Endocrine Abstracts

Introduction: Serum C Peptide is traditionally used to diagnose factitious Hypoglycaemia due to exogenous Insulin. However in our case we were able to initiate child protection work up on the basis of skin marks which were noted during child’s admission in hospital.

Case report: 2-year-old male presented with 3 days history of diarrhoea and vomiting. Past history and examination were unremarkable. Mother had gestational diabetes and was on insulin during pregnancy whilst Grandmother who died 1 month previously had type 2 diabetes managed with Insulin. He was admitted and commenced on ORS. His blood glucose (BG) dropped to 2.8 mmol/l. He had Hypoglycaemia screen and BG improved with sugary fluids. He continued good oral intake and was discharged the following day. He had 2 further repeat admissions with history of poor oral intake, floppy episodes, none of which were witnessed on the wards. On 3rd readmission he was kept in for prolonged observation during which he was noted to have low BG (2.6 mmol/l) with low blood ketones of 0.3 mmol/l. He required >8mg/kg per minute of i.v. glucose to maintain euglycaemia. This was consistent with hyperinsulinism. Hypoglycaemia screen was repeated. Marks which matched imprints made by an insulin pen, were noted on the legs and arm of the child the next day. We instituted strict 1:1 nursing to ensure mother and other family members had only supervised access to child and his BG improved. Police Protection Order was put in place. Results showed insulin >100 mU/l, C Peptide <50 pmol/l, confirming exogenous insulin administration. Mother was arrested by the police. Child remained well and now is fostered.

Discussion: Presence of insulin pen imprints enabled us to suspect exogenous insulin administration prior to receiving hypoglycaemia screen results. We recommend thorough skin examination in any child with persistent hypoglycaemia.