title: Spontaneous hypoglycemia: diagnostic evaluation and management.
abstract: Spontaneous hypoglycemia is a puzzling clinical problem and an important reason for referral to endocrinologists. Several clinical conditions such as insulinomas, non-insulinoma pancreatogenous hypoglycemia syndrome, insulin autoimmune syndrome, postprandial hypoglycemia (reactive hypoglycemia), non-islet cell tumor hypoglycemia, primary adrenal insufficiency, hypopituitarism, and critical illness can be associated with spontaneous hypoglycemia. Rarely, in patients with mental health issues, factious hypoglycemia from extrinsic insulin use or ingestion of oral hypoglycemic agents can obfuscate the clinical picture for clinicians trying to identify an organic cause. In those presenting with Whipple's triad (symptoms ± signs of hypoglycemia, low plasma glucose, and resolution symptoms ± signs after hypoglycemia correction), a 72-h supervised fast test with measurement of plasma insulin, c-peptide, pro-insulin, and beta-hydroxybutyrate levels, coupled with plasma/urine sulphonylurea screen, forms the first step in diagnostic evaluation. A mixed meal test is preferable for those with predominantly postprandial symptoms. Additional non-invasive and/or invasive diagnostic evaluation is necessary if an organic hypoglycemic disorder is suspected. With the aid of a few brief clinical case scenarios, we discuss the diagnostic evaluation and management of spontaneous hypoglycemia through this comprehensive article.
authors.affiliation: Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK.
authors.forename: Leelavathy
authors.initials: L
authors.lastname: Kandaswamy
authors.affiliation: Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Raghavan
authors.affiliation: Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK. drpappachan@yahoo.co.in.
authors.forename: Joseph M
authors.identifier: http://orcid.org/0000-0003-0886-5255
authors.initials: JM
authors.lastname: Pappachan
mesh_terms: D000328:Adult; D001786:Blood Glucose; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000175:diagnosis* / Q000628:therapy*; D007328:Insulin / Q000097:blood; D007340:Insulinoma / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000175:diagnosis*; D019518:Postprandial Period
chemical_list: D001786:Blood Glucose; D007328:Insulin
keywords: 72-Hour supervised fast test; Insulin autoimmune syndrome; Insulinoma; Non-insulinoma pancreatogenous hypoglycemia syndrome; Non-islet cell tumor hypoglycemia; Postprandial hypoglycemia (reactive hypoglycemia); Spontaneous hypoglycemia