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Factitious Hypoglycemia in an Infant With Undetectable Exogenous Insulin by a Commercial Insulin Immunoassay: A

Hisham Arabi1, Amir Babiker1, Asma M Awadalla1

  • 1Pediatrics, King Abdullah Specialist Children's Hospital, Riyadh, SAU.

Cureus
|February 3, 2023
PubMed

Insights

Factitious hypoglycemia in infants, a form of Munchausen syndrome by proxy, can be life-threatening. A diagnostic pitfall occurred due to an insensitive insulin assay, delaying the identification of exogenous insulin administration.

Area of Science:

  • Pediatrics
  • Endocrinology
  • Child Abuse

Background:

  • Factitious hypoglycemia in infancy is a rare but severe manifestation of Munchausen syndrome by proxy (MSBP).
  • Classic diagnostic markers include low C-peptide with high insulin levels during hypoglycemic episodes.
  • MSBP poses significant diagnostic challenges in pediatric cases.

Observation:

  • A male infant presented with recurrent severe hypoglycemia from six months of age, with two siblings having similar histories.
  • Endocrine and metabolic investigations were normal, and the infant underwent invasive procedures.
  • Hypoglycemic episodes resolved upon maternal separation, suggesting non-organic etiology.

Findings:

  • Exogenous insulin administration was confirmed only after a laboratory insulin assay upgrade revealed detectable insulin with low C-peptide.
  • The previous immunoassay lacked sensitivity for the mother's long-acting insulin, creating a diagnostic pitfall.
  • Maternal diabetes, insulin use, and psychosocial stressors were noted.

Implications:

  • Highlights a critical diagnostic pitfall in factitious hypoglycemia due to assay limitations.
  • Emphasizes the importance of considering MSBP in unexplained pediatric hypoglycemia, even with negative initial workups.
  • Suggests reassessment of laboratory methods when clinical suspicion for factitious disorders is high.
Keywords:
analogue insulin cross-reactivitychild protectionexogenous insulinfactitious hypoglycemiainsulin assay sensitivitymunchhausen by proxy

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