Differentiating Hypoglycemia from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differentiating Hypoglycemia from other Diseases

Hypoglycemia should be differentiated from other causes of autonomic hyperactivity symptoms which includes:

	History and signs	Investigations
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.[2] Computed tomography: Radiological evaluation should follow lab tests to locate site of the tumour.[1]
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 reuslts 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	+ [16]	-
autoimmune hypoglycemia.	-	-	high	high	high	-	+ [17]
NIPHS*	-	+	high	high	high	-	-
exogenous insulin	-	-	high	low	low	-	-
nonislet cell tumors	-	-	low	low	low	-	-

*(NIPHS) noninsulinoma pancreatogenous hypoglycemia syndrome

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		✔	Cancer cells	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		✔	Xanthochromia	CT scan without contrast	✔	✔	✔	✔	✔	✔	✔	✔	Trauma/fall	Confusion, dizziness, nausea, vomiting
Stroke		✔	Normal	CT scan without contrast		✔	✔		✔	✔		✔	TIAs, hypertension, diabetes mellitus	Speech difficulty, gait abnormality
Neurosyphilis		✔	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive	✔	✔	✔	✔		✔		✔	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 HbA1c		✔				✔		✔	History of diabetes	Palpitations, sweating, dizziness, low serum, glucose

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