Factitious Hypoglycemia and Insulin Edema due to Surreptitious Insulin Use in a Patient with Type 1 Diabetes Mellitus

Abstract

Background: Insulin edema is an uncommon but well-known complication of insulin therapy, mostly appreciated in patients soon after commencement or intensification of insulin therapy. Objectives: To report a case insulin edema in Type 1 Diabetes due to surreptitious excess self-insulin use triggered by poverty driven psychosocial stressors. Case Presentation: A 14-year girl with T1DM since age 8 years, with chronic poor glycemic control (Insulin 48 units/day basal-bolus; HbA1c 12.5%, despite 100% free medical care, medicines, diagnostics and counselling), presented with multiple episodes of unexplained hypoglycemia with documented low blood sugar readings (30-60 mg/dl) and “apparently” grossly decreased recent insulin requirements (4 units/day) This was associated with rapid weight gain, swelling of her face, limbs and abdomen as well as shortness of breath. Work up for acute/sub-acute renal, hepatic, cardiac, pulmonary or infectious disorders was negative. Fluid and salt restriction, close clinical monitoring and compassionate counselling resulted in prompt amelioration of hypoglycemia, resolution of edema, weight gain and shortness of breath. In-depth clinical assessment suggested the diagnosis of surreptitious excess insulin use, triggered by psychosocial and economic stressors, leading to factitious hypoglycemia and consequent insulin edema causing fluid retention and dyspnea. Discussion: To our knowledge, this is the first documented case of insulin edema in a patient previously diagnosed with T1DM due to the surreptitious use of insulin by the patient resulting from psychosocial stressors, similar to those in other published encounters. Conclusion: Insulin edema resulted from transient surreptitious (nontherapeutic) excess self-insulin use, triggered by psychosocial stressors.