Confirmed Hypoglycemia Without Whipple Triad: A Rare Case of Hyper-Warburgism.

Spontaneous hypoglycemia in nondiabetic patients poses a diagnostic challenge. Hypoglycemia in malignancy has several etiologies; an extremely rare mechanism is the Warburg effect causing excess lactate production and avid glucose consumption. We describe the clinical course of a 52-year-old man admitted for chest wall mass and severe but asymptomatic hypoglycemia. Laboratory workup was obtained for insulin vs noninsulin-mediated hypoglycemia, and biopsy of the chest wall mass and 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG-PET/CT) scan were performed. D10 infusion and intravenous/oral steroids started for severe hypoglycemia. Chemotherapy was initiated after biopsy, and blood glucose (BG) and lactate levels followed with clinical response in tumor size and changes in PET/CT. Investigations were significant for venous BG in the 40s (Ademolus Classification of Hypoglycemia grade 2 hypoglycemia), plasma insulin of less than 2 µU/mL (2-20 µU/mL), C-peptide of 0.2 ng/mL (0.8-6.0 ng/mL), insulin-like growth factor 2 (IGF-2) of 113 ng/mL (333-967 ng/mL), serum lactate of 16 mmol/L (0.5-2 mmol/L), and albumin of 2.3 g/dL (3.4-5.4 g/dL). Biopsy showed diffuse large B-cell lymphoma, and PET revealed highly FDG-avid disease in the chest, abdomen, and pelvis, but no FDG uptake was seen in the brain. Hypoglycemia and lactic acidosis improved remarkably after chemotherapy. PET/CT at 4 weeks showed complete metabolic response with reappearance of physiological FDG uptake in the brain. Noninsulin-mediated hypoglycemia was likely due to the combination of profound malnutrition and rapid glucose use by cancer cells. The patient presented with exaggerated Warburg effect (hyper-Warburgism), evident by extreme glucose consumption, severe lactic acidosis, and large tumor burden on PET/CT. Absence of cognitive symptoms was probably due to use of lactate by the brain. Chemotherapy corrected these abnormalities rapidly, and must be instituted in a timely manner.

The role of gamont entry into erythrocytes in the specificity of Hepatozoon species (Apicomplexa: Adeleida) for their frog hosts.

Hepatozoon species are apicomplexan parasites that infect blood cells and viscera of terrestrial vertebrates. One species, Hepatozoon clamatae, primarily infects green frogs, Rana clamitans , whereas another, Hepatozoon catesbianae, primarily infects bullfrogs, Rana catesbeiana , although both species of parasite are capable of infecting either species of frog. The aim of this study was to determine whether the basis for this partial host specificity is manifested at the gamont, or intraerythrocytic, stage of the parasite's life cycle. Blood was drawn from infected frogs and treated in vitro with a saline solution to induce intracellular gamonts to emerge from host erythrocytes. This treated blood was added to in vitro samples of uninfected blood of green frogs and bullfrogs. After 1 hr, samples were analyzed to determine the level of re-entry of the parasites into uninfected erythrocytes. Results obtained using multiple combinations of donor and recipient frogs indicate that extracellular gamonts of both parasite species do not exhibit preference for erythrocytes of 1 frog species over those of another. These results suggest that the basis for the observed host specificity is not determined at the gamont stage and is more likely dependent on another stage in the parasite life cycle.

Blood collection from the facial (maxillary)/musculo-cutaneous vein in true frogs (family Ranidae).

Collection of blood from amphibians, as in other classes of vertebrate animals, is essential to evaluate parameters of health, diagnose hemoparasitism, identify viral and bacterial pathogens, and measure antibodies. Various methods of blood collection have been described for amphibians. Most can be cumbersome (venipucture of femoral vein, ventral abdominal vein or lingual venus plexus) or result in pain or deleterious health consequences (cardiac puncture and toe-clipping). We describe an easy and practical technique to collect blood from frogs and toads that can be used in multiple species and is minimally invasive. The technique consists of puncturing either the facial or, less commonly, the musculo-cutaneous vein and collecting the blood with a capillary tube. These veins run dorsal and parallel to the maxillary bone and can be accessed by quick insertion and withdrawal of a needle through the skin between the upper jawline and the rostral or caudal side of the tympanum. The needle should be of 27 or 30 gauge for anurans weighing more or less than 25 g, respectively. Although the technique has been used by some amphibian researchers for years, it is little known by others and has never been fully described in a peer-reviewed publication.