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Factitious hypoglycemia (FH) in a diabetic patient represents a difficult diagnostic and costly management problem. An adolescent diabetic with FH is reported. A literature search revealed 10 adolescent and 45 adult diabetic patients with FH. Tests currently available for diagnosis are evaluated. The role of psychiatric therapy in relation to overall management and prognosis is stressed.
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Self-inflicted injuries are probably more common than is generally appreciated. Three patients with self-inflicted hand injuries are described. A delay in making the correct diagnosis resulted in severe hand disability in 2 of the patients. Early diagnosis of this entity, combined with prompt psychotherapy, prevented disability in the third. The pertinent literature is reviewed and the importance of early diagnosis and psychotherapy is stressed.
Wallace aptly described patients with overriding psychological problems and upper extremity complaints as possessing the Shaft syndrome. SHAFT patients studied fell into two categories. The first group inflicted physical harm on themselves, creating factitious injuries. The second group postured their limbs in attitudes that are not explainable anatomically. This latter group is described by Simmons as the clenched fist syndrome. Although patients who had factitious injuries invariably healed with protective casting, 4 patients relapsed. Eight of 14 patients who were employed at the onset of their complaints returned to gainful employment. Some patients received psychological counseling but most lacked sufficient insight to make gainful progress. Reaching a diagnoses was often difficult. At least 5 patients had unwarranted operations. The surgeon needs a high index of suspicion when the history and findings do not match for patients harboring complaints of pain, numbness, stiffness, or inability to use their limb.
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The authors report a case of factitious cyanosis in a psychiatric inpatient. To their knowledge, this is the first report of factitious cyanosis in the medical literature. They discuss the relationship of isolated factitious signs and symptoms to Munchausen syndrome and other psychiatric diagnoses. They explore the underlying dynamic of displaced anger in this patient. They suggest that avoiding confrontation with these patients may lead to a better therapeutic outcome and caution physicians to be alert to the possibility of factitious etiology when presented with confusing symptom clusters.
A 29-year-old married nurse with pancytopenia was discovered to be surreptitiously ingesting alkylating agents. Despite her life-threatening behavior, there was no evidence that she was psychotic, depressed, or cognitively impaired. Psychological testing was indicative of a sociopathic personality. The patient and her behavior elicited considerable affect and controversy among members of her health team. It is hypothesized that the patient's behavior resulted from longstanding low self-esteem. The production of a dramatic illness gratified dependency needs and fooling physicians gave her a sense of power.
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A 36-year-old woman without significant medical history complained of "spells" of diplopia, fatigue, and dizziness. On formal fasting, her glucose dropped to 40 mg/dL, with simultaneous insulin levels of 15 microU/mL (normal <6 microU/mL) and C-peptide of 2.5 ng/ml (normal <2 ng/mL). An isolated plasma sulfonylurea screen done during the fast was positive for tolbutamide, suggesting the diagnosis of factitious hypoglycemia, but further workup revealed multiple pancreatic masses resulting in an eventual diagnosis of multiple insulinomas that was confirmed surgically. We discuss the approach to hypoglycemia caused by insulin excess and distinguishing clinical and biochemical features.
'Diarrhoea' remains a common problem presented to gastroenterologists. Assessment of the history will in most cases point to the investigations that will distinguish between organic and functional causes and lead to diagnosis. There exists a small group of patients either in whom there may be difficulties in distinguishing between organic and functional causes, or in whom a diagnosis of factitious diarrhoea is suspected. These patients should be admitted for a short in-patient assessment and undergo an analysis of 72-h stool weights. If these are less than 225 g/ day a functional cause should be suspected. If they are raised, then further investigations to exclude a factitious cause should include analysis of fluid balance, stool osmolality and stool electrolyte and creatinine content. A laxative screen should also be performed according to available quality control guidelines.
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We report two cases of bathtub suction-induced purpura. Two girls, ages 9 and 14 years, developed recurring purpura "spontaneously" in the same lower back location and in the same U-shaped distribution. The patients had similar histopathologic findings, with extravasated erythrocytes and a sparse superficial inflammatory infiltrate. After extensive evaluation, one patient eventually admitted to self-inducing her lesions by creating suction against a bathtub. The second patient denied self-inflicting her lesions; however, her purpura improved when she stopped taking baths.