Factitious hypoglycemia in insulin-treated diabetic patients.

Factitious hypoglycemia is a factitious disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), referring to intentionally covertly induced hypoglycemia, with potentially severe consequences. Knowledge of factitious hypoglycemia relies on case reports, and evidence-based information and guidelines are lacking. Diagnosing factitious hypoglycemia in insulin-treated diabetic persons is therefore challenging and often requires a long and costly process. Moreover, the typical metrics proposed to differentiate insulin-induced factitious hypoglycemia from insulinoma (i.e., high insulin and low C-peptide versus high insulin and high C-peptide, respectively) are not always applicable, depending on whether the insulin quantification method can detect the insulin analog. When factitious hypoglycemia is suspected, an emerging trend from recent publications advocates a combination of two insulin quantification methods with different cross-reactivity for insulin analogs, early on in the diagnostic process.

Triparesis: an unusual presentation of factitious disorder.

Factitious disorder (FD) has diverse presentations but neurological presentation is unusual. In this report, we discuss a case of FD who presented with triparesis, that is, weakness of both lower limbs and right upper limb. Diagnosis of FD was made after detailed clinical evaluation, review of past medical records that revealed extensive evaluation to rule out physical illness, and inability to find any associated stressful event or material gain associated with illness. Management was largely supportive and was based on psychotherapy. Identification of FD depends on a high index of suspicion by the physician and the presence of atypical and medically unexplainable signs/symptoms.

Approach to diagnosis of factitious disorder with unexplained hemoptysis: A case report.

RATIONALE: Hemoptysis or hematemesis is a common clinical symptom in adults, but is unusually to be observed in children. Hemoptysis can occur with circulatory diseases, injuries, several types of systemic diseases, or systemic factors including factitious disorder (FD), which is difficult to be diagnosed. Here, we report a case of hemoptysis caused by FD to provide a diagnostic flow chart for such kind of disease. PATIENT CONCERNS: An 11-year-old female patient had a history of hemoptysis or hematemesis for 6 months and suffered with paroxysmal syncope for a month. DIAGNOSIS AND INTERVENTION: A series of examinations had been launched to evaluate any possible malformation or abnormalities of the patient including fiberoptic bronchoscopy, cardiac catheterization, gastroscopy, nasolaryngoscopy, electrocardiogram, electroencephalogram, and enhanced magnetic resonance image of the paranasal sinus. Several methods had been performed and tried to stop hemoptysis such as taking hemostatic medications, lavage of fiberoptic bronchoscopy, and embolism for abnormal bronchial arterial using cardiac catheter. All the interventions, however, failed to achieve our treatment goal. Given that more careful observation during hospitalization had been done, and we suspected the symptom of hemoptysis from this patient might be originated from an FD. OUTCOMES: Based on the diagnosis of FD, targeted psychological intervention was provided by experts. After the treatment completed, the patient did not present hemoptysis anymore. LESSONS: FD is an uncommon type of disease. This rare case described here is to help us to reconsider the long diagnosis process of hemoptysis with a series of examinations including some invasive procedures, whether all the examinations and interventions are necessary for a nonsevere hemoptysis patient.

Factitious disorder: a rare cause of haematemesis.

Acute upper gastrointestinal (GI) bleeding is a common condition in the UK with 50-70,000 admissions per year. In 20% of cases no cause can be found on endoscopy. Here, we present the case of a young female patient who was admitted on three occasions with large volume haematemesis and bleeding from other sites. She was extensively investigated and underwent multiple endoscopic procedures. She was eventually diagnosed with factitious disorder after concerns were raised about the inconsistent nature of her presentations. She was found to be venesecting herself from her intravenous cannula, and ingesting the blood to simulate upper GI bleeding. This is a rare cause of 'haematemesis' but perhaps not as rare as is thought.

[Factitious disorders in dermatology: Value of the dissociative state concept]. / Troubles factices en dermatologie : intérêt du concept d'état dissociatif.

BACKGROUND: Factitious disorders in dermatology consist of intentionally self-inflicted skin lesions that vary in morphology and distribution and occur on surfaces readily accessible to the patient's hands. They tend to be a chronic condition that waxes and wanes according to the circumstances of the patient's life. Patient management poses a particular challenge to the clinician and the prognosis is considered poor. The aetiopathogenesis of factitious disorders in dermatology is not completely understood. We present a case in which we suggested the occurrence of factitious behaviour during a dissociative state, and we briefly describe our diagnostic and therapeutic approach. PATIENTS AND METHODS: A 48-year-old unemployed woman was referred to our department of psychiatry by her dermatologist for suspected factitious disorder. The patient was diagnosed with diabetes mellitus type 1 and had been hospitalized repeatedly for confirmed diabetic ketoacidosis. The onset of the disease was related to marital discord with her spouse. Numerous skin lesions had appeared on her face, arms, legs, neck and back. These lesions resulted in multiple hospital admissions and in amputation of her left leg. The condition had worsened considerably after her separation from her husband. During the initial conversation, the patient was unable to provide a clear history of the disease. She denied any knowledge of the circumstances in which these skin lesions appeared, and she did not admit self-infliction. Her mood was depressed and her speech was slow. We suspected that our patient was herself causing her skin lesions while in a dissociative state. Several arguments militate in favour of our hypothesis, particularly her history of childhood maltreatment and the association of traumatic life events with simultaneous deterioration of the skin. The explanation of the dissociative mechanism helped us to strengthen the therapeutic relationship. Within a few days, we noted a slow regression of the lesions, but the patient was still unable to explain how the lesions had occurred. DISCUSSION: The pathophysiology of factitious disorders in dermatology is poorly understood. It has strong ties with other psychiatric disorders, and according to several authors, skin lesions occur in dissociative states, after which patients do not remember how the skin change started. Management of this disease is challenging. An improved understanding of its mechanisms may enhance the prognosis for this particular group of patients.

Identifying and Addressing the Hidden Reasons Why Patients Refuse Discharge From the Hospital.

BACKGROUND: Consultation-liaison psychiatrists are often asked to evaluate patients who refuse discharge from a medical facility. Literature to guide clinicians on the management of these patients is very limited. OBJECTIVE: This article seeks to explain this phenomenon through a case series, provide a differential diagnosis of patients who request to stay in the hospital, as well as provide clinicians with direction in the management of these difficult situations. METHODS: We discuss a case series of 3 patients treated at a large academic medical center, who refused discharge, discuss potential differential diagnoses, and provide management recommendations to guide clinicians. DISCUSSION: Providing care for a patient who refuses discharge can present several dilemmas for the treatment provider. Additionally, patients who refuse discharge may face emotional, physical, and financial costs secondary to continued unnecessary medical hospitalization. A variety of psychiatric conditions may contribute to a patient׳s desire to stay in the hospital. CONCLUSIONS: Patients who refuse medical discharge can present unique challenges for hospital-based medical providers as well as consultation psychiatrists who care for these patients. Careful consideration of diagnostic etiologies as well as coordination of care across the treatment team may be required to manage these unique and challenging cases.

Gardner-Diamond syndrome.

Gardner-Diamond syndrome, which also is knownas autoerythrocyte sensitization disorder, is a raresyndrome of inflammatory, edematous papulesthat evolve into painful ecchymoses on the trunkand lower legs after a period of stress with no priorhistory of trauma. This syndrome usually occurs inwomen with a history of psychiatric disorders, themost common one being depression. Although theexact mechanism of injury is not well understood,it is hypothesized that these patients haveautoantibodies to phosphatidylserine, which is aphospholipid membrane component in erythrocytes.Treatment for this disorder includes symptomatictherapies and psychotropic medications to treat theunderlying psychiatric disorder.

Astasia-Abasia and Ganser Syndrome in a Preadolescent Girl: A Case Report.

INTRODUCTION: Astasia is the inability to maintain an upright body position without assistance in the absence of motor weakness or sensory loss. Abasia is described as the inability to walk or as uncoordinated walking, while preserving mobility of the lower limbs. Ganser syndrome is described as a dissociative disorder characterized by approximate answers, somatic conversion symptoms, clouding of consciousness, as well as visual and auditory pseudohallucinations. The aim of this study is to present a case that seemed like a combination of neurological and internal disturbances, but actually represented a psychogenic disorder. CASE OUTLINE: This paper presents the case of a 13-year-old patient with the first manifestation of the inability to walk and stand. Medical history, diagnostic instruments and differential diagnostic methods have been presented in detail. The clinical manifestation was initially interpreted as a neurological disorder. However, after the application of diagnostic procedures and a change in family circumstances, the patient was diagnosed with a psychogenic movement disorder, astasia-abasia, with progressive clinical presentation that included dissociative psychotic reactions (Ganser syndrome). Differential diagnosis as well as the elements of the therapeutic approach have been discussed. CONCLUSION: Presenting a case of psychogenic astasia-abasia in children contributes to a better understanding and differentiating between conditions with a clinical presentation of signs and symptoms dealt with by other branches of medicine.

Recalcitrant Supraventricular Tachycardia: Occult Albuterol Toxicity Due to a Factitious Disorder.

BACKGROUND: We report a case of a factitious disorder presenting with recurrent episodes of supraventricular tachycardia (SVT). CASE REPORT: A 26-year-old woman presented with recurrent episodes of SVT. Medical history included SVT, asthma, anxiety, depression, type 2 diabetes, and migraine headaches. The patient had frequent emergency department (ED) visits with complaints of chest pain, palpitations, and heart rates typically between 130 and 150 beats/min. Electrocardiograms revealed sinus tachycardia; laboratory studies were consistently normal except for periodic episodes of hypokalemia. Over the 3 years, the patient had more than 50 visits for health care and underwent multiple diagnostic evaluations, including comprehensive laboratory testing, echocardiography, Holter monitoring, and event monitoring. Given the constellation of clinical features, a plasma albuterol concentration was obtained during an ED visit for SVT, which was 17 ng/mL (reference range for peak plasma concentration after 0.04-0.1-mg inhaler dose = 0.6-1.4 ng/mL). A subsequent ED visit with a similar presentation revealed a plasma albuterol level of 11 ng/mL. The patient adamantly denied using this medication. Due to concerns about a factitious disorder, a multidisciplinary hospital discussion was planned for subsequent interventions; however, the patient was lost to follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is a compelling case report of a factitious disorder and occult albuterol abuse resulting in recalcitrant SVT with numerous ED visits and interventions. Patients with factitious disorders can have multiple visits for emergency care and are challenging to evaluate and treat. Albuterol toxicity can present with pronounced sinus tachycardia, fine tremor, and often with transient hypokalemia.

Fatal non-thrombotic pulmonary embolization in a patient with undiagnosed factitious disorder.

BACKGROUND: Factitious fever is extremely challenging to diagnose in patients with complicated chronic medical problems, and represents as much as 10% of fevers of unknown origin. Factitious fever caused by self-injecting oral medications through indwelling central catheters is a diagnostic challenge. CASE PRESENTATION: We present a 32-year-old Caucasian female with history of short gut syndrome, malnutrition requiring total parental nutrition, and pancreatic auto-islet transplant with fever of unknown origin. Multiple episodes of bacteremia occurred with atypical pathogens, including α-hemolytic Streptococcus, Achromobacter xylosoxidans, and Mycobacterium mucogenicum. Chest computed tomography was notable for extensive tree-in-bud infiltrates. Sudden cardiac arrest with right-sided heart failure following acute hypoxemia led to her death. Diffuse microcrystalline cellulose emboli with foreign body granulomatosis was found on autopsy. Circumstantial evidence indicated that this patient suffered from factitious disorder, and was self-injecting oral medications through her central catheter. CONCLUSION: A high index of suspicion, early recognition, and multifaceted team support is essential to detect and manage patients with factitious disorders before fatal events occur.

Anxiety- and depressive-like behaviors in olfactory deficient Cnga2 knockout mice.

There is a close neuroanatomical connection between odor and emotional processing. Olfactory dysfunction is found in various neurodegenerative and neuropsychiatric disorders. Here, mice take the cyclic nucleotide gated channel 2 mutant gene (Cnga2), which is critical for olfactory sensory neurons to generate odor induced action potentials were used. The Cnga2 mice were congenitally anosmic. Adult mice were tested in a series behavioral paradigm such as open field, light/dark box, forced swim test and Y-maze. Our study found that Cnga2 mice showed increased anxiety- and depressive-like behaviors than their wide type siblings. However, Cnga2 mice showed no difference from the wide types when tested in the two-trial recognition Y-maze. The results indicate that innate olfactory deficiency might modulate emotional behaviors in mice.