Recurrent Hypothermia and Hypoglycemia as the Initial Presentation of Hepatitis C

Abstract

Purpose: Hypothermia and hypoglycemia on initial presentation is sepsis until proven otherwise. However, hypothermia and hypoglycemia can coexist in other conditions such as severe malnutrition, neurological injury, alcoholism, hypothyroidism, and adrenal insufficiency. Hepatitis C most commonly manifests with asymptomatic elevations in transaminase levels. We describe the case of a 50-year-old African American male who had recurrent hypothermia and hypoglycemia as the initial presentation of Hepatitis C. Methods: Case: A 50-year-old African American male with a past medical history of diabetes mellitus 2, hypothyroidism, seizure disorder, and remote alcoholism presented with acute onset of altered mental status and hypothermia in the ER. He had been hypoglycemic at the nursing home in the absence of insulin or other medications associated with hypoglycemia. Laboratory evaluation on admission revealed an unremarkable complete metabolic panel, ammonia level, amylase, lipase, urine drug screen, and blood alcohol level. A head CT was unremarkable for an acute neurological event. It was presumed that the patient's disorientation was secondary to hypoglycemia at his nursing home and possible sepsis, given his hypothermia. Broad spectrum antibiotics were initiated. However, the patient continued to experience hypoglycemia despite a 10% dextrose drip and recurrent hypothermia in the absence of sepsis. Further investigations including thyroid studies, AM cortisol, insulin, proinsulin, c-peptide, insulin antibodies, adrenocorticotropic hormone (ACTH), aldosterone, HIV studies, and microbial cultures were all negative. An abdominal CT revealed a dilated common bile duct, a possible hepatoma, and a dilated pancreatic duct. An endoscopic ultrasound (EUS) was performed to evaluate for malignancy, such as a hepatoma that may secrete insulin growth factor causing hypoglycemia. EUS revealed severe chronic pancreatitis without evidence of a mass. Hepatitis studies done when there was suspicion for a hepatoma revealed the patient to be positive for hepatitis C antibody, which was confirmed by positive RNA. He was found to have a low glucagon level, which explained his hypoglycemia, while his liver disease explained his hypothermia. His mental status improved with aggressive glucose supplementation and warming blankets. Later in his hospital course, the patient developed sequelae of liver disease being ascites and coagulopathy. Conclusion: We describe a rare case of Chronic Hepatitis C that presented with recurrent hypoglycemia as a result of glucagon depletion and recurrent hypothermia from advanced liver disease without previous liver disease sequelae.