Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia

Wexler, Deborah J.; Macias‐Konstantopoulos, Wendy; Forcione, David G.; Xiong, Lillian; Cauley, Christy E.; Pierce, Kirsten J

doi:10.1056/nejmcpc1802828

Cited by 15 publications

(8 citation statements)

References 28 publications

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“…Hypoglycemia was more likely to develop in those with elevation of transaminases greater than three times normal and in those with greater severity of malnutrition, as evidenced by 27% of those with AN-R developing hypoglycemia vs. 11% of individuals with AN-BP. Thus, hypoglycemia as a surrogate of severity of illness was supported [22,23]. This is very important because our experience suggests lean people do not typically have the customary adrenergic or neuroglycopenic warning symptoms typical of severe hypoglycemia [22].…”

Section: Discussionmentioning

confidence: 81%

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Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

et al. 2020

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Background: Extreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m 2 in those meeting DSM-V diagnostic criteria for AN. This study seeks to define the frequency of medical complications in this group of patients in order to help inform the care of individuals < 65% ideal body weight who seek treatment for their extreme eating disorders. Methods: Through retrospective chart review and computerized data collection, we obtained the baseline characteristics and medical findings of 281 adult patients, with AN restricting and binge-purge subtypes, admitted to the ACUTE unit for medical stabilization between May 2013 and August 2018. Results: In this population, with a mean admitting BMI of 12.1 kg/m 2 (range = 7.5-15.7), 56% admitted with bradycardia, 45% demonstrated increased liver function tests (LFTs) on admission, 64% admitted with leukopenia, 47% with anemia, and 20% presented with thrombocytopenia. During admission, 38% developed hypoglycemia, 35% developed refeeding hypophosphatemia, nearly 33% of patients developed edema, and low bone mineral density was diagnosed in almost 90% of the patients. Highly elevated LFTs (>3x upper limits of normal) predicted hypoglycemia, and low BMI predicted refeeding hypophosphatemia (p = .001). Conclusions: Although conclusions drawn from the findings presented in this descriptive study must be tempered by relevant clinical judgement, these findings showcase that patients with extreme AN are at significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

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Section: Discussionmentioning

confidence: 81%

“…Thus, hypoglycemia as a surrogate of severity of illness was supported [22,23]. This is very important because our experience suggests lean people do not typically have the customary adrenergic or neuroglycopenic warning symptoms typical of severe hypoglycemia [22].…”

Section: Discussionmentioning

confidence: 81%

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

et al. 2020

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“…Insulinoma is a rare neuroendocrine tumor that produces excess endogenous insulin, resulting in hypoglycemia [4]. As previously shown, hypoglycemia unawareness is not rare in patients with insulinoma, and it can obscure a patient's notice of hypoglycemia [3].…”

Section: Discussionmentioning

confidence: 99%

“…remains a clinical issue [4]. One of the main causes of delay is hypoglycemia unawareness, which can obscure a patient's notice of hypoglycemia and worsen the outcomes [3][4][5]. In this context, continuous glucose monitoring (CGM) has been demonstrated to be a useful tool to detect hypoglycemia in cases of insulinoma with hypoglycemia unawareness [5][6][7].…”

mentioning

confidence: 99%

Factory-calibrated continuous glucose monitoring and capillary blood glucose monitoring in a case with insulinoma: usefulness and possible pitfall under chronic hyperinsulinemic hypoglycemia

et al. 2020

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The accuracy of factory-calibrated continuous glucose monitoring (fCGM) within hypoglycemic ranges, especially under the status of chronic hyperinsulinemic hypoglycemia like insulinomas, remains an issue. Even so, fCGM is known to be useful for detecting hypoglycemia unawareness in insulinoma cases. A 25-year-old woman presenting with sudden unconsciousness was diagnosed with insulinoma; fCGM facilitated diagnosis by continuous monitoring for hypoglycemia. Before surgery, she was treated with continuous and frequent bolus infusions of 50% glucose via central venous catheter. To evaluate the accuracy of fCGM values in this case, a comparison between fCGM and capillary blood glucose (CBG) values was also performed. According to the simultaneously measured values, those of fCGM were largely in accordance with those of CBG. Moreover, compared with the previously reported case not having glucose infusions via central venous catheter, both the mean absolute relative differences (MARDs) and the absolute differences (Δ glucose) between fCGM and CBG values were larger in the present case, although no significant differences of MARDs and Δ glucose between the two cases were observed in several different conditions including fasting, post-meal, hypoglycemia, and others. Therefore, we should note possible increased differences between fCGM and CBG values in cases using frequent intravenous glucose infusions as well as case-dependent differing levels of consistency between them.

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“…Delays to a diagnosis can be caused by a number of factors (Wexler et al, 2018). For example, insulinoma can exhibit various neurogenic and neuroglycopenic symptoms.…”

Section: Discussionmentioning

confidence: 99%

Insulinoma Presenting as a Complex Partial Seizure: Still a Possible Misleading Factor

et al. 2020

Front. Neurosci.

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Delayed diagnosis of insulinoma remains an intractable clinical challenge because the symptoms are in most cases misattributed to other disorders. In this study, a 64-yearold man presented with intermittent seizure episodes after being misdiagnosed with epilepsy and receiving anti-epileptic drugs for 4 years. During this period, the patient continued to suffer from repeated seizures. A starvation test, pancreatic enhancement CT, MRI scan, and pathological examination clinically diagnosed insulinoma, and the symptoms improved following surgical removal of the tumor. The appearance of unusual manifestations and insulinoma imaging makes it difficult to accurately diagnose the condition. This case emphasizes the need for careful reassessment of all atypical and refractory seizures for neurologists.

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Case 23-2018: A 36-Year-Old Man with Episodes of Confusion and Hypoglycemia

Cited by 15 publications

References 28 publications

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

Factory-calibrated continuous glucose monitoring and capillary blood glucose monitoring in a case with insulinoma: usefulness and possible pitfall under chronic hyperinsulinemic hypoglycemia

Insulinoma Presenting as a Complex Partial Seizure: Still a Possible Misleading Factor

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