Factitious Disorder: A Paradox Case with Recurrent Symptomatic Hypoglycemia

The patient was hospitalized and started on a Dextrose intravenous infusion. She underwent primary adrenal insufficiency testing with a normal co-syntropin stimulation test. She had normal glucose levels throughout her hospitalization. She was discharged home with instruction to discontinue use of oral hypoglycemic medications. A week after discharge the patient was found unresponsive and was brought to the emergency department for further evaluation. En route to the hospital, the patient was noted to have a blood glucose in the 20s. In the emergency department her blood glucose was 44. She was again admitted and started on a dextrose intravenous infusion. Despite continuous dextrose administration she was noted to have recurrent hypoglycemic episodes. Insulin, proinsulin, c-peptide, sulfonylurea, and meglitinide blood tests were collected. Insulin and c-peptide levels resulted as 116.6 mIU/mL and 9.24 ng/mL, respectively which suggested either insulinoma or insulin secretagogue induced hypoglycemia. She underwent abdominal computerized technology which showed no evidence of a pancreatic mass to suggest insulinoma. The patient requested to be discharged prior to the results of the additional laboratory tests. She was discharged and again advised to avoid using her home diabetes medications which she agreed to. After discharge, sulfonylurea level resulted at 1700 Introduction