HYPOGLYCEMIA MIMICKING STROKE

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Here is a case I have seen:

A 65 year old woman, weaver presented to casualty at 7: 30 am with the complains of :
Right upper limb weakness since 4am
Right lower limb weakness since 4am
Slurred speech since 4 am

Patient used to work as a weaver until 2 years back. She got married to a weaver and has 5 children - 3 daughters and 2 sons. Her attendants give a long standing history of fever since 10 years on and off though it wasn't associated with weight loss. 5 years ago, she was diagnosed to be hypertensive and diabetic on routine check up and is on OHAs and Anti hypertensive medications ever since. She has been on Tab Glimiperide 1mg once a day, Tab Gliclazide 60mg once a day and Tab Cilnidipine 10mg OD. Since 4 years she has been admitted twice at OMNI hospital for ? LRTI and since 4 years the attendant tells that she has been having fever along with productive cough on and off though she hasn't been evaluated for Pulmonary Kochs. She was put on Oseltamavir, N-acetylcysteine and Monteleukast. In 2017, an Upper GI endoscopy was performed which showed normal study as she complained of epigastric pain and indigestion. Her reports from Dec 2019 shows albuminuria for 3 plus and with a serum creatinine 2 mg/dl with grade 1 RPD changes. Also, she started to complain of hard stools and was diagnosed with hemorrhoids in an outside hospital for which she has been using a syrup.
Her attendants tell us that she has gained weight over the last 6 months and eats only one meal a day since 3 years.
On 10/8/2020,
The attendants heard a cry at 4 am and when they went to check on the patient they noticed that the patient couldn't get up from her bed and was having difficulty in speech. They took her to a nearby hospital where they were told that she had high blood pressure of 160/100 mmhg and was given Tab Amlong 5mg.
The patient presented to our casualty at 7:30 am.

General Examination:

The patient was conscious and coherent. She was obese, appeared pale, and bilateral pedal edema was present. She had a slurred speech and was complaining of right upper and lower limb weakness.

Vitals: Afebrile, BP: 150/100, Pulse: 67 bpm, RR: 17 cpm, Saturations at 98 %, GRBS: 40 mg/dl

Pallor +

No H/O icterus, cyanosis, clubbing, and lymphadenopathy

Systemic Examination:

CNS Examination:

Higher motor functions are normal

All cranial nerves are intact

Tone is normal in all the limbs on both sides.

Power:
Her Left UL and LL showed a power of 4/5 and 3/5 respectively. Though she had only flicker movements in her right upper and lower limbs.

Reflexes: Right                Left

    Biceps         4+/5 4+/5

    Triceps 4+/5 4+/5

    Supinator    4+/5 4+/5

    Knee Absent 3/5

    Ankle         Absent            Absent

    Plantars Flexion Flexion

CVS Examination:

    S1 S2 heard

    No murmurs

Respiratory Examination:

    Her lungs are clear on auscultation

    Bilateral air entry present

    No added sounds

Abdomen on palpation - Multiple painless lipomas could be palpated, mobile in the right hypochondriac, right lumbar region - Dercums disease ( Multiple, painful, fatty benign lipomas chiefly in obese, post menopausal women).

She was started on 25% dextrose. After 25 minutes , her speech improved and so did the power in all the limbs.

Her Bp at 11am - 110/70mmhg

Grbs - 39 mg/dl

She was started on 25% dextrose again.

 

Her Chest XRAY PA showed Cardiomegaly 

This along with her bilateral pedal edema made us decide to get a 2DECHO done to rule out Heart failure

                                  ECG showed sinus rhythm with a Heart rate of 75 bpm

            

                                                            2D Echo

                                                                Ultrasound Report

Course in the hospital and disease discussion

On Day 1,

The patients blood sugars were maintained within the normal range with  the help of 25 % dextrose infusion.
Fundoscopy was done to look for any diabetic or hypertensive retinopathy changes which showed Grade 1 hypertensive retinopathy in both her eyes.

HER BLOOD SUGAR MONITORING ON THE DAY OF ADMISSION

By Day 2, the patient was tapered off 25 % dextrose infusion
The blood sugars were well maintained without the need for 25% dextrose

Only her biceps reflex was exagerrated bilaterally

By Day 3,
The patient was able to walk with support, she says she is able to walk just like before
Her BP was at 150/100mmhg
With a PR of 70bpm

Problem Representation :

66 year old woman with Right Upper limb and Lower limb weakness and slurred speech since 3 hours due to hypoglycemia

1.Recurrent Hypoglycemia ( resolved) secondary to Sulfonylureas on Renal failure 2. ? HFpEF with Ef - 64 % 3.Kco CKD since 1 year ( eGFR - 34mL/min/1.73 m2) 4. Kco Type 2 DM and HTN With Grade 1 Hypertensive Retinopathy changes 5. Cholithiasis since 2 years - Asymptomatic 6. ? Iron Deficiency anemia

1) For hypoglycemia she was put on 25 % dextrose for 1 day until the blood sugars got back into normal range and OHA's were put hold.

Few cases have been reports presenting in a similar pattern of hypoglycemia mimicking stroke which eventually resolved on treating hypoglycemia. The patient fulfills the Whipples triad. Lecuocystosis of 18,000 cells/cumm was attributed to pro inflammatory effects induced by hypoglycemia which eventually got down to 13,000 cells/cumm once the patient recovered from hypoglycemia.

https://pubmed.ncbi.nlm.nih.gov/28115398/

2) Cardiomegaly was seen on chest xray PA and the patient even had bilateral pedal edema which could be due to renal failure or heart failure. 2decho for perfomed which showed an EF of 64% with Mild LVH, Trivial TR and AR, Grade 1 diastolic dysfunction - ? HFPEF 3) The patient was advised a fluid and salt restricted diet and sulfonylureas were put on hold Furthermore, her hypoglycemic events have been attributed to the use of sulphonylureas on renal failure. Studies have showed that patients on sulfonylureas with a lesser egfr had more frequent episodes of hypoglycemia. As renal failure leads to reduced clearance of insulin metabolites and there is reduced renal gluconeogenesis. There is a debate on more hypoglycemic events with sulfonylureas with active vs inactive metabolites. Our patient was on both Glimiperide and Gliclazide which were put on hold.

https://www.bmj.com/content/354/bmj.i3625

The patient was also advised to consume small, frequent meals. For hypertension, her blood pressure was continued to be put under control with the help of Tab Cilinidipine 10mg once a day Her hemoglobin was on a downtrend since the day of admission, Keeping in mind her history of being diagnosed with hemorrhoids a general surgery opinion was taken to look for any bleeding per rectum - On per rectal examination there was no bleeding per rectum found, no fissures except for an external skin tag.

Her absolute reticulocyte count was 1.6 indicating it as hypoproliferation.

The patient was discharged on Tab Metformin 500mg at 8am as it is known to not cause any hypoglycemic events and as the patient is obese. She was asked to continue Tab Cilinidipine 10mg for her Hypertension along with iron supplementation. The patient was asking to frequently monitor blood sugars at home and also was adviced to loss weight and ask to consume small frequent meals.