Prime-Time Hypoglycemia: Factitious Hypoglycemia During Insulin-Pump Therapy

Abstract

Unexplained hypoglycemia in a pediatric diabetic patient can perplex even the savviest health care providers and lead to an extensive medical workup. We present here the cases of 2 children with type 1 diabetes mellitus treated with insulin pumps who were hospitalized for episodes of hypoglycemia. Review of their insulin pumps revealed normal basal and bolus insulin delivery. However, subsequent review of the priming history in the pump revealed that both children were receiving additional insulin under the manual-prime function, which is not included in the daily totals and, therefore, was initially unnoticed. Ultimately, both children confessed to surreptitiously using this priming function to self-administer extra insulin. It is important that health care professionals who are caring for diabetic patients be aware of this possibility.

Factitious hypoglycemia in children and adolescents with diabetes

“…Many inventive strategies have been described for surreptitious insulin administration. Our patient is not the first to have used the priming function of her insulin pump . Only through careful review of the “priming” or “cannula fill” history was this technique discovered, while the review of daily insulin dosing does not include the amount used for priming.…”

“…She had first learned about self‐induced hypoglycemia when attending a summer camp for children with type 1 diabetes (similar to reports in References and ) at the age of 8 years. The diagnosis was delayed because of misleading laboratory results (no or low plasma insulin concentrations due to the use of a highly specific insulin assay which did not cross‐react with insulin analogs, also described in References and due to only reviewing the insulin pump's memory of total daily insulin doses, and not downloading the insulin pump's “priming history” (see References and ). Our interventions consisted primarily in consolidation of care and individual psychotherapy.…”

“…Our patient is not the first to have used the priming function of her insulin pump. 30,32 Only through careful review of the "priming" or "cannula fill" history was this technique discovered, while the review of daily insulin dosing does not include the amount used for priming. Finally, we highlight a lack of knowledge on effective treatments and long-term outcome.…”

A 39-Year-Old Man with Polymicrobial Bacteremia

“…Relatively few cases have been published of factitious disorder in patients with an underlying medical disorder, and most detail exaggeration of the underlying disorder, most commonly factitious hypoglycemia in patients with diabetes. [9][10][11] Recently, the Internet has been recognized as an important source of information for patients with factitious disorder, as well as medical records and radiographic images. 12 A newly described phenomenon of "Munchausen's by Internet" has emerged, in which patients infiltrate disease-specific online forums and form relationships with sufferers and caregivers.…”

Case Files of the Harvard Medical Toxicology Fellowship at Children’s Hospital Boston: An Insulin Overdose

“…There were multiple additional reports related to nonfatal hypoglycemic events that "appeared to be device-related" and two reports of attempted suicide via intentional bolus of insulin through the pump [9]. There are also at least three reports in the literature of factitious nonfatal hypoglycemia in pediatric patients using CSII, where the function normally used to prime the pump tubing was used to bolus insulin and thereby escape recording by the bolus memory feature [23,24]. Finally, in an unusual isolated case report, an insulin pump has been successfully used as a murder weapon to deliver a lethal dose of etomidate and atracurium [25].…”