6992 Unveiling Factitious Hypoglycemia

Disclosure: T.A. Patel: None. S. Chlebek: None. T. Porter: None. Background: Factitious disorder causing hypoglycemia is a condition in which a patient intentionally uses a glucose-lowering agent without any apparent external gains. This is a rare and challenging clinical diagnosis, which often results in the use of unnecessary medical resources. Clinical Case: A 31-year-old woman, with a history of Type 1 Diabetes and Hypothyroidism, was admitted to the Intensive Care Unit (ICU) for persistent severe hypoglycemia. The patient reported an increase in the frequency and severity of hypoglycemic episodes despite a progressive reduction in her total daily insulin use; most recently, with complete cessation of insulin use for 2 months. A review of outside medical records revealed multiple emergency room visits and hospitalizations due to hypoglycemia. Notably, the patient was an emergency department registered nurse (RN). On admission, the patient was placed on a dextrose infusion with as needed dextrose boluses. Despite these interventions, she continued to become intermittently hypoglycemic. Initial tests were consistent with exogenous insulin use: critically low serum glucose (31 mg/dL, normal 60-99 mg/dL), undetectable C-peptide (<0.1 ng/mL, normal 1.1-4.4 ng/mL), and elevated insulin (32.3 uIU/mL, normal 2.6-24.9 uIU/mL). The patient denied recently self-administering insulin and she was not treated with insulin in the hospital prior to obtaining these labs. Additionally, there was a significant rise in the glucose level (58 mg/dL, positive >30 mg/dL) after intramuscular administration of 1 mg glucagon, which confirmed insulin mediated hypoglycemia. The remainder of the biochemical work-up was unremarkable. GAD65 and IA-2 autoantibodies were positive, confirming the patient’s history of type 1 diabetes. It was recommended that the patient have a one-to-one sitter for continuous direct observation. The patient, thereafter, became hyperglycemic with no further episodes of hypoglycemia for the remainder of the hospitalization. Psychiatry was placed on consult and diagnosed the patient with factitious disorder. Conclusion: Factitious disorder is a rare but important condition to be included in the differential diagnosis of recurrent hypoglycemia. Biochemical findings will include a low serum glucose, undetectable C-peptide, and an inappropriately elevated insulin. Psychiatric evaluation can, thereafter, support the diagnosis and clinical management. Establishing the diagnosis of factitious hypoglycemia is critical for appropriately treating these patients, minimizing unnecessary testing, and avoiding multiple hospitalizations. Presentation: 6/3/2024