Home
|
Inbox
|
Search
|
View Abstract
Refractory Hypoglycemia and Coma as Presentation of Fournier Gangrene
Description
.abstract img { width:300px !important; height:auto; display:block; text-align:center; margin-top:10px } .abstract { overflow-x:scroll } .abstract table { width:100%; display:block; border:hidden; border-collapse: collapse; margin-top:10px } .abstract td, th { border-top: 1px solid #ddd; padding: 4px 8px; } .abstract tbody tr:nth-child(even) td { background-color: #efefef; } .abstract a { overflow-wrap: break-word; word-wrap: break-word; }
A5299 - Refractory Hypoglycemia and Coma as Presentation of Fournier Gangrene
Author Block: V. Mock1, B. Li2, J. Sunderram2; 1Department of Medicine, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2Division of Pulmonary and Critical Care, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
INTRODUCTION
Hypoglycemia without obvious cause should encourage evaluation for occult infection as it confers a higher mortality and when severe or prolonged leads to significant neurological morbidity. We present a unique case of intractable hypoglycemia with coma secondary to Fournier gangrene.
CASE REPORT
An 89-year-old man with type 2 diabetes was found unresponsive at his nursing home with a fingerstick glucose of 34. He was last seen normal 9 hours prior after having eaten a full dinner. No oral hypoglycemics or insulin was given in the preceding 12 hours. The patient remained unresponsive despite dextrose administration and was intubated and admitted to the medical intensive care unit for hypoglycemia of unclear etiology. His exam was notable for erythema and induration of the penis and scrotum. Labs showed albumin 1.5 grams/deciliter, neutrophilic leukocytosis to 15500 per microliter, and persistent hypoglycemia despite 10% dextrose infusion and glucagon. Ammonia, AM cortisol and thyroid stimulating hormone were normal. Insulin and C-peptide levels were elevated and hemoglobin a1c was 8.4%. Drug screens, urine and blood cultures were negative. Head computed tomography (CT) was unremarkable. A CT Chest, Abdomen, Pelvis was ordered to rule out paraneoplastic syndrome-induced refractory hypoglycemia after a mass was detected on chest x-ray. Surprisingly, CT revealed a perineal fluid collection involving the base of the penis and scrotum as well as a right psoas fluid collection, concerning for Fournier gangrene. Emergent drainage and debridement were performed. With infectious source control achieved, hypoglycemia finally resolved and patient became normoglycemic. Unfortunately he remained comatose with extensor posturing and electroencephalogram showing diffuse slowing. Family ultimately decided on termination of life-sustaining measures.
DISCUSSION
Pathophysiology of infection and sepsis can produce extremes of glycemia. Acute stress with cortisol and epinephrine surge stimulates hepatic glycogenolysis and gluconeogenesis causing hyperglycemia. In severe infection, increased metabolic rate and glucose utilization can surpass the amount supplied and cause unexpected hypoglycemia. Blood glucose below 50 evokes neuroglycopenic symptoms ranging from mildly impaired consciousness to coma. Our patient with protracted severe hypoglycemia and coma demonstrated a rare presentation of hypoglycemia secondary to Fournier gangrene. This case highlights the importance of early recognition of hypoglycemia as a manifestation of occult infection.
Author Block: V. Mock1, B. Li2, J. Sunderram2; 1Department of Medicine, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, United States, 2Division of Pulmonary and Critical Care, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
INTRODUCTION
Hypoglycemia without obvious cause should encourage evaluation for occult infection as it confers a higher mortality and when severe or prolonged leads to significant neurological morbidity. We present a unique case of intractable hypoglycemia with coma secondary to Fournier gangrene.
CASE REPORT
An 89-year-old man with type 2 diabetes was found unresponsive at his nursing home with a fingerstick glucose of 34. He was last seen normal 9 hours prior after having eaten a full dinner. No oral hypoglycemics or insulin was given in the preceding 12 hours. The patient remained unresponsive despite dextrose administration and was intubated and admitted to the medical intensive care unit for hypoglycemia of unclear etiology. His exam was notable for erythema and induration of the penis and scrotum. Labs showed albumin 1.5 grams/deciliter, neutrophilic leukocytosis to 15500 per microliter, and persistent hypoglycemia despite 10% dextrose infusion and glucagon. Ammonia, AM cortisol and thyroid stimulating hormone were normal. Insulin and C-peptide levels were elevated and hemoglobin a1c was 8.4%. Drug screens, urine and blood cultures were negative. Head computed tomography (CT) was unremarkable. A CT Chest, Abdomen, Pelvis was ordered to rule out paraneoplastic syndrome-induced refractory hypoglycemia after a mass was detected on chest x-ray. Surprisingly, CT revealed a perineal fluid collection involving the base of the penis and scrotum as well as a right psoas fluid collection, concerning for Fournier gangrene. Emergent drainage and debridement were performed. With infectious source control achieved, hypoglycemia finally resolved and patient became normoglycemic. Unfortunately he remained comatose with extensor posturing and electroencephalogram showing diffuse slowing. Family ultimately decided on termination of life-sustaining measures.
DISCUSSION
Pathophysiology of infection and sepsis can produce extremes of glycemia. Acute stress with cortisol and epinephrine surge stimulates hepatic glycogenolysis and gluconeogenesis causing hyperglycemia. In severe infection, increased metabolic rate and glucose utilization can surpass the amount supplied and cause unexpected hypoglycemia. Blood glucose below 50 evokes neuroglycopenic symptoms ranging from mildly impaired consciousness to coma. Our patient with protracted severe hypoglycemia and coma demonstrated a rare presentation of hypoglycemia secondary to Fournier gangrene. This case highlights the importance of early recognition of hypoglycemia as a manifestation of occult infection.
|
Home
|
Inbox
|
Search
|