Hypoglycemia and Factitious Disorders: A Case Report and Review.

Hypoglycemia may present with a multitude of signs and symptoms ranging from subjective feelings of anxiety or diaphoresis to neuroglycopenic manifestations of altered sensorium or seizure. The differential diagnosis of hypoglycemic disorders is broad, and in rare instances may occur following intentional induction by undisclosed insulin administration or insulin secretagogue ingestion in patients with an underlying factitious disorder. While basic laboratory studies can reliably confirm the presence of exogenous insulin in patients with hyperinsulinemic hypoglycemia, increased endogenous insulin secretion following sulfonylurea ingestion can mimic a biochemical pattern of findings also seen with insulinoma, a rare pancreatic insulin-producing tumor. We present a case of severe hypoglycemia manifesting as diminished consciousness in a patient with multiple medical comorbidities. Following initial laboratory workup suggestive of endogenous hyperinsulinemic hypoglycemia, the results of a serum oral hypoglycemic panel confirmed the presence of glipizide, an unprescribed insulin secretagogue of the sulfonylurea class, in the patient's serum. In conjunction with psychiatric services, the patient was diagnosed with an underlying factitious disorder and her hypoglycemia was deemed likely the result of surreptitious sulfonylurea ingestion as a pathologic healthcare-seeking behavior. Our case report and subsequent review shed light on critical components in the diagnostic approach to hypoglycemic disorders, which carry significant morbidity for patients regardless of the underlying cause and emphasize several clinical and ethical considerations associated with the identification and management of persons with factitious disorder in medical practice.