title: Refractory hypoglycemia and subsequent cardiogenic shock in starvation and refeeding: report of three cases.
abstract: OBJECTIVE
  Although starvation is associated with high in-hospital mortality, its related cardiac complications are not sufficiently understood. The aim of this study was to determine the clinical course and pathogenesis of cardiac complications in malnourished patients.
  
  
  METHODS
  We reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac complications in starvation.
  
  
  RESULTS
  This report concerns three patients, respectively suffering from anorexia nervosa, esophageal carcinoma, and Parkinson's disease. Their ages ranged from 18 to 70 y, body mass index was 11.5 ± 1.5 kg/m2 (mean ± SD), and the main symptom was coma. The average blood glucose level was 15.7 ± 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypoglycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 ± 4 mg/dL and 10 ± 9.1 μEq/L, respectively). Levels of serum potassium, phosphate, and magnesium were almost normal at admission. The main cardiac complications included Takotsubo cardiomyopathy and cardiac arrest. All patients survived as a result of intensive treatment.
  
  
  CONCLUSIONS
  Repetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding.
authors.affiliation: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan. Electronic address: shimiken@hp-emerg.med.osaka-u.ac.jp.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Shimizu
authors.affiliation: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Ogura
authors.affiliation: Medical Education Center, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Masafumi
authors.initials: M
authors.lastname: Wasa
authors.affiliation: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Tomoya
authors.initials: T
authors.lastname: Hirose
authors.affiliation: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Shimazu
authors.affiliation: Department of Pediatrics, Takarazuka City Hospital, Hyogo, Japan.
authors.forename: Hironori
authors.initials: H
authors.lastname: Nagasaka
authors.affiliation: Laboratory of Cardiovascular Disease, Novel, Non-invasive and Nutritional Therapeutics (CNT), Graduate School of Medicine, Osaka University, Osaka, Japan.
authors.forename: Ken-ichi
authors.initials: K
authors.lastname: Hirano
mesh_terms: D000293:Adolescent; D000368:Aged; D000856:Anorexia Nervosa / Q000097:blood / Q000150:complications; D001786:Blood Glucose / Q000378:metabolism; D015992:Body Mass Index; D003128:Coma; D004938:Esophageal Neoplasms / Q000097:blood / Q000150:complications; D005230:Fatty Acids, Nonesterified / Q000097:blood; D005260:Female; D005947:Glucose / Q000627:therapeutic use; D006323:Heart Arrest / Q000097:blood / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D007003:Hypoglycemia / Q000097:blood / Q000188:drug therapy / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D010300:Parkinson Disease / Q000097:blood / Q000150:complications; D055677:Refeeding Syndrome / Q000097:blood / Q000150:complications*; D012770:Shock, Cardiogenic / Q000097:blood / Q000188:drug therapy / Q000209:etiology*; D013217:Starvation / Q000097:blood / Q000150:complications / Q000178:diet therapy; D054549:Takotsubo Cardiomyopathy / Q000097:blood / Q000188:drug therapy / Q000209:etiology; D014131:Trace Elements / Q000097:blood; D014280:Triglycerides / Q000097:blood
chemical_list: D001786:Blood Glucose; D005230:Fatty Acids, Nonesterified; D014131:Trace Elements; D014280:Triglycerides; D005947:Glucose
keywords: Hypoglycemia; Hypophosphatemia; Hypotriglyceridemia; Refeeding; Starvation; Takotsubo cardiomyopathy