Clinicians screened the boy for INSR defects, but no mutation in the gene was identified. He was retested but again c-peptide was in normal range (not suppressed during profound hypoglycemia). These inconsistent lab tests, the patient’s past history of multiple hospitalization, and the suspicious coincidence of the hypoglycemic episodes occurring when the mother was in the hospital led clinicians to suspect fabricated illness.  Permission was granted for the clinicians to use covert video surveillance and the video showed the mother giving her son various substances through different routes of administration.

After confronting the mother, clinicians were able to establish that she had been giving the child regular insulin SC/IV, glyburide, progesterone, and furosemide occasionally on the same day. She also admitted to giving the boy laxatives to induce episodes of diarrhea which led to the hospitalizations. Once the boy was removed from his mother, his glucose and electrolyte profiles became normal and hirsuitism had resolved.

Given that the clinicians had previous experience with RMS, this case appeared to mimic the features of RMS due to the multiple drugs given by the mother.  The simultaneous administration of insulin along with a long-acting insulin secretagogue (glyburide) made the interpretation of the lab results confusing because it also resulted in normal c-peptide levels. Hirsuitism, which was caused by progesterone administration, is also a common finding in RMS. The metabolic alkalosis could be attributed to the long-term furosemide administration. The sepsis episodes were believed to be brought on by the IV injections the mother performed without antiseptic care.

The negative results from the genetic screening of INSR gene coupled with some missing features of RMS raised suspicion of fabricated illness along with close observation of the mother-son relationship (extreme difficulty managing daily care, loneliness as the only caregiver, and defensive attitude during discussion of diagnostic hypothesis). Also, hypoglycemic crisis was only detected in the presence of the mother.