214: HYPOGLYCEMIA: COMMON BUT UNCOMMONLY IRREVERSIBLE

Abstract

Introduction: Whipple’s Triad is comprised of symptomatic low blood glucose (< 55 mg/dL) and resolution of symptoms after correction of glucose level, indicating the presence of hypoglycemic disorder. Hypoglycemia is often easily reversed with standardized treatment, however; in few cases, hypoglycemia is refractory to standard treatment, requiring further investigation. Hypoglycemia can be associated with prolonged hospitalizations as well as higher morbidity and mortality. Description: 86-year-old white female was admitted to the intensive care unit (ICU) with sepsis. Patient presenting symptoms included: worsening of baseline confusion, generalized weakness, and diaphoresis. Patient arrived to ICU with tremors and a blood glucose level of 50mg/dL (74-99mg/dL). She had no insulin or oral glycemic agents prior to admission. The hypoglycemia protocol was initiated, which included dextrose containing fluids and glucagon. Octreotide and steroids were added, and dextrose fluid concentration increased due to persistent hypoglycemia. Her lack of response led to further evaluation. Differential diagnoses included: cortisol deficiency, insulinoma, insulin autoimmune syndrome and beta cell hypertrophy. Laboratory studies during hypoglycemic episode were obtained which revealed: random cortisol 13.2 mcg/dL, proinsulin greater than 700 pmol/L (3.6-22 pmol/L), insulin level 103 uIU/mL (2.6-24.9 uIU/mL), C-peptide 22.8 ng/mL (1.1-4.4 ng/mL), and insulin antibody (Ab) level zero. Absence of gastric bypass history made beta cell hypertrophy unlikely. Elevated proinsulin levels as well as an insulin and C-peptide ratio of less than one, both present in this patient, are highly suggestive of insulinoma in the absence of oral hypoglycemic use. No further investigation was pursued due to family wishes to focus on comfort care. Discussion: Hypoglycemia is prevalent in critical care. One should keep an open mind when investigating causes of hypoglycemia when standard treatment does not lead to resolution. A detailed history is important when hypoglycemia persists. Insulin, proinsulin, C-peptide levels, and appropriate imaging should be checked during hypoglycemic episode to determine correct diagnosis and management.