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hypoglycaemia_nondiabetic

hypoglycaemia in the non-diabetic patient

introduction

  • hypoglycaemia in patients who are not taking oral hypoglycaemics or insulin is an uncommon presentation to ED
  • Whipple's triad:
    • documentation of low blood sugar
    • presence of symptoms
    • reversal of these symptoms when the blood sugar level is restored to normal
  • absence of Whipple's triad suggests hypoglycaemia is NOT the cause of symptoms

aetiology

neonatal

  • hypoglycaemia is a common life-threatening issue in the newborn, especially small for dates infants, infants of diabetic mothers, erythroblastosis foetalis

children

  • starvation-induced or stress-induced in children with inborn errors of metabolism:
    • inherited liver enzyme deficiencies that restrict hepatic glucose release:
      • deficiencies of glucose-6-phosphatase
      • fructose-1,6-diphosphatase
      • phosphorylase
      • pyruvate carboxylase
      • phosphoenolpyruvate carboxykinase
      • glycogen synthetase
    • inherited defects in fatty acid oxidation, including:
      • that resulting from systemic carnitine deficiency
      • inherited defects in ketogenesis (3-hydroxy-3-methylglutaryl-CoA lyase deficiency)
  • following food:
    • galactosaemia
    • hereditary fructose intolerance
  • accidental poisoning with oral hypoglycaemic agents
  • excessive alcohol intake
  • Reye's syndrome
  • drugs (see under adults)
  • nesidioblastosis (diffuse budding of insulin-secreting cells from pancreatic duct epithelium and pancreatic microadenomas of such cells) is a rare cause in infants and adults, but cases have been reported after gastric bypass surgery
  • ingestion of too many unripe lychee, rambutan, longan or ackee on an empty stomach - these contain an amino acid which can cause hypoglycemia in children - more than 100 die each year in India

adults

  • ovedose with oral hypoglycaemic agents or insulin
  • excessive alcohol intake
  • other drugs which may cause hypoglycaemia:

occurring after more than 5hrs food deprivation

appears ill
  • hypopituitarism
  • Addison's disease
  • large non-islet cell tumour
    • most commonly retroperitoneal or mediastinal malignant mesenchymal tumors
    • tumor secretes abnormal insulinlike growth factor (large IGF-II), which does not bind to its plasma binding proteins.
    • this increase in free IGF-II exerts hypoglycemia through the IGF-I or the insulin receptors.
  • acquired severe liver disease
  • sepsis
  • severe dehydration and starvation (inanition)
appears well
  • low plasma insulin:
    • ketotic hypoglycaemia of childhood
    • alcohol
    • some drugs (see above)
    • prolonged exercise
    • glycogen storage disease
    • ?glucagon deficiency
  • high plasma insulin:
    • low plasma C peptide levels and presence of insulin antibodies:
      • insulin factitial hypoglycaemia
      • insulin autoimmune syndrome (rare)
    • elevated plasma C peptide levels and no insulin antibodies:
      • factitial sulphonylurea intake
      • insulinoma
        • may occur as an isolated abnormality or as a component of the multiple endocrine neoplasia type I (MEN) syndrome
      • insulin-receptor antibodies

occurring within 5 hours of food

appears ill
  • galactosaemia
  • hereditary fructose intolerance
  • Ackee fruit poisoning (Jamaican national fruit but unripe fruit contains hypoglycins and ingestion causes Jamaican vomiting sickness )
appears well
  • early diabetes?
  • alimentary hypoglycaemia (post-GIT surgery)
  • gin and tonic
  • rarely, insulinoma
hypoglycaemia_nondiabetic.txt · Last modified: 2017/02/02 10:29 (external edit)