ABSTRACT
Introduction: Hypoglycaemia has manifold potential aetiologies, from environmental to iatrogenic, presenting in isolation to as part of syndrome, from insulin excess to defects in endogenous pathways, and simple Mendelian to complex modes of inheritance. We investigated 3 patients with Hypoglycaemic Episodes (HE) in December 2020 in a District General Hospital. Case series: • A 27-year- old man without co-morbidities presenting with neuroglycopaenic symptoms and HE, with a family history of maternal neuroendocrine tumour. During the 72-hour fast, patient developed hypoglycaemia (1.8 mmol/L) with inappropriately raised c-peptides (718 nmol/L) and insulin (25.7 pmol/L) levels. MRI pancreas demonstrated 1-cm lesion in tail. MRI pituitary was normal in spite of raised prolactin (687 mIU/L). Started on Diazoxide, he is awaiting pancreatic surgery and genetic testing. • A 85-year- old woman with heart failure presented with hypothermia, hypotension and hypoglycaemia (1.4 mmol/L). Treated for urosepsis with normal 9 am cortisol, fasting HE persisted. Medication review led to sacubitril as rare cause for HE. This was proven on resolution of HE on stopping of culprit agent. • A 67-year- old woman, type 1 diabetic for 50 years with dementia, referred for severe HE throughout 24 hours. Normal 9 am cortisol ruled out Addison's and clinical examination ruled out lipoatrophy/hypertrophy. Though erratic diet accounted for HE, district nurse administration made BD mix insulin imperative. Careful written dietary guidance with carer supervision was introduced to avoid life-threatening HE. Conclusion: Hypoglycaemia affects life and livelihood with varying aetiologies. Thus we should always be on the lookout for causes and think outside the box.