Endocrine Abstracts

Introduction: An atypical manifestation of disease combined with inconsistent results of examination, long history of multiple past health care services without effect requires to consider factitious disorders.

Case report: A 46 year-old woman was suffering from episodes of severe hypokalemia (K+ 1.9 - 3.4 mmol/l (ref. 3.5-5.1 mmol/l) and hypertensive crises up to 240/145 mm Hg for 4 years. She stated that there was no clear provoking factor for these episodes and the hypertension was resistant to multicomponent treatment. Previous exams showed normal levels of aldosterone and renin, but elevated normetanephrine in 24-hour urine (1548 mg/24 h (ref. 35-445 mg/24 h)) and normal metanephrine. During the last years, the patient underwent 11 different imaging studies, including MRI of the abdomen, scintigraphy with SPECT/CT with In-111 and with MIBG, PET/CT with 68Ga-DOTA-TATE that were negative and ultrasound endoscopy and CT of the abdomen, that showed conflicting results and suspicion for two 3 mm tumors in the descending part of the duodenum or adjacent head of the pancreas. At admission, there was also slightly increased level of normetanephrine (708 mg/24 h) and normal metanephrine. During the first days of hospitalization, the patient developed severe progressive hypokalemia despite IV potassium infusions and spironolactone treatment. Blood pressure monitoring showed hypotension and no episodes of hypertension, thus antihypertensive therapy was stopped. The 24-hour urine collection also demonstrated a high potassium level (174 mmol/24 h (25-125)). The patient denied taking any additional drugs, but diuretic abuse was suspected. The high-performance liquid chromatography–high resolution tandem mass spectrometry of the patient’s serum sample confirmed the presence of torasemide. The patient was advised to consult a psychiatrist which she refused.

Conclusion: Munchausen Syndrome can be difficult to diagnose and should be suspected in cases of atypical presentation. Diagnosis should be guided by clinical reasoning as multiple laboratory and imaging studies can lead to incidental findings. Liquid chromatography–mass spectrometry can be an invaluable tool to uncover artificial disorders.