Anamnese und klinischer Befund: Eine 33-jährige Krankenschwester
(verheiratet; zwei Kinder; BMI 30,9 kg/m2 )
litt seit einigen Monaten unter rezidivierenden symptomatischen
Hypoglykämien.
Untersuchungen: Zwei Hungerversuche
wurden nach 26 Stunden aufgrund von Bewusstlosigkeit abgebrochen.
Das verbesserte Insulin/Glukose-Verhältnis betrug ∞ und
6,1 [mU/l]/[mg/dl] (Normalwert < 0,5).
In einem hyperinsulinämisch-hypoglykämischen »Clamp«-Versuch
trat eine C-Peptid-Suppression auf minimal 0,26 bis 0,38 nmol/l
(Normalwert 0,06 ± 0,01 nmol/l) auf. Weder im
Hungerversuch noch im »Clamp«-Versuch zeigten sich
spontane oder paradoxe Anstiege der Insulin-, bzw. C-Peptid-Konzentrationen.
Eine Serumanalyse auf Sulfonylharnstoffe ergab den mehrfachen Nachweis
von Glibenclamid in Konzentrationen über dem therapeutischen
Bereich.
Therapie und Verlauf: Die Patientin verneinte jegliche
Einnahme oraler Antidiabetika. In den Folgemonaten traten keine
Hypoglykämien mehr auf.
Diagnose: Aufgrund des Sulfonylharnstoff-Nachweises
im Serum wurde die Diagnose einer Hypoglycaemia factitia gestellt.
Folgerung: Hinsichtlich einer Insulin-
oder C-Peptid-Suppression unterschieden sich die Ergebnisse von
Hungerversuch und »Clamp«-Test bei Hypoglycaemia factitia nicht
von denen bei einem Insulinom. Allerdings kommt es unter Sulfonylharnstoffen nicht
zu dem insulinomtypischen Auftreten von Insulin- oder C-Peptid-»Bursts«.
Der Suchtest auf Sulfonylharnstoffe im Serum bzw. im Urin ist im
Zweifel die einzige sichere Möglichkeit, eine Hypoglycaemia factitia durch
Sulfonylharnstoffeinnahme zu diagnostizieren.
Differences in insulin secretion facilitate
the differential diagnosis of insulinoma and factitious hypoglycaemia
History: A 33-year-old female nurse
(married; two children; BMI 30.9 kg/m²) had recurrent
episodes of symptomatic hypoglycaemia over some months.
Investigations: Two fasting tests were
terminated after 26 hours because the patient became unconscious.
Improved insulin/glucose ratio was ∞ and 6.1 [mU/l]/[mg/dl] (normal
value < 0.5). An hyperinsulinaemic-hypoglycaemic »clamp« test
produced a C-peptide suppression to minimally 0.26 - 0.38
nmol/l (normal value 0.06 ± 0.01 nmol). There
was no spontaneous or paradoxical burst in insulin or C-peptide
concentration after either the fasting or the »clamp« test.
Serum analysis of sulphonylurea on several occasions documented
an increase of glibenclamide above therapeutic range.
Treatment and course: The patient denied
any intake of oral antidiabetic preparations, but there were no
further hypoglycaemia attacks in subsequent months.
Diagnosis: The demonstration of sulphonylurea
in serum confirmed the diagnosis of factitious hypoglycaemia.
Conclusion: With regard to insulin or
C-peptide suppression, the results of the fasting and clamp tests
are the same in factitious hypoglycaemia and insulinoma. However,
under the influence of sulphonylurea drugs there are no insulin
or C-peptide bursts so typical of insulinoma. In case of doubt,
detection of sulphonylurea preparations in serum or urine is the
only reliable way of diagnosing factitious hypoglaema due to the
ingestion of sulphonylurea.
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Korrespondenz
Prof. Dr. med. Michael Nauck
Diabetes-Zentrum Bad Lauterberg
Kirchberg 21
37431 Bad Lauterberg
Phone: 05524/81218
Fax: 05524/81398
Email: M.Nauck@diabeteszentrum.de