December 23, 2007
A1c (Glycohemoglobin, HgbA1c), Behavior
Question from Montreal, Canada:
A 13-year-old female patient with type 1 diabetes on insulin pump therapy with persistent elevated A1cs (over 14%) and elevated fructosamine (checked with different laboratories) has normal home blood glucose monitoring 80% of the time. Screening blood work, including hemoglobin electrophoresis, was normal.
The glucometer, which was calibrated, correlates with blood glucoses reported. Occasional random blood sugars were high, 10 mmol/L [180 mg/dl] to 12 mmol/L [216 mg/dl] in clinic.
Pump history – daily boluses of 70 to 75 units, hardly any missing of boluses.
Hospital admission (three days) showed 35 % readings are high. Subsequently, basal and boluses were adjusted.
Recent CGMS: 25% readings were moderately high and 10% were low and the rest are within target range. But, the A1c remained over 14% and the patient looked well. Urine was negative for ketone and glucose.
The family and patient denied any foul play, but we cannot rule out non compliance 100%.
What do you think is going on?
Answer:
Most likely, there were falsified blood glucose results. Spit will do this as will anything else used to dilute the blood. Parents may be collaborators, i.e., Munchausen by proxy. If the A1c and fructosamine are both high, then there is not likely a laboratory error or any laboratory interference, and SBGM not elevated, not much else possible especially if you have confirmation from CGMS. The patient could be admitted to a hospital unit for 72 hours with 100% direct nursing staffing so that no shenanigans are possible, but I think you already have your diagnosis. Under such circumstances, I usually think of sexual or physical abuse as the underlying psychosocial rationale, almost always denied, for such manipulation so the treatment will be to continue to keep communications open, try to be non-accusatory and wait for maturity to allow appropriate counseling.
SB
