Endocrine Abstracts

JOINT452

Introduction: Hypoglycemia is a frequent and potentially severe complication in insulin-treated diabetics, requiring meticulous management to prevent instability and adverse outcomes. While its primary etiology often stems from insulin mismanagement, hypoglycemia can also have multifactorial origins. Here, we present the case of an adult with recurrent hypoglycemia due to a combination of complex, overlapping factors.

Case Report: A 56-year-old male, diabetic for 36 years, presented with recurrent unrecognized hypoglycemic episodes, occasionally resulting in loss of consciousness. His medical history included combined spinal sclerosis and bipolar disorder, managed with sodium valproate and risperidone. The patient was on a basal-bolus regimen of human insulin (1.25 IU/kg), administered exclusively postprandially. Clinical examination revealed severe malnutrition (BMI: 13.8 kg/m²), depressive syndrome, edentulism, and prominent lipodystrophies at the arms, the sole injection sites. An extensive evaluation for malnutrition, including biological tests, tumor markers, tuberculosis screening, and imaging, yielded negative results, and hormonal profiles revealed no deficiencies. Initial management involved correcting therapeutic errors, transitioning to insulin analogs with appropriate dose adjustments, and implementing gradual nutritional repletion. While these interventions led to partial improvement, recurrent hypoglycemia persisted. Hypoglycemic episodes confirmed exogenous hyperinsulinism. The persistence of hypoglycemia prompted suspicion of iatrogenic factors. Sodium valproate and risperidone were reviewed, and their potential contributions to hypoglycemia were explored. Discontinuation of risperidone and dose reduction of sodium valproate (guided by elevated serum levels) resulted in resolution of hypoglycemia and progressive weight gain.

Discussion and Conclusion: Severe hypoglycemia in insulin-treated diabetics often originates from improper insulin administration, as seen in our patient’s use of restricted injection sites with associated lipodystrophy. Insulin overdose, although common, is frequently underestimated. The multifactorial malnutrition in this case required a multidisciplinary approach, particularly collaboration with the treating psychiatrist to optimize nutritional status. Sodium valproate-induced hypoglycemia, though rare, is attributed to impaired hepatic gluconeogenesis mediated by decreased L-carnitine levels. Similarly, risperidone has been implicated in hyperinsulinism through pancreatic alpha-2 receptor antagonism, although this mechanism remains debated. The absence of hypoglycemia awareness in this patient likely resulted from autonomic neuropathy compounded by recurrent episodes and vitamin B12 deficiency. This case underscores the importance of a comprehensive evaluation in patients with insulin-treated diabetes and recurrent hypoglycemia. Identifying and addressing multifactorial causes, including drug-induced hypoglycemia, is essential. Long-term follow-up is critical to ensure sustainable therapeutic success and to mitigate the risk of recurrence.