ESPE Abstracts (2015) 84 P-3-686

Diabetes

A Rare Reason of Hyperinsulinism: Münchausen Syndrome by Proxy

Ediz Yesilkaya, Onur Akin, Erkan Sari, Enes Macit, Cagdas Akar & Husamettin Gun

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Gulhane Military Medical Academy, Ankara, Turkey


Background: Drug intoxication is one of the rare reasons of hyperinsulinism; it may occur not only accidentally but also deliberately.

Objective and hypotheses: Herein, we report a case who presented with factitious hyperinsulinaemic hypoglycemia and diagnosed with Münchausen syndrome by proxy (MSBP) which is an uncommon condition of child abuse.

Method: A 7-year-old girl was referred to our department due to hyperglycemic and hypoglycemic episodes. Her father has been treated with metformin and several sulphonilureas for more than 10 years. Blood glucose monitoring showed hyperglycaemia reaching 300 mg/dl and no hypoglycaemia. We didn’t detect any other clinical or laboratory findings so that gliclazide (1 mg/kg per day) was initiated and increased to 2 mg/kg per day because of persisting hyperglycemia. However, episodes of hypoglycemia occurred during the patient follow up, thus gliclazide treatment was stopped. Few weeks later she was admitted to the emergency room with hypoglycemic seizure. Plasma levels of insulin (156 mIU/ml) and C peptide (6 ng/dl) were discordant with the concurrent blood glucose level (33 mg/dl) and urinary ketones were negative, suggesting endogenous hyperinsulinism. Diazoxide and dextrose (10%) was administered and hypoglycemia was prevented. Computed tomography and MRI of the abdomen was normal. In spite of diazoxide therapy, hypoglycemia was detected, so octreotide therapy was initiated and dose was increased to 35 μg/kg per day gradually due to resistant hypoglycemia. However, the mood of the patient’s mother was discordant with the situation. Blood and urine samples were sent to toxicology laboratory in order to investigate hypoglicemic agents. Toxic levels of gliclazide were detected.

Results: Patient was immediately isolated. Glucose infusion was decreased gradually. Finally on the 4th day of isolation, gliclazide was not detected in urine and blood samples. The patient was diagnosed as MSBP.

Conclusion: MSBP is an unusual and difficult to identify cause of child abuse. It should be considered in the differential diagnosis of hyperinsulinism particularly in cases without apparent origin.

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