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Hyperinsulinism Among Malingerers
HYPERINSULINISM AMONG MALINGERERS
EnwARD H.
RYNEARSON,
M.D., F.A.C.P. o
THE diagnosis of hyperinsulinism caused by a turn or of the islands of Langerhans is usually not difficult. The story of hypoglycemic reactions in a patient who is not receiving insulin is suggestive. Such a patient has a story which follows a definite pattern. Symptoms are present only when· he has not eaten or has exercised and he is promptly relieved by the administration or ingestion of glucose or sugar. Conn and his associatesl have· reported a case in which hyperinsulinism was proved to be caused by the self-administration of insulin. He proved this by finding the patient's bottle of insulin and introducing some typhoid vaccine. When next she gave herself an injection she had both insulin and vaccine reactions. I wish to present three other cases in which hyperinsulinism was self-induced.
REPORT OF CASES CASE I.-The patient was admitted to the Mayo Clinic on January 3, 1940, when she was 28 years of age. She Ilad been well until 1935 when, following an app·endectomy, she had gained in weight and by the following spring (1936) had presented the characteristic symptoms of diabetes mellitus. She was a rather unstable diabetic and in an effort to control her diabetes more carefully she had learned to determine the concentration of blood sugar. In January, 1937, she required 72 ~nits of insulin daily. At about that time her requirement for insulin began to decrease and by April, 1937, she required none. She reported that in October of that year she had a fasting blood sugar reading of 60 mg. per 100 cc. of blood and that in August, 1938, she had her first severe reaction during which she estimated she was unconscious for six hours. Other severe reactions followed, .·but there were periods of several months during which she would have no symptoms. While the patient was undergoing a·fast in a hospital in August, 1939, the level of blood sugar was found to be as low as 22 mg. per 100· cc. The findings at surgical exploration the following month 'were
From the Division of Medicine, Mayo Clinic,Rochester, Minnesota. • Associate Professor of Medicine,Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota; Consulting Physician in Division of Medicine, Mayo Clinic.
477
478
EDWARD H. RYNEARSON
reported as negative. puring October and November she had occasional reactions and she had had none during December. She was a patient at the Mayo Clinic from January 3 to April 10, 1940, from October 21 to December 21, 1940, from October 25, 1941, to January 16, 1942, from March 18 to July 4, 1942, from March 26 to September 22, 1948, and from December 16, 1944, to February 17, 1945. It is impossible to include all of our studies. In summary it may be said that the patient's symptoms and the laboratory findings were consistently those of severe organic hyperinsulinism. Between 1940 and 1942 several operations were performed in an effort to find an adenoma of the island cells of the pancreas. Dr. Waltman WaIters operated first on January 19, 1940. No tumor was found and a ligation of the pancreas was done. On November 29, 194q, he explored the pancreas again. The ligation had caused the disappearance of .the body and tail of the pancreas. No tumor was felt in the head of the pancreas. A biopsy of the liver showed it to be normal. Because of the patient's continued hypoglycemia another exploratory operation was performed on November 25, 1941. Marked regeneration of the pancreas had taken place and a subtotal pancreatectomy was carried out. Another partial pancreatectomy was performed on March 24, 1942, and again on May 22, 1942. Following the latter operation frank diabetes appeared, but the patient continued to have severe episodes of hypoglycemia interspersed with episodes of diabetic acidosis. In 1944, the patient was carefully studied in Boston and another exploratory operation was performed there, primarily because of adhesions. Thus this patient underwent a total of seven exploratory operations but an islet cell adenoma was not found and the hyperinsulinism was not improved. Presumably as a consequence of surgical removal of almost all pancreatic tissue, she had become diabetic. The persistence of hyperinsulinism in the presence of diabetes was, to say the least, most unusual. Nevertheless, the deception remained quite complete. The patient was again hospitalized here and Dr. Keating finally became suspicious and had her removed from her room. A careful search revealed a supply of insulin and the bottles, after being marked, were replaced. When the patient was next unconscious the marked bottles told the story. When confronted with this evidence the patient admitted that she had b,een giving herself unneeded insulin for several years, but she steadfastly refused to ,tell us the exact dates and insisted that early in her illness she had had genuine hyperinsulinism. With repeated reactions· marked mental deterioration had occurred and I, therefore, do not believe her story. Life had treated her cruelly and my opinion is that she seized on these self-induced reactions as· means for personal dramatization. Before her final dismissal she acknowledged that she had attempted suicide once with seconal and several times with in-
HYPERINSULINISM AMONG MALINGERERS
479
sulin. Shortly after her dismissal, she died at home reputedly from diabetic ~oma. This report from a relative was not corroborated by a physjcia~;Js statement. CASE II.-A young woman,' 32 years of age, was admitted to the Mayo Clinic on December 21, 1945. In June, 1942, diab,etes mellitus had developed. From then until June, 1945, she had had several episQdes of acidosis, some trouble with insulin reactions, a carbuncle, and so forth. In June, 1945, her reactions had become more severe and more frequent even though for six weeks prior to her admission she stated she had taken no insulin. Yet in spite of the fact that she had not been taking insulin, she had continued to have reactions of such severity as to produce unconsciousness and generalized convulsions. She had been referred with a diagnosis of spontaneous hypoglycemia, caused either by an adenoma of the islands of Langerhans or by hepatic failure. Following admission the patient had severe hypoglycemic reactions; the lowest reading of blood sugar was 22 mg. per 100 cc. She and her sister were told that a study of the skin temperature was important. The patient was removed to the laboratory where thermocouples were taped to her fingers and toes and where she was kept for twentyfour hours. During this time the levels of blood sugar rose as they would in any other diabetic patient; in this case the level rose to 267 mg. per 100 cc. The patient was a graduate nurse and she and her sister were much on the defensive. Since it was desirable to have conclusive evidence, permission to administer radioactive phosphorus was asked for and granted. The patient was given an injection of sterile water while she was receiving the so-called studies of skin temperature. Dr. Keating then went' to her room and after a diligent search found bottles of insulin. He injected the radioactive phosphorus into these bottles. The following day when the patient was unconscious in another reaction her urine was tested with the aid of a Geiger counter and found to be strongly radioactive. . The following evening we informed the patient and her sister that the episodes of, hyperinsulinism were known to have been self-induced. Even when confronted with the empty insulin bottles found in the snow beneath the patient's window they refused to acknowledge the deceit. With permission the patient was given amytal intravenously and interviewed again. Under narcosis she not only confessed that the attacks were self-induced, but also revealed the deeply rooted psychic digturbances which had led to her behavior. CASE 111.-This patient had been admitted to the Mayo Clinic for the first time on August 30, 1943, when she was 16 years of age. Diabetes had developed five years before and the patient had been
480
ED'VARD H. RYNEARSON
referred for -regulation of this disease. There had been no complications and the disease had been satisfactorily .controlled with 14 units of protamine zinc insulin and 40 units of regular insulin administered as a mixture once daily before breakfast. The patient was admitted for the second time on February 19,-1945. She had enjoyed good health and had not changed the amount of insulin until the summer of 1944, when she began -to decrease the amount. By December of 1944 she was not requiring any insulin and yet continued to have severe reactions. She was referred to the· clinic with the diagnosis of hyperinsulinism. Following her second admission the patient had peliods of hypo.. glycemia (lowest blood sugar reading was 38 mg. per 100 cc.) and periods of hyp,erglycemia (higllest blood sugar reading was 258 mg.). On February 22, with her mother present, her belongings were searched and her insulin was found. The bottles were marked and left. "rhe next day she had another reaction and after administering glucose which resulted in the usual prompt recovery, I asked her when she had last taken insulin. She replied, "In December." I then opened her suitcase and her mother and I confirmed the fact that a large amount of insulin had been withdrawn since the bottles were marked. Even when confronted with this evidence the patient steadfastly refused to acknowledge that she had injected insulin into herself, unless she had done it unconsciously. Even under narcosis she would not change her story. However, she did stop her malingering and was dismissed with instruction to take a mixture of 12 units of protamine zinc insulin and 32 units of regular insulin once daily b·efore breakfast. COMMENT
The term "hyperinsulinism" should be reserved for those patients whose hypoglycemia is caused either by the injection of too much insulin or by a turoor of the island cells of the pancreas. Hypoglycemia also nlay be caused by severe hepatic insufficiency, or in association with Addison's disease or with severe pituitary insuffi.. ciency. -l\1ild hypoglycemia with changes in the sugar tqlerance curves is found in many nervous individuals in whom it can be considered a part of the clinical picture rather than a cause of their trouble. Three cases have been presented to illustrate that hyperinsulinism Inay be produced as a result of malingering. All three were cases of diabetes. The first patient conditioned my colleagues and me for the diagnosis of the next two.
REFERENCE
l.Conn, J. W., Johnston, Margaret W. and Conn, Elizabeth S.: Hyperinsulinism of an Unusual Type: a Metabolic Study. Ann. Int. Med., 24:487-498 (March) 1946.
EnwARD H.
RYNEARSON,
M.D., F.A.C.P. o
THE diagnosis of hyperinsulinism caused by a turn or of the islands of Langerhans is usually not difficult. The story of hypoglycemic reactions in a patient who is not receiving insulin is suggestive. Such a patient has a story which follows a definite pattern. Symptoms are present only when· he has not eaten or has exercised and he is promptly relieved by the administration or ingestion of glucose or sugar. Conn and his associatesl have· reported a case in which hyperinsulinism was proved to be caused by the self-administration of insulin. He proved this by finding the patient's bottle of insulin and introducing some typhoid vaccine. When next she gave herself an injection she had both insulin and vaccine reactions. I wish to present three other cases in which hyperinsulinism was self-induced.
REPORT OF CASES CASE I.-The patient was admitted to the Mayo Clinic on January 3, 1940, when she was 28 years of age. She Ilad been well until 1935 when, following an app·endectomy, she had gained in weight and by the following spring (1936) had presented the characteristic symptoms of diabetes mellitus. She was a rather unstable diabetic and in an effort to control her diabetes more carefully she had learned to determine the concentration of blood sugar. In January, 1937, she required 72 ~nits of insulin daily. At about that time her requirement for insulin began to decrease and by April, 1937, she required none. She reported that in October of that year she had a fasting blood sugar reading of 60 mg. per 100 cc. of blood and that in August, 1938, she had her first severe reaction during which she estimated she was unconscious for six hours. Other severe reactions followed, .·but there were periods of several months during which she would have no symptoms. While the patient was undergoing a·fast in a hospital in August, 1939, the level of blood sugar was found to be as low as 22 mg. per 100· cc. The findings at surgical exploration the following month 'were
From the Division of Medicine, Mayo Clinic,Rochester, Minnesota. • Associate Professor of Medicine,Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota; Consulting Physician in Division of Medicine, Mayo Clinic.
477
478
EDWARD H. RYNEARSON
reported as negative. puring October and November she had occasional reactions and she had had none during December. She was a patient at the Mayo Clinic from January 3 to April 10, 1940, from October 21 to December 21, 1940, from October 25, 1941, to January 16, 1942, from March 18 to July 4, 1942, from March 26 to September 22, 1948, and from December 16, 1944, to February 17, 1945. It is impossible to include all of our studies. In summary it may be said that the patient's symptoms and the laboratory findings were consistently those of severe organic hyperinsulinism. Between 1940 and 1942 several operations were performed in an effort to find an adenoma of the island cells of the pancreas. Dr. Waltman WaIters operated first on January 19, 1940. No tumor was found and a ligation of the pancreas was done. On November 29, 194q, he explored the pancreas again. The ligation had caused the disappearance of .the body and tail of the pancreas. No tumor was felt in the head of the pancreas. A biopsy of the liver showed it to be normal. Because of the patient's continued hypoglycemia another exploratory operation was performed on November 25, 1941. Marked regeneration of the pancreas had taken place and a subtotal pancreatectomy was carried out. Another partial pancreatectomy was performed on March 24, 1942, and again on May 22, 1942. Following the latter operation frank diabetes appeared, but the patient continued to have severe episodes of hypoglycemia interspersed with episodes of diabetic acidosis. In 1944, the patient was carefully studied in Boston and another exploratory operation was performed there, primarily because of adhesions. Thus this patient underwent a total of seven exploratory operations but an islet cell adenoma was not found and the hyperinsulinism was not improved. Presumably as a consequence of surgical removal of almost all pancreatic tissue, she had become diabetic. The persistence of hyperinsulinism in the presence of diabetes was, to say the least, most unusual. Nevertheless, the deception remained quite complete. The patient was again hospitalized here and Dr. Keating finally became suspicious and had her removed from her room. A careful search revealed a supply of insulin and the bottles, after being marked, were replaced. When the patient was next unconscious the marked bottles told the story. When confronted with this evidence the patient admitted that she had b,een giving herself unneeded insulin for several years, but she steadfastly refused to ,tell us the exact dates and insisted that early in her illness she had had genuine hyperinsulinism. With repeated reactions· marked mental deterioration had occurred and I, therefore, do not believe her story. Life had treated her cruelly and my opinion is that she seized on these self-induced reactions as· means for personal dramatization. Before her final dismissal she acknowledged that she had attempted suicide once with seconal and several times with in-
HYPERINSULINISM AMONG MALINGERERS
479
sulin. Shortly after her dismissal, she died at home reputedly from diabetic ~oma. This report from a relative was not corroborated by a physjcia~;Js statement. CASE II.-A young woman,' 32 years of age, was admitted to the Mayo Clinic on December 21, 1945. In June, 1942, diab,etes mellitus had developed. From then until June, 1945, she had had several episQdes of acidosis, some trouble with insulin reactions, a carbuncle, and so forth. In June, 1945, her reactions had become more severe and more frequent even though for six weeks prior to her admission she stated she had taken no insulin. Yet in spite of the fact that she had not been taking insulin, she had continued to have reactions of such severity as to produce unconsciousness and generalized convulsions. She had been referred with a diagnosis of spontaneous hypoglycemia, caused either by an adenoma of the islands of Langerhans or by hepatic failure. Following admission the patient had severe hypoglycemic reactions; the lowest reading of blood sugar was 22 mg. per 100 cc. She and her sister were told that a study of the skin temperature was important. The patient was removed to the laboratory where thermocouples were taped to her fingers and toes and where she was kept for twentyfour hours. During this time the levels of blood sugar rose as they would in any other diabetic patient; in this case the level rose to 267 mg. per 100 cc. The patient was a graduate nurse and she and her sister were much on the defensive. Since it was desirable to have conclusive evidence, permission to administer radioactive phosphorus was asked for and granted. The patient was given an injection of sterile water while she was receiving the so-called studies of skin temperature. Dr. Keating then went' to her room and after a diligent search found bottles of insulin. He injected the radioactive phosphorus into these bottles. The following day when the patient was unconscious in another reaction her urine was tested with the aid of a Geiger counter and found to be strongly radioactive. . The following evening we informed the patient and her sister that the episodes of, hyperinsulinism were known to have been self-induced. Even when confronted with the empty insulin bottles found in the snow beneath the patient's window they refused to acknowledge the deceit. With permission the patient was given amytal intravenously and interviewed again. Under narcosis she not only confessed that the attacks were self-induced, but also revealed the deeply rooted psychic digturbances which had led to her behavior. CASE 111.-This patient had been admitted to the Mayo Clinic for the first time on August 30, 1943, when she was 16 years of age. Diabetes had developed five years before and the patient had been
480
ED'VARD H. RYNEARSON
referred for -regulation of this disease. There had been no complications and the disease had been satisfactorily .controlled with 14 units of protamine zinc insulin and 40 units of regular insulin administered as a mixture once daily before breakfast. The patient was admitted for the second time on February 19,-1945. She had enjoyed good health and had not changed the amount of insulin until the summer of 1944, when she began -to decrease the amount. By December of 1944 she was not requiring any insulin and yet continued to have severe reactions. She was referred to the· clinic with the diagnosis of hyperinsulinism. Following her second admission the patient had peliods of hypo.. glycemia (lowest blood sugar reading was 38 mg. per 100 cc.) and periods of hyp,erglycemia (higllest blood sugar reading was 258 mg.). On February 22, with her mother present, her belongings were searched and her insulin was found. The bottles were marked and left. "rhe next day she had another reaction and after administering glucose which resulted in the usual prompt recovery, I asked her when she had last taken insulin. She replied, "In December." I then opened her suitcase and her mother and I confirmed the fact that a large amount of insulin had been withdrawn since the bottles were marked. Even when confronted with this evidence the patient steadfastly refused to acknowledge that she had injected insulin into herself, unless she had done it unconsciously. Even under narcosis she would not change her story. However, she did stop her malingering and was dismissed with instruction to take a mixture of 12 units of protamine zinc insulin and 32 units of regular insulin once daily b·efore breakfast. COMMENT
The term "hyperinsulinism" should be reserved for those patients whose hypoglycemia is caused either by the injection of too much insulin or by a turoor of the island cells of the pancreas. Hypoglycemia also nlay be caused by severe hepatic insufficiency, or in association with Addison's disease or with severe pituitary insuffi.. ciency. -l\1ild hypoglycemia with changes in the sugar tqlerance curves is found in many nervous individuals in whom it can be considered a part of the clinical picture rather than a cause of their trouble. Three cases have been presented to illustrate that hyperinsulinism Inay be produced as a result of malingering. All three were cases of diabetes. The first patient conditioned my colleagues and me for the diagnosis of the next two.
REFERENCE
l.Conn, J. W., Johnston, Margaret W. and Conn, Elizabeth S.: Hyperinsulinism of an Unusual Type: a Metabolic Study. Ann. Int. Med., 24:487-498 (March) 1946.