An 8-week-old infant presented to the emergency department with lethargy, tachycardia, and a blood glucose concentration of 1.8 mmol/L. After admission, hypoglycemia recurred on 3 additional occasions. Initial urinalysis results were negative for ketones, and the results of additional laboratory tests did not support the diagnosis of cortisol or growth hormone deficiency, oral hypoglycemic ingestion, or an inborn error of metabolism. Difficulty restoring and maintaining glucose concentrations along with a transient response to glucagon during 1 hypoglycemic episode suggested hyperinsulinism. In 1 hypoglycemic episode, elevated insulin and low C-peptide concentrations suggested exogenous insulin administration, but 2 subsequent blood samples obtained during hypoglycemia contained appropriately decreased concentrations of insulin. The insulin immunoassay initially used in this case (Roche ElecSys/cobas [Roche Diagnostics, Indianapolis, IN]) was insensitive to insulin analogs. Two additional immunoassays, 1 with intermediate (Immulite [Siemens, Deerfield, IL]) and 1 with broad (radioimmunoassay [Millipore, Inc, Billerica, MA]) reactivity to insulin analogs were used to characterize insulin in each of the critical blood samples. Samples obtained during hypoglycemia displayed a graded reactivity similar to that observed in type 1 diabetic patients prescribed insulin analogs, whereas a sample obtained from the patient and a control subject during euglycemia showed equal reactivity among the 3 assays. These data suggested administration of insulin analog to the child, and further characterization of insulin by using tandem mass spectrometry confirmed the presence of Humalog. The child was subsequently placed in foster care with no further recurrence of hypoglycemia.
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May 01 2010
Detection of Surreptitious Administration of Analog Insulin to an 8-Week-Old Infant
Rebecca P. Green, MD, PhD;
Rebecca P. Green, MD, PhD
aDepartment of Pediatrics, Washington University, St Louis, Missouri; and
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Abby S. Hollander, MD;
Abby S. Hollander, MD
aDepartment of Pediatrics, Washington University, St Louis, Missouri; and
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Mario Thevis, PhD;
Mario Thevis, PhD
bInstitute of Biochemistry, German Sport University Cologne, Cologne, Germany
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Andreas Thomas, PhD;
Andreas Thomas, PhD
bInstitute of Biochemistry, German Sport University Cologne, Cologne, Germany
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Dennis J. Dietzen, PhD
aDepartment of Pediatrics, Washington University, St Louis, Missouri; and
Address correspondence to Dennis J. Dietzen, PhD, Department of Pediatrics, Box 8116, Washington University School of Medicine, 660 S Euclid, St Louis, MO 63110. E-mail: dietzen_d@kids.wustl.edu
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Address correspondence to Dennis J. Dietzen, PhD, Department of Pediatrics, Box 8116, Washington University School of Medicine, 660 S Euclid, St Louis, MO 63110. E-mail: dietzen_d@kids.wustl.edu
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2010) 125 (5): e1236–e1240.
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Accepted:
January 06 2010
Citation
Rebecca P. Green, Abby S. Hollander, Mario Thevis, Andreas Thomas, Dennis J. Dietzen; Detection of Surreptitious Administration of Analog Insulin to an 8-Week-Old Infant. Pediatrics May 2010; 125 (5): e1236–e1240. 10.1542/peds.2009-2273
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