A Case of Hypoglycemia: Multifactorial Overlooked Mechanisms

Presentation Number: MON 605
Date of Presentation: April 3rd, 2017

Omar Mohamed El Kawkgi* and Chelsea Gordner
Baystate Medical Center- University of Massachusetts Medical School, Springfield, MA

Abstract

Background: In patients not currently being treated for diabetes, hypoglycemia is uncommon. We aim to utilize a multifactorial approach that encompasses common yet overlooked risk factors.

Clinical Case: A 46 year old female with history of lifestyle controlled T2DM, Roux-En-Y gastric bypass 3 years ago complicated by recurrent self reported hypoglycemia episodes, discoid lupus, previously treated with steroids over 5 years ago, & chronic opioid use with oxycodone 20 mg/d, presented with abdominal pain associated with nausea, vomiting and tremulousness. Vitals were unremarkable and exam significant only for epigastric tenderness. Septic work up, abdominal imaging, and liver and pancreatic enzymes were unrevealing. Routine labs revealed a glucose level of 45 mg/dL (ref:70-99 mg/dL). She denied any oral antihyperglycemic or insulin use for over 9 years, and suspicion for surreptitious insulin use was low. 25 gm of dextrose brought blood glucose to 121 mg/dL albeit transiently. 1 mg of glucagon increased pre- glucagon glucose level from 79 mg/dL to 109 mg/dL approximately 20 minutes later. Repeat glucose level again decreased to 61 mg/dL within 30 minutes requiring ICU level of care and continuous dextrose infusion. C-peptide, insulin and pro-insulin level at the time of hypoglycemia (45 mg/dL) were 2.2 ng/mL (ref: 1.1-4.4), 16.6 mIU/mL (ref:2.6- 24.9), and 11 pmol/L (ref: 3-20) respectively. Beta hydroxybutyrate level was unavailable. Additional endocrinological markers were obtained revealing an inappropriately low random cortisol level at 2.7 μg/dL (ref: 6.2-19.4 μg/dL), and ACTH level of <5.0 pg/mL (ref: 10-60 pg/mL). Standard cortrosyn stimulation test yielded cortisol levels of 12.2 and 18.7 μg/dL at 30 and 60 minutes respectively from baseline of 1.3 μg/dL. Hypoglycemia improved with stress dose steroids transitioned to oral steroids, & with nutritional advice.

Conclusion: The etiology of hypoglycemia is less discernible in patients without diabetes and may be multifactorial. Common overlooked risk factors are history of Roux-En-Y gastric bypass and chronic narcotic use. With increasing prevalence of obesity and bariatric surgery, post prandial hypoglycemia remains a significant risk. Robust glucagon response is suggestive of insulin mediated hypoglycemia, likely from beta cell hypertrophy. “Opioid endocrinopathy” is another under emphasized mechanism leading to hypoglycemia. With an inhibitory effect on ACTH secretion, acute stress response and counterregulatory hormone production is compromised, particularly complicated in this case by presumed low glycogen stores in the setting of recent weight loss. A multi factorial approach should be utilized when identifying hypoglycemia in patients without diabetes; common risk factors such as opioid use and gastric bypass surgery and their effects on hormonal regulatory mechanisms should be considered early on.

 

Nothing to Disclose: OME, CG