Cases Wild


"Factitious Hypoglycemia," the poster title said. What on earth is that about, I thought to myself.

I was checking out the posters at the British Society for Endocrinology's BES meeting last month in Manchester, England, when the poster caught my eye. I had to read the poster to remind myself what "factitious" meant.

The full title was "Factitious hypoglycaemia in a patient without diabetes" and it described a supermarket manager who, for no apparent reason, was injecting himself with insulin. The authors noted that insulin has an anabolic effect, and rapid decreases in blood glucose can cause euphoria, but the patient's motives in this case were unclear.

Turns out that it wasn't the only such report at BES. A couple rows over, another poster was titled "Forensic endocrinology: a case report of factitious hypoglycaemia," about a nondiabetic woman with a nine-month history of fainting and other symptoms suggestive of low blood glucose.

The researchers in this case also sleuthed out the likelihood that she was injecting insulin. Her high levels of serum insulin and low blood sugar, in the absence of other abnormalities, left no other plausible alternatives.

It also transpired that the woman was in trouble with the law. Her doctors surmised that she was trying to evade jail time.

In fact, a Google search disclosed a considerable literature on factitious hyperglycemia.

I bring this up because it highlights the continued importance of case reports in medicine. It's popular nowadays to pooh-pooh any publication that isn't a large, prospective, randomized, non-industry-sponsored trial, and indeed MedPage Today hardly ever reports on cases, no matter how interesting.

It's true, probably 99.9% of case reports don't have any long-term importance and don't deserve much attention.

But, on the other hand, most of what we know about medicine began with case reports.

They certainly make small meetings like BES more interesting. Out of several hundred posters and podium presentations, I think there was only one randomized trial. Most of the reports were retrospective single-institution experiences or in vitro studies.

Useful to somebody, I'm sure. But if it weren't for the case reports, I might never have known that:

  • Eating seaweed can damage your thyroid
  • Car wrecks can disrupt your electrolyte balance
  • When you're fat despite heavy exercise, suspect an endocrine tumor
  • Polypharmacy in patients can diminish sodium levels fatally
  • Magnesium deficiency is a serious clinical condition
  • Licorice tea is not necessarily benign
It would be a shame if there were never room for reports like these.