsevier.es]
  • Effects of low blood sugar on the body include: Changes in heartbeat Mood changes Dizziness Headache Sleep disturbance Clumsiness Hunger Foggy thinking One-third of diabetics fail to report to doctors about nighttime hypoglycemia New research suggests[belmarrahealth.com]
  • Early symptoms include: Confusion Dizziness Feeling shaky Hunger Headaches Irritability Pounding heart ; racing pulse Pale skin Sweating Trembling Weakness Anxiety Without treatment, you might get more severe symptoms, including: Poor coordination Poor[webmd.com]
  • Headache (occasionally), double vision, difficulty in concentrating. Slurring of speech, confusion, change of behaviour, truculence. Stupor, coma. Subacute hypoglycaemia Also known as hypoglycaemia unawareness.[patient.info]
  • Insufficient glucose supply to the brain causes headache, blurred or double vision, confusion, difficulty speaking, seizures, and coma.[msdmanuals.com]
Stupor
  • Stupor, coma. Subacute hypoglycaemia Also known as hypoglycaemia unawareness.[patient.info]
  • SIGNS-SYMPTOMS-Physical-Exam 1) General : confusion, lethargy 2) HEENT: diplopia 3) CVS : tachycardia 4) Neurologic: tremulousness, weakness, paresthesias, stupor, seizure, or coma 5) Mental status: irritability, inability to concentrate, or short-term[slideshare.net]
  • […] vision Flashes of light in the field of vision Automatic behavior, also known as automatism Difficulty speaking, slurred speech Ataxia, incoordination, sometimes mistaken for drunkenness Focal or general motor deficit, paralysis, hemiparesis Headache Stupor[en.wikipedia.org]

Workup

  • An isolated plasma sulfonylurea screen done during the fast was positive for tolbutamide, suggesting the diagnosis of factitious hypoglycemia, but further workup revealed multiple pancreatic masses resulting in an eventual diagnosis of multiple insulinomas[ncbi.nlm.nih.gov]
  • Useful For Suggests clinical disorders or settings where the test may be helpful Diagnostic workup of hypoglycemia: -Diagnosis of factitious hypoglycemia due to surreptitious administration of insulin -Evaluation of possible insulinoma -Surrogate measure[mayomedicallaboratories.com]
  • The typical workup for hypoglycemia includes plasma glucose level and insulin, but the patient’s lab results for insulin are normal.[aacc.org]
  • Serologic workup demonstrated no evidence of factitious hypoglycemia and it discarded the diagnosis of islet cell-induced hypoglycemia.[bmccancer.biomedcentral.com]
  • . • Some patients have symptoms but normal blood glucoses; they need no further workup, in spite of their insistence. 20.[slideshare.net]
Glucose Decreased
  • The fast is terminated at 72 h if the patient has experienced no symptoms and glucose remains normal, sooner if glucose decreases to 45 mg/dL ( 2.5 mmol/L) in the presence of hypoglycemic symptoms.[msdmanuals.com]

Treatment

  • Spontaneous symptomatic hypoglycemia, in the absence of glucose-lowering treatment, is rare and requires evaluation to prevent harm.[ncbi.nlm.nih.gov]
  • Transplantation 765 65 Treatment of Diabetes in the Hospitalized Patient 1103 66 The Diabetic Foot Strategies for Treatment 1111 BIOLOGY OF THE COMPLICATIONS OF DIABETES 793 67 Vascular Disease of the Lower Extremities 1123 Cameron M Akbari and Frank[books.google.com]
  • Treatment is primarily psychiatric, and success so far is limited.[scholars.opb.msu.edu]
  • Make the best clinical decisions with an enhanced emphasis on evidence-based practice and expert opinions on treatment strategies. Zero in on the most relevant and useful references with the aid of a more focused, concise bibliography.[books.google.com]

Prognosis

  • The role of psychiatric therapy in relation to overall management and prognosis is stressed.[ncbi.nlm.nih.gov]
  • The generally poor prognosis for patients with factitious hypoglycemia underscores the importance of early recognition of factitious disorders.[ncbi.nlm.nih.gov]
  • In diabetics, difficulty is increased and long-term prognosis becomes unpredictable.[endocrine-abstracts.org]
  • […] especially in persons who are in the medical profession, persons in close contact with diabetic patients, and patients who are diabetic. 2, 3 Although the clinical manifestations simulate insulinoma or autoimmune hypoglycemia, it carries a poor long-term prognosis[aafp.org]
  • Surreptitious administration of insulin is a serious psychiatric disturbance with a poor prognosis ( 1 ).[academic.oup.com]

Etiology

  • One patient underwent an exploratory laparotomy with subtotal pancreatectomy before the etiology of the hypoglycemia was discovered. Inboth patients, the diagnosis was made by detecting sulfonylurea agents in blood.[ncbi.nlm.nih.gov]
  • After excluding an endogenous etiology, a factitious hypoglycemia was quicky suspected by clinicians. However, several venous samples showed normal insulinemia and a moderately decreased C-peptide.[ncbi.nlm.nih.gov]
  • Use Additional Use Additional Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • Those that are not operable, malignant or aggressive in etiology may respond to a combination of treatment modalities.[diapedia.org]
  • Persistent hyperinsulinemic hypoglycemia of infancy Self-induced hyperinsulinemia Transitory neonatal hypoglycemia Tumor-induced hypoglycemia Clinical Information Syndrome with excessively high insulin levels in the blood; it may cause hypoglycemia; etiology[icd9data.com]

Epidemiology

  • Insulinoma Epidemiology Between 1927 and 1986, 224 hypoglycemic patients underwent their first pancreatic exploration at the Mayo Clinic and were found to have insulinoma.[what-when-how.com]
  • Epidemiology Hypoglycaemia is uncommon in people without diabetes [ 2 ]. Aetiology [ 2, 4 ] Alcohol is the most common non-iatrogenic (non-physician) cause of hypoglycaemia in adults.[patient.info]
  • Insulin autoimmune syndrome (Hirata Disease) : Epidemiology in Asia including Japan. Diabetol Int 2010; 1: 21-25. [3] Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P. Autoimmune forms of hypoglycaemia.[article.sapub.org]
  • View Article PubMed Google Scholar Tran T, Davila JA, El-Serag HB: The epidemiology of malignant gastrointestinal stromal tumors: an analysis of 1,458 cases from 1992 to 2000.[bmccancer.biomedcentral.com]
  • Epidemiology Hypoglycemia is common in type 1 diabetes, especially in patients receiving intensive therapy, in whom the risk of severe hypoglycemia is increased more than threefold.[slideshare.net]
Sex distribution
Age distribution

Pathophysiology

  • The main pathophysiological characteristic of endogenous hyperinsulinism is lack of suppression of insulin secretion during hypoglycemia.[elsevier.es]
  • Pathophysiology C-peptide is connecting peptide for beta and alpha chain of proinsulin. C-peptide is formed during the conversion of proinsulin to Insulin. Proinsulin is cleaved into Insulin C-peptide (inactive biologically).[labpedia.net]
  • Children with hypoglycemia pose a diagnostic challenge because hypoglycemia is an uncommon pediatric condition and its presenting signs and symptoms may be either nonspecific or suggestive of a pathophysiology other than hypoglycemia.[ahcmedia.com]
  • […] insulin secretory reserve -Monitoring pancreatic and islet cell transplant function -Monitoring immunomodulatory therapy aimed at slowing progression of preclinical, or very early stage type 1 diabetes mellitus Clinical Information Discusses physiology, pathophysiology[mayomedicallaboratories.com]
  • Although originally believed to be a late manifestation of the dumping syndrome, post-gastric bypass hypoglycemia is likely a separate condition with a distinct pathophysiology.[bariatrictimes.com]

Prevention

  • Spontaneous symptomatic hypoglycemia, in the absence of glucose-lowering treatment, is rare and requires evaluation to prevent harm.[ncbi.nlm.nih.gov]
  • New chapters cover stem cell therapy for type 1 diabetes; genetics and treatment of obesity; new therapies to promote insulin action; vasculopathy; islet cell protocols; triglycerides in muscle; hypoglycemia in the adult; and the Diabetes Prevention Program[books.google.com]
  • It is advisable to be aware of and to suspect this phenomenon so as to prevent false diagnoses and unnecessary tests. References [1] J.B. Field. Hypoglycemia: definition, clinical presentations, classification, and laboratory tests.[elsevier.es]
  • […] hypoglycemia at night To avoid complications related to nighttime hypoglycemia, try these tips to prevent it from occurring.[belmarrahealth.com]
  • Continued Preventing Hypoglycemia If you have diabetes, ways you can prevent hypoglycemia include: Follow your meal plan. Eat at least three evenly spaced meals each day with between-meal snacks as prescribed.[webmd.com]

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