Whipple Triad Its Limitations in Diagnosis and Management of Hypoglycemia as a Co-morbidity in Covid-19 Diabetics and Diabetes Mellitus in General- A Review

Abstract

In 1938 Allen Oldfather Whipple (1881-1963) an American surgeon invented a triad of two clinical and one laboratory parameter to give the Whipple triad which had been in clinical use for decades and beneficial to perhaps millions of people worldwide with hypoglycemia as health challenges. The Whipple triad is characteristically presence of hypoglycemic symptoms, documentation of low blood sugar at the time of hypoglycemic symptoms, and reversal of these symptoms when the blood glucose level is restored to normal. Of note is the fact that over the years Whipple triad had been invaluable in diagnosing hypoglycemia in diabetics, but we should not lose sight of this singular fact that though good and useful for diagnostic purposes, Whipple triad has it's limitations as a diagnostic tool. With Corona virus disease 2019 (COVID 19) pandemic caused by severe acute respiratory distress syndrome coronavirus 2 (SARS CoV-2) affecting the immunosuppresed including diabetics, knowing the limitation of the diagnostic tool for diagnosing the hypoglycemia, a lifelong challenging issue in diabetics is a proactive way of recognizing a possible additional co-morbidity that if not recognized may further put the COVID-19 diabetic patient at risk. Though the issue of hypoglycemia in infected diabetic patient with COVID 19 has not been a major issue for now worldwide, the fact that asymptomatic carrier of COVID 19 diabetic patient could develop hypoglycemia makes it an important issue to be borne in mind by physicians. A google search was conducted in English by typing in the words Whipple, hypoglycemia, diabetes, probable hypoglycemia in pubmed. A literature review was done going through relevant articles. The limitations to Whipple triads were found in hypoglycemia with reversible neurological damage, hypoglycemia with irreversible neurological sequelae, hypoglycemia unawareness and in patients with rebound hypoglycemia. Similarly, Whipple triad limitation of application was found in unconscious patient from other causes other than hypoglycemia. Further limitations were also found in probable symptomatic hypoglycemia and in symptomatic hypoglycemia. Whipple triad has its limitation in medical practice which may be diverse and this have to be borne in mind by the clinician for a holistic approach to patient management especially during this COVID-19 pandemic and thereafter. The question to be addressed in the future remains of all hypoglycemic episodes occurring annually worldwide in diabetic and non diabetic subjects, how many can Whipple triad diagnose? In other words what is the sensitivity, specificity and predictive value of Whipple triad?