Differentiating Hypoglycemia from other diseases: Difference between revisions
Jump to navigation
Jump to search
Prince Djan (talk | contribs) |
No edit summary |
||
| Line 6: | Line 6: | ||
==Differentiating Hypoglycemia from other Diseases== | ==Differentiating Hypoglycemia from other Diseases== | ||
Neonatal hypoglycemia should be differentiated from other causes of neurological symtpoms in neonates: | |||
{| class="wikitable" | |||
!Disease | |||
! | |||
! | |||
! | |||
|- | |||
|Sepsis | |||
| | |||
| | |||
| | |||
|- | |||
|Inborn errors of metabolism | |||
| | |||
| | |||
| | |||
|- | |||
|Hyponatremia | |||
| | |||
| | |||
| | |||
|- | |||
|perinatal asphyxia | |||
| | |||
| | |||
| | |||
|} | |||
In neonates, nonspecific signs of sepsis are often similar to those of hypoglycemia, such as irritability, lethargy, and tachypnea. | |||
Because of the serious consequences, | |||
empiric antibiotic therapy should be provided (after cultures are obtained) to infants with suspected sepsis pending definitive culture-based diagnosis, in addition to administrating interventions directed towards hypoglycemia. | |||
Metabolic diseases that often present between 12 and 72 hours of age after the initiation of oral feeding include hyperglycinemia, urea cycle disorders, and branched-chain organic acidemias. Hypoglycemia may also be an associated finding in patients with some metabolic diseases (table 1) and will persist despite measures to increase blood glucose levels. The diagnosis of inborn errors of metabolism and specific disorders is discussed separately. | |||
Patients typically are not symptomatic until serum or plasma sodium falls below 125 mEq/L, and present with neurologic manifestations including lethargy, obtundation, and, eventually, seizures. The diagnosis of hyponatremia is made by obtaining serum electrolyte levels | |||
Neonatal encephalopathy can present with lethargy and irritability, but symptoms fail to improve with an increase in blood glucose levels. Evidence by magnetic resonance imaging of acute brain injury confirms the diagnosis of encephalopathy. | |||
{| | {| | ||
|-style="background: #4479BA; color: #FFFFFF; text-align: center;" | |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | ||
! rowspan="2" |<small>Diseases</small> | ! rowspan="2" |<small>Diseases</small> | ||
! colspan="4" |<small>Diagnostic tests</small> | ! colspan="4" |<small>Diagnostic tests</small> | ||
| Line 30: | Line 67: | ||
!<small>Altered mental status</small> | !<small>Altered mental status</small> | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumour]]<ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref><ref name="pmid3883130" /> | | style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumour]]<ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref><ref name="pmid3883130" /> | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px text-align:center" |Cancer cells<ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327 }}</ref> | | style="background: #F5F5F5; padding: 5px text-align:center" |Cancer cells<ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327 }}</ref> | ||
|style="background: #F5F5F5; padding: 5px;" |MRI | | style="background: #F5F5F5; padding: 5px;" |MRI | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms | | style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Delirium tremens]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Delirium tremens]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis | | style="background: #F5F5F5; padding: 5px;" |Clinical diagnosis | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
| style="background: #F5F5F5; padding: 5px;text-align:center" | | | style="background: #F5F5F5; padding: 5px;text-align:center" | | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |[[Alcohol]] intake, sudden witdrawl or reduction in consumption | | style="background: #F5F5F5; padding: 5px;" |[[Alcohol]] intake, sudden witdrawl or reduction in consumption | ||
|style="background: #F5F5F5; padding: 5px;" |[[Tachycardia]], [[diaphoresis]], [[hypertension]], [[tremors]], [[mydriasis]], [[positional nystagmus]], | | style="background: #F5F5F5; padding: 5px;" |[[Tachycardia]], [[diaphoresis]], [[hypertension]], [[tremors]], [[mydriasis]], [[positional nystagmus]], | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Subarachnoid hemorrhage|Subarachnoid hemorrhage]]<ref name="pmid14585453">Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14585453 Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases.] ''J Emerg Med'' 25 (3):265-70. PMID: [http://pubmed.gov/14585453 14585453]</ref> | | style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Subarachnoid hemorrhage|Subarachnoid hemorrhage]]<ref name="pmid14585453">Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14585453 Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases.] ''J Emerg Med'' 25 (3):265-70. PMID: [http://pubmed.gov/14585453 14585453]</ref> | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628 }}</ref> | | style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628 }}</ref> | ||
|style="background: #F5F5F5; padding: 5px;" |CT scan without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755 }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345 }}</ref> | | style="background: #F5F5F5; padding: 5px;" |CT scan without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755 }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345 }}</ref> | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |Trauma/fall | | style="background: #F5F5F5; padding: 5px;" |Trauma/fall | ||
|style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[dizziness]], [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]] | | style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[dizziness]], [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Stroke]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Stroke]] | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| Normal | | style="background: #F5F5F5; padding: 5px; text-align:center" | Normal | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| CT scan without contrast | | style="background: #F5F5F5; padding: 5px; text-align:center" | CT scan without contrast | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"| | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|TIAs, [[hypertension]], [[diabetes mellitus]] | | style="background: #F5F5F5; padding: 5px; text-align:center" |TIAs, [[hypertension]], [[diabetes mellitus]] | ||
|style="background: #F5F5F5; padding: 5px; text-align:center"|Speech difficulty, gait abnormality | | style="background: #F5F5F5; padding: 5px; text-align:center" |Speech difficulty, gait abnormality | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824 }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref> | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824 }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref> | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]] | | style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]] | ||
|style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc | | style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc | ||
CSF FTA-Ab -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697 }}</ref> | CSF FTA-Ab -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697 }}</ref> | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |Unprotected sexual intercourse, [[STI]]<nowiki/>s | | style="background: #F5F5F5; padding: 5px;" |Unprotected sexual intercourse, [[STI]]<nowiki/>s | ||
|style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]], | | style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]], | ||
Abnormal [[gait]] | Abnormal [[gait]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Viral encephalitis]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Viral encephalitis]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or xanthochromia, [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]] | | style="background: #F5F5F5; padding: 5px;" |Increased [[RBC]]S or xanthochromia, [[Mononuclear cells|mononuclear]] [[lymphocytosis]], high protein content, normal [[glucose]] | ||
|style="background: #F5F5F5; padding: 5px;" |Clinical assesment | | style="background: #F5F5F5; padding: 5px;" |Clinical assesment | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" | ✔ | | style="background: #F5F5F5; padding: 5px;" | ✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |Tick bite/mosquito bite/ viral prodome for several days | | style="background: #F5F5F5; padding: 5px;" |Tick bite/mosquito bite/ viral prodome for several days | ||
| style="background: #F5F5F5; padding: 5px;" |Extreme lethargy, rash [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes | | style="background: #F5F5F5; padding: 5px;" |Extreme lethargy, rash [[hepatosplenomegaly]], [[lymphadenopathy]], [[behavioural]] changes | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Herpes simplex encephalitis]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Herpes simplex encephalitis]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |Clinical assesment | | style="background: #F5F5F5; padding: 5px;" |Clinical assesment | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |History of [[hypertension]] | | style="background: #F5F5F5; padding: 5px;" |History of [[hypertension]] | ||
|style="background: #F5F5F5; padding: 5px;" |[[Delirium]], cortical [[blindness]], [[cerebral edema]], [[seizure]] | | style="background: #F5F5F5; padding: 5px;" |[[Delirium]], cortical [[blindness]], [[cerebral edema]], [[seizure]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Wernicke’s encephalopathy | | style="background: #DCDCDC; padding: 5px; text-align: center;" |Wernicke’s encephalopathy | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |Normal | | style="background: #F5F5F5; padding: 5px;" |Normal | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse | | style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse | ||
|style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]] | | style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[CNS abscess]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[CNS abscess]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |'''↑''' [[leukocytes]] >100,000/ul, '''↓''' [[glucose]] and '''↑''' protien, '''↑''' red blood cells, [[lactic acid]] >500mg | | style="background: #F5F5F5; padding: 5px;" |'''↑''' [[leukocytes]] >100,000/ul, '''↓''' [[glucose]] and '''↑''' protien, '''↑''' red blood cells, [[lactic acid]] >500mg | ||
|style="background: #F5F5F5; padding: 5px;" |Contrast enhanced MRI is more sensitive and specific, | | style="background: #F5F5F5; padding: 5px;" |Contrast enhanced MRI is more sensitive and specific, | ||
[[Histopathological]] examination of brain tissue | [[Histopathological]] examination of brain tissue | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |History of [[drug abuse]], [[endocarditis]], '''↓''' [[immune]] status | | style="background: #F5F5F5; padding: 5px;" |History of [[drug abuse]], [[endocarditis]], '''↓''' [[immune]] status | ||
|style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]] | | style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[Nausea and vomiting|nausea]], [[vomiting]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" | | |||
| style="background: #F5F5F5; padding: 5px;" | | |||
| style="background: #F5F5F5; padding: 5px;" | | |||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" |[[Lithium]], Sedatives, [[phenytoin]], [[carbamazepine]] | |||
|style="background: #F5F5F5; padding: 5px;" |[[Lithium]], Sedatives, [[phenytoin]], [[carbamazepine]] | |||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]] | ||
| style="background: #F5F5F5; padding: 5px;" | | |||
| style="background: #F5F5F5; padding: 5px;" | | |||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion | |||
|style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion | |||
| style="background: #F5F5F5; padding: 5px; text-align:center" | | | style="background: #F5F5F5; padding: 5px; text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
| style="background: #F5F5F5; padding: 5px;text-align:center" | | | style="background: #F5F5F5; padding: 5px;text-align:center" | | ||
|style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px;text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
| style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | | style="background: #F5F5F5; padding: 5px; text-align:center" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]] | | style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Electrolyte disturbance]] | ||
|style="background: #F5F5F5; padding: 5px; text-align:center" |'''↓''' or '''↑''' | | style="background: #F5F5F5; padding: 5px; text-align:center" |'''↓''' or '''↑''' | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |Depends on the cause | | style="background: #F5F5F5; padding: 5px;" |Depends on the cause | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
|style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[Seizure|seizures]] | | style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[Seizure|seizures]] | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Febrile convulsion]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Febrile convulsion]] | ||
Revision as of 17:06, 18 July 2017
|
Hypoglycemia Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Differentiating Hypoglycemia from other diseases On the Web |
|
American Roentgen Ray Society Images of Differentiating Hypoglycemia from other diseases |
|
Differentiating Hypoglycemia from other diseases in the news |
|
Risk calculators and risk factors for Differentiating Hypoglycemia from other diseases |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Differentiating Hypoglycemia from other Diseases
Neonatal hypoglycemia should be differentiated from other causes of neurological symtpoms in neonates:
| Disease | |||
|---|---|---|---|
| Sepsis | |||
| Inborn errors of metabolism | |||
| Hyponatremia | |||
| perinatal asphyxia |
In neonates, nonspecific signs of sepsis are often similar to those of hypoglycemia, such as irritability, lethargy, and tachypnea.
Because of the serious consequences,
empiric antibiotic therapy should be provided (after cultures are obtained) to infants with suspected sepsis pending definitive culture-based diagnosis, in addition to administrating interventions directed towards hypoglycemia.
Metabolic diseases that often present between 12 and 72 hours of age after the initiation of oral feeding include hyperglycinemia, urea cycle disorders, and branched-chain organic acidemias. Hypoglycemia may also be an associated finding in patients with some metabolic diseases (table 1) and will persist despite measures to increase blood glucose levels. The diagnosis of inborn errors of metabolism and specific disorders is discussed separately.
Patients typically are not symptomatic until serum or plasma sodium falls below 125 mEq/L, and present with neurologic manifestations including lethargy, obtundation, and, eventually, seizures. The diagnosis of hyponatremia is made by obtaining serum electrolyte levels
Neonatal encephalopathy can present with lethargy and irritability, but symptoms fail to improve with an increase in blood glucose levels. Evidence by magnetic resonance imaging of acute brain injury confirms the diagnosis of encephalopathy.
| 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 tumour[1][2] | ✔ | Cancer cells[3] | MRI | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Cachexia, gradual progression of symptoms | ||||
| Delirium tremens | ✔ | Clinical diagnosis | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Alcohol intake, sudden witdrawl or reduction in consumption | Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, | ||||
| Subarachnoid hemorrhage[4] | ✔ | Xanthochromia[5] | CT scan without contrast[6][7] | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Trauma/fall | Confusion, dizziness, nausea, vomiting | |
| Stroke | ✔ | Normal | CT scan without contrast | ✔ | ✔ | ✔ | ✔ | ✔ | TIAs, hypertension, diabetes mellitus | Speech difficulty, gait abnormality | ||||
| Neurosyphilis[8][9] | ✔ | ↑ Leukocytes and protein | CSF VDRL-specifc
CSF FTA-Ab -sensitive[10] |
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | 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 prodome for several days | Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes | ||
| Herpes simplex encephalitis | ✔ | Clinical assesment | ✔ | ✔ | ✔ | ✔ | ✔ | History of hypertension | Delirium, cortical blindness, cerebral edema, seizure | |||||
| Wernicke’s encephalopathy | Normal | ✔ | ✔ | ✔ | History of alcohal 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 assesment and MRI | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | History of relapses and remissions | Blurry vision, urinary incontinence, fatigue | ||||
| Hypoglycemia | ↓ or ↑ | Serum blood glucose | ✔ | ✔ | ✔ | History of diabetes | Palpitations, sweating, dizziness, low serum, glucose | |||||||
References
- ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
- ↑
- ↑ 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.
- ↑ 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
- ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
- ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
- ↑ 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.
- ↑ 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.
- ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
- ↑ 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.