Dr.Bosnak’s
DRUG DETECTIVES
A Life on the Edge
Episode 43
Marcus, a 7-year-old boy, has been showing signs of unusual thirst, frequent trips to the bathroom, and excessive tiredness at school. His teacher, Mrs. Anderson, contacts Marcus’s mother after noticing these symptoms, and she insists that Marcus be taken to the doctor. Marcus’s mother, who is a close friend of Dr. Emily Torres, reaches out to her for advice. Emily, though hesitant at first, decides to have the case checked out more thoroughly, even though it doesn’t seem like a potential criminal case. Emily suspects that Marcus may be dealing with Type-1 Diabetes Mellitus (T1DM), but since the symptoms are so vague, she decides to call on her colleague, Dr. Ethan, to take a second look.
Marcus is diagnosed with Type-1 Diabetes Mellitus (T1DM) after a blood test reveals elevated blood glucose levels and high HbA1c. Emily and Ethan decide to admit Marcus to the hospital for stabilization. His treatment starts with the administration of insulin glargine for basal control, and insulin aspart for bolus doses with meals. The treatment goals are set to bring Marcus’s blood glucose levels to within the ADA guidelines: 80-130 mg/dL before meals and 100-140 mg/dL at bedtime. I. Insulin Glargine: 0.5 units/kg body weight (approximately 12 units for Marcus, who weighs 24 kg). II. Insulin Aspart: 0.1 units/kg body weight per meal (about 2-3 units per meal based on carbohydrate intake). His blood glucose is carefully monitored, and he is started on IV fluids (normal saline) to correct dehydration and prevent complications. Emily feels reassured after seeing initial improvements in Marcus's condition.
On the second night, Marcus’s condition deteriorates rapidly. His blood glucose suddenly spikes to dangerous levels despite the insulin regimen, and his heart rate becomes irregular. Despite efforts to stabilize him, Marcus unexpectedly passes away in his sleep, leading to shock and confusion among the medical staff. Emily and Ethan are both devastated. Dr. Ethan calls Detective Mack, to come to the hospital. Although Marcus's death doesn’t initially seem suspicious, the rapid deterioration catches the team's attention, and they start to question the cause. Is it a complication of the diabetes, or something more sinister?
Dr. Ethan, Detective Mack and YOU start the process of investigating. Ethan is the one who first raises concerns about Marcus’s treatment plan, taking a deeper look at the clinical details. Dr. Emily Torres delve deeper, a seemingly unrelated piece of information emerges that distracts the team. Emily discovers traces of a rare bacterium, Stenotrophomonas maltophilia, on the IV catheter site used during Marcus's hospital stay. This bacterium is often associated with hospital-acquired infections and can cause severe complications, especially in immunocompromised patients or those with diabetes. Initially, Dr. Emily Torres and the medical team consider the possibility of a hospital-acquired infection (HAI) due to Marcus’s rapid deterioration, which is often associated with sepsis or other infections in hospitalized patients. YOU had exhibited a few early warning signs of infection: rapid heartbeat, and signs of systemic distress.
Initial findings reveal that: I. The IV line was changed within hospital protocol timelines, and no evidence of contamination was noted during routine checks. II. The patient showed no typical systemic symptoms (fever, chills) associated with an active infection. III. The bacterium was only detected on the external surface of the catheter, not in blood cultures or tissue samples.
Initially, Dr. Emily Torres and the medical team consider the possibility of a hospital-acquired infection (HAI) due to Marcus’s rapid deterioration, which is often associated with sepsis or other infections in hospitalized patients. Marcus had exhibited a few early warning signs of infection: rapid heartbeat, and signs of systemic distress. I. His blood cultures is negative for pathogens II. Marcus’s white blood cell count remained within the normal range III. Though Marcus showed signs of distress early on, he did not develop a sustained fever or chills
Your forensic approach turned the investigation’s focus toward Marcus’s treatment. The team began to examine the medication administration process. The potential for insulin overdose or hypoglycemia due to this mix-up was high, and this could have led to Marcus’s sudden decline and eventual death. Ethan’s forensic background was pivotal in identifying the medication error as the critical issue, and the team immediately shifted their attention to investigating the pharmacy records and medication administration process more closely. Despite initial interventions, Marcus’s blood glucose levels remain unstable. Over the next 48 hours, he experiences sharp fluctuations in blood sugar despite receiving the correct insulin doses.
YOU uncovered that Marcus’s insulin prescription had been recently refilled at a local pharmacy, could an error have occurred when the pharmacist mistakenly dispensed insulin detemir instead of the prescribed insulin glargine? You toughed that both are a long-acting basal insulin. Both are similar in function but have different pharmacokinetics. At that point, the best idea is to make a visit to local pharmacy. You called Mack immediately.
The pharmacy staff initially insists that the correct medication was dispensed, but the records show discrepancies between the prescribed insulin and the one given to Marcus. The pharmacist, Sarah Miller, claims that the substitution was an innocent mistake and that she followed standard protocols. Despite her calm demeanor, You and Mack become more suspicious. Emily, trying to be methodical, contacts the lab to review Marcus’s blood test results. While she waits for further analysis, the team is uncertain about how to proceed with the investigation.
Emily receives unexpected lab results from the hospital’s forensic lab: a marked elevation in C-peptide levels. The elevated C-peptide indicates that Marcus’s body had been producing excessive insulin, but the insulin administered was not absorbed properly. This sharply suggests that Marcus may have been overdosed on insulin, potentially leading to a fatal hypoglycemic event. Emily realizes that this finding could change the direction of the investigation.
We’ve gathered everything. Now it’s your call—what’s your decision?
Which of the following can cause the patient's death?
A. Although blood cultures and clinical signs didn't immediately indicate sepsis, Stenotrophomonas maltophilia contamination of Marcus’s IV catheter might have caused a localized infection that went undetected. Such infections can rapidly become systemic, leading to septic shock. This hypothesis seemed plausible at first but was ruled out due to the lack of systemic infection markers like fever, elevated white blood cell count, or positive blood cultures.
B. Marcus’s T1DM might have been accompanied by an undiagnosed autoimmune condition, such as autoimmune polyglandular syndrome. This rare syndrome can affect multiple endocrine organs, leading to adrenal insufficiency or thyroid dysfunction. A sudden adrenal crisis due to unrecognized Addison’s disease could explain Marcus’s rapid decline and cardiac arrest.
C. An insulin overdose occurred due to a dispensing error at the pharmacy. Instead of the prescribed insulin glargine, Marcus received insulin detemir. Although both are long-acting insulins, detemir's different pharmacokinetics led to fluctuations in his blood glucose levels, creating a mismatch with his treatment plan. This error caused severe hypoglycemia during the night, leading to Marcus’s sudden death.
