Case discussion: patient with persistent hypoglycemia

Dr Serenity · Oct 8, 2007

First off...NOT meant to be a pimping thread...just tossing out a case for discussion amongst fellow colleagues 😀

So...imagine that while on call, you are called to admit a 47 year old white man who presented to the ER after being found unresponsive on the floor by his girlfriend. When the EMTs arrived at the patient's home, they found that his capillary blood sugar was in the low 30s. He was given an amp of D50 and glucagon enroute, after which he regained consciousness. Upon arrival in the ER, labs (Chem-10, CBC) were drawn; his glucose at that time was 40. Another amp of D50 was given and the patient was placed on a D5 drip before you were called to come to the ER.

When you question the patient, he states that he is currently asymptomatic...no F/C/nausea/vomiting/CP/SOB. He is awake, alert and oriented to person, place and date. He has no past medical history to speak of, though he admits to current polysubstance abuse (cocaine, EtOH, MJ, tobacco). Currently does not take any medications; he has not done so for several months. No known drug allergies and no family history to speak of. He lives with his girlfriend who is a diabetic who takes "pills" to manage her diabetes; he is currently unemployed.

Vitals are within normal limits and stable. Physical exam does not reveal any gross abnormalities. EKG demonstrates NSR. While you interview the patient, a nurse comes by to take another CBG reading; this time it's 43.

Any thoughts on how you would manage this patient? Should he go to the floor or to the unit? What other pieces of information would you like to know?

redzz · Oct 8, 2007

I'd like to know his EtOH level and if he has taken any of those mysterious "pills" of his girlfriends.

BADMD · Oct 9, 2007

Since no one else has taken the bait, I'll throw some things out there.

Have to assume it is an ingestion. Likely sulfonylurea, however other drugs such as meglitinides can give a similar picture. Insulin is also possible, but then he would have to inject (unless he got a hold of Exubera). I doubt he is in Jamaica, so I'll toss Akee fruit ingestion as a possibility. I want to know about herbals, supplements and OTC. Aspirin and other uncouplers can cause hypoglycemia in overdose and some herbal preparations, especially those formulated for diabetics, have been know to be tainted with prescription diabetes medications.

Other potential diagnoses include alcohol (although recurrent hypoglycemia on D5 is unlikely) and sepsis. A sudden onset insulinoma seems pretty unlikely. I'm sure there are other possible Dx, however most will not give recurrent hypoglycemia while on a glucose infusion.

So, this is most likely a sulfonylurea ingestion but there are I want an ASA level and I want to see if I can ID this mystery pill. Then I want to block insulin secretion.

I'll leave the explaination for his recurrent episodes andhow to treat it to someone else.

madcadaver · Oct 11, 2007

You can measure plasma or urine sulfonylurea levels to confirm ingestion-- I have only done this once and it was sent out to who knows where.

Check insulin and c-peptide. Check cortisol.

spinalman · Nov 19, 2011

i wouldl ike to think about addison crisis ...we could withdraw serum cortisol ,,we could give hydrocortisone 200 mg and see if any improvemnet of serum glucose level is present ??

IMdocT · Nov 19, 2011

first post as a bump to a 4-year-old thread, eh? not that there's anything wrong with that.

jdh71 · Nov 19, 2011

This ****** got into his GF's pills looking to get I'm sure and took her sulfonylureas. He gets a glucogon drip and an ICU stay. Done.

turkeyjerky · Nov 20, 2011

jdh71 said:
This ****** got into his GF's pills looking to get I'm sure and took her sulfonylureas. He gets a glucogon drip and an ICU stay. Done.

Glucagon? I thought the Rx was Octeotide and dextrose as needed.

jdh71 · Nov 20, 2011

turkeyjerky said:
Glucagon? I thought the Rx was Octeotide and dextrose as needed.

You could do that. But glucagon inhibits the release of endogenous insulin plus increases blood glucose. I've found it's action to be much more predictable.

McPoyle · Nov 21, 2011

Any consideration of an insulinoma, or is the presentation too acute?

jdh71 · Nov 21, 2011

ericL said:
Any consideration of an insulinoma, or is the presentation too acute?

Well, since this is internal medicine, it's possible . . . so you'd probably do a screening work-up for that. He did have whipple's triad.

Gastrapathy · Nov 22, 2011

Nesidioblastosis.

Done.

BlackNDecker · Dec 5, 2011

I'll play. Most likely ingestion...likely gf's "sugar diabetus" pills. I've seen profound hypoglycemia from b-blocker intoxication. I probably wouldn't jump straight to IV glucagon but I would keep it on in hand just in case the pills in question were b-blockers. I would start D5W or D50W and check glucose Q1H for the first couple hrs.

The usual suspects should be considered. WHipple's triad has been confirmed so you need to sort out why. Get the labs, check the insulin, c-peptide, blah blah blah. I agree insulinoma is unlikely..but a hyperinsulin state needs to be ruled out (anti-insulin antibody syndrome).

Gastrapathy said:
Nesidioblastosis.

Done.

Unlikely. This falls under the postprandial hypoglycemic syndromes and I have never seen anyone present with "an unresponsive spell" who turned out to have nesidioblastosis...or more commonly post-gastric bypass syndrome.

Something is causing this gentleman to remain hypoglycemic (and is still exerting insulin-like effects) despite repletion of blood glucose. Ingestion. No question.

Done.

AZhopeful · Dec 5, 2011

One of my previous classmates, now a surgery intern, was just telling me about someone he had the other night who was suddenly REALLY hypoglycemic on the floor. Got amp of D50, then got hypoglycemic again. Then again. Then some more.

Intern asks, "are you sure we didn't give him something that could do this?" Nurse thinks, then goes white... nurse had switched up the pt's insulin gtt and his antibiotic bag. The antibiotic was getting dripped in at a miniscule rate, and the insulin was going in like an antibiotic- basically a big long insulin bolus.

OP: are you going to let us know what really happened?(since this is a Medicine thread and it definitely can't just be the obvious sulfonylurea intoxication).

BlackNDecker · Dec 5, 2011

The OP hasn't posted in this thread since 2007. Methinks you have a better chance of getting a lap dance from Santa Claus than you do of resolution of this case.

jdh71 · Dec 5, 2011

BlackNDecker said:
I'll play. Most likely ingestion...likely gf's "sugar diabetus" pills. I've seen profound hypoglycemia from b-blocker intoxication. I probably wouldn't jump straight to IV glucagon but I would keep it on in hand just in case the pills in question were b-blockers. I would start D5W or D50W and check glucose Q1H for the first couple hrs.

Interestingly enough you'd want to use high dose insulin for beta-blocker overdose, which wouldn't help the sugars too much. 😀

BlackNDecker · Dec 6, 2011

jdh71 said:
Interestingly enough you'd want to use high dose insulin for beta-blocker overdose, which wouldn't help the sugars too much. 😀

We used a protocol outlined by our pharmacy...as well as intermittent pushes of iv calcium for cardiogenic shock. That was a long night in the ICU and there were other drugs given (like Ativan and Keppra for status). I would never try to manage suspected b-blocker over dose "off the cuff"... I guess that's what I get for going off on a tangent above.

jdh71 · Dec 6, 2011

BlackNDecker said:
We used a protocol outlined by our pharmacy...as well as intermittent pushes of iv calcium for cardiogenic shock. That was a long night in the ICU and there were other drugs given (like Ativan and Keppra for status). I would never try to manage suspected b-blocker over dose "off the cuff"... I guess that's what I get for going off on a tangent above.

This tangent is as good as another. 😀

Did you guys use a glucagon protocol or an insulin one?

BlackNDecker · Dec 6, 2011

jdh71 said:
This tangent is as good as another. 😀

Did you guys use a glucagon protocol or an insulin one?

That's the part that is foggy...and I've been too lazy to look it up to win (or lose) an Internet argument. It very well could have been a high dose insulin infusion and the Glucagon was added to prevent hypoglycemia. If I have time this evening I will look into it.

Returning to the case, the rest of my points were valid.🙄

jdh71 · Dec 6, 2011

BlackNDecker said:
That's the part that is foggy...and I've been too lazy to look it up to win (or lose) an Internet argument. It very well could have been a high dose insulin infusion and the Glucagon was added to prevent hypoglycemia. If I have time this evening I will look into it.

Returning to the case, the rest of my points were valid.🙄

I didn't know we were arguing.

I'm going to have to get much more unpleasant if we are. :laugh:

BlackNDecker · Dec 6, 2011

So I just spoke with pharmacy here and we do in fact use a high dose glucagon infusion. The purpose of the high dose glucagon is to harness the sympathomimetic activity (glucagon acts as a weak inotrope at sufficiently high doses), whereas the purpose of the insulin is simply to counteract the hyperglycemia.

This is such a rare scenario I couldn't remember all the details...but thanks for getting me to knock the dust off and look into this again :laugh:

Case discussion: patient with persistent hypoglycemia

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