Endocrine Abstracts

Introduction

COVID-19 is an evolving disease and its clinical picture is constantly being updated. Severe hypoglycemia has not been usually recognized as a COVID-19 symptom (except when caused by hydroxychloroquine toxicity) but in our patient it has been apparently triggered by the disease.

Methods

Review of the patient’s records and the relevant literature.

Clinical case

A 55 year-old woman (a licensed nurse) was referred to our Endocrinology Clinic for severe, frequent, invalidating episodes of hypoglycemia. She had primary hypothyroidism, correctly substituted with levothyroxine, and a history of gastroesophageal reflux, treated with a Nissen fundoplication the previous year, and was asymptomatic. In April 2020 she was admitted in our Hospital for severe SARS-CoV-2 respiratory infection and was discharged with residual emphysema. Immediately after the discharge she had almost daily episodes of postprandial hypoglycemia, occasionally severe with loss of consciousness, and she was admitted to our Emergency Room, with plasma glucose 40 mg/dl but normal insulin and C-peptide (respectively 9.34 µ/u/ml and 3.22 ng/ml) in the lab tests. An abdominal CT scan did not suggest insulinoma or other abnormal mass. The 72-hour fasting test did not suggest insulinoma either, and the 24-hour Holter monitoring was near normal, not suggesting triggering of the symptoms by arrhythmia. A gastric emptying scintigraphy did not suggest dumping syndrome. In our Clinic the patient was trained in a fractionated diet with servings of 30–40 g of complex carbohydrates 4–5 times daily, and in the use of a flash glucose monitoring device with alarm capacity. She was able to resume work but still had frequent non severe hypoglycemia during the afternoon and evening, but rarely in the night. Acarbose 50 mg was added at lunchtime, initially with minor intolerance symptoms (occasional meteorism) but the variability of her glucose profile was largely improved and the episodes of hypoglycemia became milder and infrequent (less than 1/15 days). The follow-up lab tests (December 2020) were: Glycemia 82 mg/dl, HbA_1C 5.3%, plasma insulin 8.32 µ/u/ml, proinsulin 1.6 pmol/l, C-peptide 2.77 ng/ml, normal free T4 and TSH.

Conclusion

Although postprandial hypoglycemia is frequent after gastric surgery, including fundoplication, there was a clear-cut temporal coincidence in our patient between the COVID-19 disease and the triggering of the hypoglycemic episodes, suggesting a causative or unmasking relationship.