Case Report B6

(Laboratory interpretation report)

Name of clinician (student): _________________________________ Date: 2007 04 16.

Barbara Miel, a 55-year-old woman, has a seven-month history of fatigue and weakness.
She complain that she is very tired in the morning before eating and also after meals.
About every 2 days she feels lightheaded and has found that eating relieves the
symptoms.

Additional information on request:

Obese.

Laboratory results and differential diagnosis:

Obviously hypoglycaemia is suspected. 5 hour oral glucose tolerance test performed
(100g of glucose)
Fasting 5.7 mmol/L (3.5-5.0)
1 hour 4.8
2 hours 4.9
3 hours 2.2
4 hours 3.8
5 hours.4.3
Symptoms happened at glucose of 2.2 mmol/L
Insulin was performed on this specimen and was 55 IU/L (1-20 fasting)
Elevated insulin with low glucose.
About 25% of normal people with have a glucose of 2.2 mmol/L by 3 hours. 50% of
normal people will have at least one glucose in the 2.8-3.3 nnol/L range.
High insulin level by itself is non-diagnostic as a glucose load provoked it.
Whipple’s triad
1. Low plasma glucose but what is low glucose? Many women have fasting glucose
of 2.6 mmol/L without symptoms.
2. Symptoms at the time of hypoglycaemia.
3. Relief of symptoms by correction of hypoglycaemia
Reactive - low glucose in response to a glucose load
Hypoglycaemia on fasting, extremely rare. True fasting 1 in 250,000.
Best test is 72 hour fast.

Differential dx Test Result Range Interpretation

Drug induced
Liver disease
Renal disease
Endocrine
Non islet cell
CA
Insulinoma 72 hour fast
Autoimmune
(Working diagnosis underlined).
Comments, qualifications:

Further tests (more invasive or specialized) indicated:

Hours fasting Glucose Insulin mU/L C peptide mg/L Insulin-glucose
mmol/L (0.0-20) (0.50-2.00) ratio (<0.30)
16 5.0 13 3.43 0.14
22 5.3 18 0.19
28 4.8 17 3.42 0.2
34 4.6 21 3.58 0.25
40 4.9 22 3.71 0.26
46 5.2 17 3.44 0.18
52 4.8 20 4.02 0.23
58 4.1 10 3.51 0.14
64 4.2 13 3.38 0.17
72 4.6 9 2.02 0.11

What advice would you give her?

Over weight, she needs to worry about developing NIDDM in the future.

How do you think she will be treated on referral to a specialist?

Nutrition and exercise advice.

Reference(s):
Cryer PE, Glucose homeostasis and hypoglycaemia in Williams Textbook of
Endocrinology 8th edition Philadelphia, Saunders 1992 123-52.