Differentiating Hypoglycemia from other diseases: Difference between revisions

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==== Hypoglycemia should be differentiated from other causes of autonomic hyper activity symptoms which include: ====
==== Hypoglycemia should be differentiated from other causes of autonomic hyper activity symptoms which include: ====
{| class="wikitable"
{| class="wikitable"
! rowspan="3" |Disease
! colspan="5" |Clinical Manifestation
!
!
!History and signs
|-
! colspan="4" |Symptoms
!Signs
!Investigations
!Investigations
|-
!Tachycardia
!Fever
!Sweating
!Headache
!
!
|-
|-
|Anxiety disorders
|Anxiety disorders
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* A family history of anxiety disorders
* A family history of anxiety disorders
* Medical examination is free.
* Medical examination is free.
|
|
|
|
|No abnormal investigations
|No abnormal investigations
|-
|-
|Pheochromocytoma
|Pheochromocytoma
|Paroxysms of '''headache, sweating, palpitations''', and [[hypertension]]. <sup>[[Anxiety disorder history and symptoms#cite note-1|[1]]]</sup>
|Paroxysms of '''headache, sweating, palpitations''', and [[hypertension]]. <sup>[[Anxiety disorder history and symptoms#cite note-1|[1]]]</sup>
|
|
|
|
|Plasma fractionated metanephrines, 24-hour urinary fractionated metanephrines, catecholamines.<ref name="pmid11903030">{{cite journal| author=Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al.| title=Biochemical diagnosis of pheochromocytoma: which test is best? | journal=JAMA | year= 2002 | volume= 287 | issue= 11 | pages= 1427-34 | pmid=11903030 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11903030  }}</ref>
|Plasma fractionated metanephrines, 24-hour urinary fractionated metanephrines, catecholamines.<ref name="pmid11903030">{{cite journal| author=Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al.| title=Biochemical diagnosis of pheochromocytoma: which test is best? | journal=JAMA | year= 2002 | volume= 287 | issue= 11 | pages= 1427-34 | pmid=11903030 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11903030  }}</ref>
<sup>[[Pheochromocytoma laboratory findings#cite note-pmid11903030-2|<nowiki>2]</nowiki>]]</sup>[[Computed tomography]]: Radiological evaluation should follow lab tests to locate site of the tumour.<sup>[[Pheochromocytoma CT#cite note-pmid1787652-1|.]]</sup><ref name="pmid1787652">{{cite journal| author=Bravo EL| title=Pheochromocytoma: new concepts and future trends. | journal=Kidney Int | year= 1991 | volume= 40 | issue= 3 | pages= 544-56 | pmid=1787652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1787652  }}</ref>
<sup>[[Pheochromocytoma laboratory findings#cite note-pmid11903030-2|<nowiki>2]</nowiki>]]</sup>[[Computed tomography]]: Radiological evaluation should follow lab tests to locate site of the tumour.<sup>[[Pheochromocytoma CT#cite note-pmid1787652-1|.]]</sup><ref name="pmid1787652">{{cite journal| author=Bravo EL| title=Pheochromocytoma: new concepts and future trends. | journal=Kidney Int | year= 1991 | volume= 40 | issue= 3 | pages= 544-56 | pmid=1787652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1787652  }}</ref>
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|Arrhythmia
|Arrhythmia
|[[Auscultation]] of the heartbeat or feeling for peripheral [[Pulse|pulses]] shows abnormality.  
|[[Auscultation]] of the heartbeat or feeling for peripheral [[Pulse|pulses]] shows abnormality.  
|
|
|
|
|ECG changes according to the cause.
|ECG changes according to the cause.
|-
|-
|Hyperthyroidism
|Hyperthyroidism
|Ocular signs: eyelid retraction and lid-lag.  
|Ocular signs: eyelid retraction and lid-lag.  
|
|
|
|
|Measuring the level of [[thyroid-stimulating hormone]] (TSH) in the blood
|Measuring the level of [[thyroid-stimulating hormone]] (TSH) in the blood
Levels of T4 and/or T3 in the blood. Measuring specific [[Antibody|antibodies]], such as anti-TSH-receptor antibodies in Graves' disease, may contribute to the diagnosis.
Levels of T4 and/or T3 in the blood. Measuring specific [[Antibody|antibodies]], such as anti-TSH-receptor antibodies in Graves' disease, may contribute to the diagnosis.

Revision as of 18:24, 21 July 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

Hypoglycemia should be differentiated from other causes of autonomic hyper-activity symptoms. Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia. Neonatal hypoglycemia should be differentiated from other causes of neurological symptoms in neonates such as sepsis, metabolic diseases: urea cycle disorders, and branched-chain organic acidemias, hyponatremia and neonatal asphyxia.

Differentiating Hypoglycemia from other Diseases

Hypoglycemia should be differentiated from other causes of autonomic hyper activity symptoms which include:

Disease Clinical Manifestation
Symptoms Signs Investigations
Tachycardia Fever Sweating Headache
Anxiety disorders
  • A family history of anxiety disorders
  • Medical examination is free.
 No abnormal investigations
Pheochromocytoma Paroxysms of headache, sweating, palpitations, and hypertension. [1] Plasma fractionated metanephrines, 24-hour urinary fractionated metanephrines, catecholamines.[1]

2]Computed tomography: Radiological evaluation should follow lab tests to locate site of the tumour..[2]

Arrhythmia Auscultation of the heartbeat or feeling for peripheral pulses shows abnormality. ECG changes according to the cause.
Hyperthyroidism Ocular signs: eyelid retraction and lid-lag. Measuring the level of thyroid-stimulating hormone (TSH) in the blood

Levels of T4 and/or T3 in the blood. Measuring specific antibodies, such as anti-TSH-receptor antibodies in Graves' disease, may contribute to the diagnosis.

Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia:

Fating symptoms Postprandial symptoms Plasma insulin C-peptide proinsulin Sulfonylurea in plasma insulin or insulin receptor antibodies
Insulinoma + - high high high - -
Oral hypoglycemia agent-induced - - high high high + -
Autoimmune hypoglycemia. - - high high high - +
NIPHS* - + high high high - -
Exogenous insulin - - high low low - -
Non-islet cell tumors - - low low low - -

*(NIPHS) non-insulinoma pancreatogenous hypoglycemia syndrome

Neonatal hypoglycemia should be differentiated from other causes of neurological symptoms in neonates:

Disease History and symptoms Investigations
Sepsis Irrritability, lethargy, and tachypnea Blood cultures
Inborn errors of metabolism
  • Family history and positive intrapartum screening tests
  • Symptoms will persist despite measures to increase blood glucose levels
 Positive blood tests
Hyponatremia lethargy, obtundation, and, eventually, seizures plasma sodium falls below 125 mEq/L
perinatal asphyxia
  • History of intrapartum complications
  • Lethargy and irritability
  • Symptoms fail to improve with an increase in blood glucose levels.
 MRI of acute brain injury confirms the diagnosis of encephalopathy.

Differentiating Comma related to Hypoglycemia from other Diseases

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumor[3][4] ✔ Cancer cells[5] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delirium tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohol intake, sudden withdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[6] ✔ Xanthochromia[7] CT scan without contrast[8][9] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[10][11] ✔ ↑ Leukocytes and protein CSF VDRL-specific

CSF FTA-Ab -sensitive[12]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodrome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioral changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohol abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High grade fever, fatigue, nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause ✔ ✔ Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assessment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose

References

  1. ↑ Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P; et al. (2002). "Biochemical diagnosis of pheochromocytoma: which test is best?". JAMA. 287 (11): 1427–34. PMID 11903030.
  2. ↑ Bravo EL (1991). "Pheochromocytoma: new concepts and future trends". Kidney Int. 40 (3): 544–56. PMID 1787652.
  3. ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  4. ↑
  5. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  6. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  7. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  8. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  9. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  10. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  11. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  12. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
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