MON-LB026 Critical Illness Associated Fatal Hypoglycemia in a Non-Diabetic Male

Abstract

Introduction: Hypoglycemia in non-diabetic patients can be diagnostically challenging. It can have various etiologies including medications, tumors, post gastric bypass surgery, alcohol use, critical illness, liver/renal disease and adrenal insufficiency. We present a case of a 55-year old male with persistent, refractory hypoglycemia in the absence of Diabetes Mellitus (DM). Case Description: Patient is a 55-year old male with past medical history of Congestive Heart Failure with ejection fraction of 30%, Chronic Kidney Disease, Atrial Fibrillation, and alcohol abuse. He presented with sudden onset severe abdominal pain. Admission vitals were stable except oxygen saturation of 70% on room air. Labs were significant for lactic acid of 5.3 mmol/L and Acute Kidney Injury (AKI). CT scan of the abdomen was unremarkable. The patient was admitted to the ICU for severe acute hypoxic respiratory failure and mesenteric ischemia. On hospital day-3, he became unresponsive. At that time, his labs revealed blood sugar of less than 10 mg/dl and worsening renal failure. The patient was given multiple ampules of Dextrose 50% and infusion of dextrose 5% was started. He was initiated on Continuous Renal Replacement Therapy (CRRT) as well. Despite this, his blood sugar remained in the 40’s. His IV fluids were switched to Dextrose 10% and eventually to Dextrose 20% because of persistent hypoglycemia, also requiring intermittent IV Glucagon. He had no family or personal history of DM. HbA1c was 5.6%. Cortisol, Pro-insulin, Insulin, C-peptide levels were normal. Sulfonylurea screen was negative. Liver Function Tests were normal. Endoscopic Ultrasound did not reveal any pancreatic mass. Paracentesis of ascitic fluid was suggestive of underlying liver cirrhosis. It was then determined that the patient’s hypoglycemia was likely secondary to critical illness along with underlying severe hepatic and renal failure. The patient’s overall prognosis was poor and his condition declined rapidly. He refused any further intervention and opted for hospice care. Conclusion: Patients with critical illness especially those with underlying advanced liver/renal disease, malnutrition and advanced age may develop profound hypoglycemia even in the absence of diabetes. These patients should have frequent monitoring of blood sugar levels. Prompt support for decompensated disease is vital for overall survival.