title: Severe hypoglycemia associated with an illegal sexual enhancement product adulterated with glibenclamide: MR imaging findings.
abstract: OBJECTIVE
  To describe the magnetic resonance (MR) imaging findings associated with severe hypoglycemia after consumption of an illegal sexual enhancement product (Power 1 Walnut) adulterated with glibenclamide, an oral hypoglycemic agent used to treat diabetes mellitus.
  
  
  METHODS
  Institutional review board approval was obtained for this retrospective study. Records in eight male patients with severe hypoglycemia of unknown cause, without prior treatment for diabetes, and with positive blood toxicology results for glibenclamide were reviewed. MR imaging included diffusion-weighted imaging and, in some patients, MR angiography, dynamic contrast material-enhanced perfusion MR imaging, and MR spectroscopy.
  
  
  RESULTS
  In seven patients, there were hyperintense abnormalities on diffusion-weighted and T2-weighted images in the hippocampus and cerebral cortex, sparing the subcortical white matter and cerebellum. Three patients had abnormalities of the splenium of the corpus callosum, and one had widespread involvement, including the caudate nucleus, basal ganglia, and internal capsule bilaterally. In three patients, unilateral cortical involvement, which did not conform to the typical cerebral arterial territories, was noted. In one patient, perfusion MR imaging showed slightly increased relative cerebral blood volume, and MR spectroscopy revealed no evidence of abnormal lactate in the affected cerebral cortex.
  
  
  CONCLUSIONS
  Diffusion-weighted MR imaging findings in patients with severe hypoglycemia showed typical lesions in the hippocampus and cerebral cortex, but the caudate nucleus and basal ganglia were involved in only the most severely affected patient. The splenium of the corpus callosum and internal capsule were also abnormal in three patients, and unilateral cortical lesions could be distinguished from acute ischemic stroke by the pattern of involvement and MR angiographic, perfusion, and spectroscopic findings.
authors.affiliation: Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. tchoyoson_lim@nni.com.sg
authors.forename: C C Tchoyoson
authors.initials: CC
authors.lastname: Lim
authors.forename: Robert
authors.initials: R
authors.lastname: Gan
authors.forename: Cheng Leng
authors.initials: CL
authors.lastname: Chan
authors.forename: Alvin W K
authors.initials: AW
authors.lastname: Tan
authors.forename: Joan J C
authors.initials: JJ
authors.lastname: Khoo
authors.forename: Su-Ynn
authors.initials: SY
authors.lastname: Chia
authors.forename: Shih Ling
authors.initials: SL
authors.lastname: Kao
authors.forename: John
authors.initials: J
authors.lastname: Abisheganaden
authors.forename: Yih Yian
authors.initials: YY
authors.lastname: Sitoh
mesh_terms: D000328:Adult; D000368:Aged; D001810:Blood Volume / Q000187:drug effects; D001921:Brain / Q000187:drug effects* / Q000473:pathology; D002561:Cerebrovascular Disorders / Q000139:chemically induced / Q000175:diagnosis; D003128:Coma / Q000139:chemically induced / Q000175:diagnosis; D003244:Consciousness Disorders / Q000139:chemically induced / Q000175:diagnosis; D038524:Diffusion Magnetic Resonance Imaging; D004292:Dominance, Cerebral / Q000502:physiology; D004340:Drug Contamination; D015600:Glasgow Coma Scale; D005905:Glyburide / Q000633:toxicity*; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced* / Q000175:diagnosis; D007004:Hypoglycemic Agents / Q000633:toxicity*; D013287:Illicit Drugs / Q000633:toxicity*; D007091:Image Processing, Computer-Assisted; D019344:Lactic Acid / Q000378:metabolism; D018810:Magnetic Resonance Angiography; D009682:Magnetic Resonance Spectroscopy; D008297:Male; D008875:Middle Aged; D008517:Phytotherapy; D010879:Piperazines / Q000633:toxicity*; D011687:Purines / Q000633:toxicity; D012189:Retrospective Studies; D012640:Seizures / Q000139:chemically induced / Q000175:diagnosis; D000068677:Sildenafil Citrate; D013450:Sulfones / Q000633:toxicity*; D014665:Vasodilator Agents / Q000633:toxicity*
chemical_list: D007004:Hypoglycemic Agents; D013287:Illicit Drugs; D010879:Piperazines; D011687:Purines; D013450:Sulfones; D014665:Vasodilator Agents; D019344:Lactic Acid; D000068677:Sildenafil Citrate; D005905:Glyburide