Case 2: Prolonged Hypoglycemia in an Adolescent without Diabetes

Abstract

1. Akshay Sharma, MBBS* 2. Irene Hong-McAtee, MD† 1. *St Jude Children's Research Hospital, Memphis, TN. 2. †Division of Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN. A 16-year-old girl who has no contributory past medical history suddenly starts experiencing generalized weakness and drowsiness. In the emergency department, her finger stick blood glucose (BG) is 22 mg/dL (1.2 mmol/L) (fasting reference range 70–99 mg/dL [3.9–5.5 mmol/L]). She is given 160 mL of 12.5% dextrose intravenously (IV) and is admitted to the pediatric intensive care unit (PICU) for monitoring and further management. On arrival to the PICU, her vital signs show sinus tachycardia (heart rate of 118 beats per minute). Her weight is 38.9 kg and height is 144.7 cm (both below the 3rd percentile). Her physical examination findings are otherwise unremarkable. Her basic metabolic profile and complete blood cell count do not reveal any abnormalities except a low BG. Blood is collected to measure serum insulin, C-peptide, proinsulin, β-hydroxybutyric acid, and ketones when her BG concentration decreases to less than 50 mg/dL (2.8 mmol/L) in the PICU. She is given 12.5% dextrose multiple times as well as a glucagon injection once for BG less than 50 mg/dL (2.8 mmol/L) (Figure). Strikingly, she does not display any other symptoms until her BG decreases to less than 20 mg/dL (1.1 mmol/L). At one point her BG reaches 12 mg/dL (0.7 mmol/L) and she develops diaphoresis but she still remains conversational. Her urine drug screen is negative for any oral hypoglycemic agents. Corticotropin and glucagon stimulation tests as well as …