E M E R G E N C Y CASE REPORT

Hypothermia ........A Sign of Hypoglycemia W. Phelps Carter, Jr, MD Portland, Maine

H y p o t h e r m i a m a y o c c u r in association with h y p o g l y c e m i a , and indeed m a y b e t h e o n l y sign, T w o cases are presented. In one, the patient pres e n t e d with h y p o g ] y c e m i c e n c e p h a l o p a t h y . In the insulin d e p e n d e n t diabetic, the condition is l i f e - t h r e a t e n i n g . S u b n o r m a l temperature is a c l u e to h y p o g l y c e m i a in the alcoholic° The m e c h a n i s m of h y p o t h e r m i a has been e x t e n s i v e l y s t u d i e d , b u t r e m a i n s u n c l e a r .

Carter WP: Hypothermia - - a sign of hypoglycemia. JACEP 5:594-595, August 1976. hypothermia, hypoglycemia and; hypoglycemia, alcoholism. INTRODUCTION W h e n faced w i t h a p a t i e n t w i t h a t e m p e r a t u r e below n o r m a l (98.6 F, 37 C), the c l i n i c i a n often considers d i u r n a l v a r i a t i o n , cold e x p o s u r e or infection. We h a v e b e e n i m p r e s s e d w i t h the significance of h y p o t h e r m i a as a n i n d i c a t i o n of h y p o g l y c e m i a . B o t h c o n d i t i o n s can c a u s e a l t e r e d s t a t e s of consciousness a n d both are life-threatening. The cases below demo n s t r a t e the diagnostic t r a p t h a t physicians can fall into when d e a l i n g w i t h hypothermia as a sign of hypoglycemia. CASE REPORTS

cohol on his breath. His vital signs were: r e c t a l t e m p e r a t u r e 94 F (34.4 C); pulse rate, 100 beats per minute; r e s p i r a t i o n rate, 15 p e r m i n u t e and b l o o d p r e s s u r e 120/84. H e w a s oriented to person, place and time. The p a t i e n t would h a v e b e e n ref e r r e d to one of t h e local alcoholic s h e l t e r s e x c e p t for h i s p e r s i s t e n t h y p o t h e r m i a . A f t e r two hours in the E m e r g e n c y Division, t h e p a t i e n t rem a i n e d h y p o t h e r m i c a n d was babb l i n g incoherently. He was a d m i t t e d to t h e h o s p i t a l w i t h a d i a g n o s i s of acute alcoholism with h y p o t h e r m i a s e c o n d a r y to e x p o s u r e a n d alcohol abuse.

Case N u m b e r One. A 52-year-old alcoholic, who h a d p a s s e d o u t a n d b e e n u n c o n s c i o u s for a n u n k n o w n l e n g t h of time, was b r o u g h t to the Emergency Division by the rescue unit. He a d m i t t e d to h e a v y - a l c o h o l c o n s u m p t i o n for t h e p r e c e d i n g 24 hours. He was disheveled and h a d al-

A review of t h e p a t i e n t ' s p a s t adm i s s i o n s r e v e a l e d t h a t two y e a r s p r i o r he w a s a d m i t t e d w i t h a core t e m p e r a t u r e of 75 F (23.8 C) t h a t responded to w a r m i n g b l a n k e t s and intravenous fluids. He recovered w i t h no specific complications.

From the Department of Emergency Medicine, Maine Medical Center, Portland, Maine. Address for reprints: W. Phelps Carter, Jr, MD, Department of Emergency Medicine, Maine Medical Center, Portland, Maine 04102.

On this admission, t h e l a b o r a t o r y reported a blood alcohol of 95 mg/109 ml (intoxicated level - - 150 m g / i 0 0 ml) a n d a blood glucose level less t h a n 10 mg/100 ml. The p a t i e n t was given a 50% dextrose solution with d r a m a t i c i m p r o v e m e n t in his m e n t a l

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status and a gradual elevation body t e m p e r a t u r e .

Case N u m b e r T w o . A 38-year-0 k n o w n j u v e n i l e d i a b e t i c , controll~ on 40 u n i t s N P H U-100, was foui cold, u n r e s p o n s i v e a n d foaming~ the mouth. He was t r a n s p o r t e d to tl E m e r g e n c y Division a n d arrived in state of g e n e r a l i z e d seizure activit T h e n i g h t p r i o r to a d m i s s k m o d e r a t e alcohol c o n s u m p t i o n w~ documented. Rectal t e m p e r a t u r e w~ 94.7 F (34.8 C); pulse rate, 72 bea per minute; r e s p i r a t i o n rate, 20 pe m i n u t e ; blood p r e s s u r e , 120/70. 50% d e x t r o s e s o l u t i o n a n d 5 ml d i a z e p a m ( V a l i u m ) , b o t h intrave nously, were a d m i n i s t e r e d . The ps tien~ r e c o v e r e d u n e v e n t f u l l y . Hi t e m p e r a t u r e was 98.6 F (37 C)t~l hours after admission. L a b o r a t o r y r e s u l t s were blood glu cose, 20 mg/100 ml. No alcohol leve was obtained.

DISCUSSION A l t h o u g h t h e p r e s e n c e of hypo t h e r m i a in association w i t h hyp0gl~ cemia is a w e l l - k n o w n clinical entJ ty, few p h y s i c i a n s a r e a w a r e of t~i sign. 1 S u b t l e v a r i a t i o n s in body te~ p e r a t u r e m a y reflect incipient hyl~ g l y c e m i a in the conscious and c0~ atose p a t i e n t . W h e n faced with a P~ t i e n t c o m a t o s e f r o m a n unkn0 ~j etiology, t h e p h y s i c i a n should alwal consider hypoglycemia. In case t~! t h e p a t i e n t p r e s e n t e d w i t h hypogl! c e m i c e n c e p h a l o p a t h y . As clasS1: catly seen in the i n s u l i n depende~l d i a b e t i c , t h e c o n d i t i o n is lifel

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reatening. Also, t h e p a t i e n t m a y confused, in a c o m a or h a v i n g avulsions. The condition is exten1ely d e s c r i b e d i n t h e l i t e r a t u r e 2 ~d c o r r e l a t e s w e l l w i t h c e r e b r a l ~0d glucose levels. H y p o t h e r m i a is !ten present. physiologically, h y p o g l y c e m i c enphalopathy is a metabolic disorder which c e r e b r a l glucose is depleted blood sugars, often to a level less an 20 mg/100 ml. 2 The correlation f cerebral function and mental ~atus w i t h blood glucose levels is ~pendent upon t h e t e m p o r a l fall in [0od g lucose.2 W h e n c e r e b r a l glu)se is depleted a n d cerebral oxidaon occurs w i t h o u t glucose, t h e relt is b r a i n destruction. N e u r a l lipid d protein are metabolized. Nervsness, h u n g e r , a n d confusion, w i t h 0p in c o r e t e m p e r a t u r e d u e to ermoregulatory dysfunction, are en in v a r y i n g s t a g e s of hypoglyceic encephalopathy. 2 In the alcoholic, h y p o g l y c e m i a can cur and case one is a n e x a m p l e . ae subnormal t e m p e r a t u r e w a s the ue to the low blood glucose. Except r the h y p o t h e r m i a , the p a t i e n t was dtially o r i e n t e d . T h e p a t i e n t ' s ~pothermia was felt to be secondary exposure, a c o m m o n f i n d i n g in ~grant alcoholics who live in uneated a n d e x p o s e d p l a c e s . T h e ~ysicians e r r o n e o u s l y i n t e r p r e t e d is change in m e n t a l s t a t u s as indic;ire of alcoholic intoxication. The a c t u a l m e c h a n i s m in alcoholic ypoglycemia h a s b e e n e x t e n s i v e l y udied by Field. 3 Blood glucose level ~presents a b a l a n c e b e t w e e n tissue ptake, h e p a t i c glucose production - hich in t u r n is d e p e n d e n t on glu)se i n t a k e - - glycogen r e s e r v e s and [uconeogenesis from a m i n o a c i d s ~eeursors: In the alcoholic, h y p o g l y c e m i a is le r e s u l t of t w o p o s s i b l e m e c h aisms. T h e f i r s t m a y be s e v e r e epatic p a r e n c h y m a l d a m a g e w i t h ecreased g l u c o n e o g e n e s i s and lycogen reserves. The second, and ~rhaps the most common, cause of [¢oholic h y p o g l y c e m i a is due to di~ct n u t r i t i o n a l decrease in glycogen !serves w i t h concomitant inhibition

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of gluconeogenesis. H y p o g l y c e m i a in the alcoholic was induced e x p e r i m e n t a l l y b y e t h a n o l c o n s u m p t i o n in c o m b i n a t i o n w i t h poor d i e t a r y intake. Controls w i t h nonalcoholic ind i v i d u a l s who f a s t e d for two d a y s with ethanol ingestions developed hypoglycemia. 3 H y p o t h e r m i a can occur in clinical s e t t i n g s o t h e r t h a n alcoholism a n d indicate hypoglycemia. Kedes and Field 4 r e l a t e five cases of hypotherm i a defined as a rectal t e m p e r a t u r e of 96 F (35.6 C) or less. One was a w o m a n b r o u g h t to t h e e m e r g e n c y d e p a r t m e n t in a catatonic state w i t h no a v a i l a b l e h i s t o r y . A p s y c h i a t r i c consult concurred with the diagnosis and while the patient was being t r a n s p o r t e d to the p s y c h i a t r i c unit, a n u r s e reported a rectal t e m p e r a t u r e of 95 F (35 C). Blood was o b t a i n e d in which blood glucose was r e p o r t e d as 14 mg/100 ml. The p a t i e n t b e c a m e lucid after a d m i n i s t r a t i o n of 50 cc of a 50% d e x t r o s e s o l u t i o n . S u b sequently, a h i s t o r y of d i a b e t e s mellitis was obtained. A second case was t h a t of a 46year-old black woman with carc i n o m a of t h e l i v e r who p r e s e n t e d w i t h w e a k n e s s a n d rectal t e m p e r a t u r e of.95.9 F (35.5 C). I n i t i a l l y , h e r h y p o t h e r m i a w a s felt to be due to progression of h e r hepatic c a r c i n o m a and was ignored. A blood glucose report of 28 mg/100 ml was finally obtained. Both o f t h e s e cases f u r t h e r d e m o n s t r a t e t h e d i a g n o s t i c t r a p of d e a l i n g with h y p o t h e r m i a as a sign of hypoglycemia. T h e a c t u a l m e c h a n i s m of h y p o t h e r m i a h a s been e x t e n s i v e l y studied b u t r e m a i n s unclear. Research into t h e s p e c i f i c m e c h a n i s m of h y p o t h e r m i a h a s involved h y p o t h a l a m i c t h e r m o r e g u l a t o r y systems. F r e i n k e l et al used 2-desoxy-D glucose (2-DG) to induce h y p o t h e r m i a in mice; 2-DG i n h i b i t s use of i n t r a c e l l u l a r glucose. In a n a t t e m p t to assess t h e thermor e g u l a t o r y m e c h a n i s m , these invest i g a t o r s found t h a t h y p o t h e r m i a was r e l a t e d to n e u r o n a l i n t r a c e l l u l a r glucose level and not to the a v a i l a b i l i t y of c i r c u l a t i n g glucose. W h e n injected into t h e b r a i n s of mice, 2-DG pro-

duced a 5-fold h y p o t h e r m i a response. Speculative r e s e a r c h on t h e hypothalamus indicates thermoregulatory centers in t h i s area. Specific hypot h a l a m i c c e n t e r s w i t h glucose sensitivity have been suggested. BRecent studies also suggest insulin-sensitive h y p o t h a l a m i c centers. 7 SUMMARY H y p o t h e r m i a in some clinical settings may indicate hypoglycemia. H y p o t h e r m i a m a y also occur w i t h m i n i m a l s i g n s of h y p o g l y c e m i a . In recording temperatures, error may o c c u r if t h e t h e r m o m e t e r is n o t a d e q u a t e l y s h a k e n down. S h e e h a n and S u m m e r s have documented the p r e v a l e n c e of t h i s omission. O t h e r drugs, besides i n s u l i n a n d ethanol, may cause hypoglycemia and h y p o t h e r m i a m a y be p r e s e n t in these patients. Subnormal temperatures are often recorded in medical records. There are m a n y causes of hypotherm i a b u t its i m p o r t a n c e as a sign of possible h y p o g l y c e m i a is i n v a l u a b l e when d i a g n o s i n g e i t h e r a conscious or comatose p a t i e n t . REFERENCES 1. Strauch BS, Felig P, Baxter JD, et al: Hypothermia in hypoglycemia. J A M A 210;345-346, 1969. 2. Wintrobe, MM (ed), et al: Harrison's Principles of Internal Medicine, ed 7. New York, McGraw-Hill, 1974, pp 1823-1829. 3. Field JB, Williams HE, Martimore GE: Studies on mechanism of ethanol induced hypoglycemia. J of Clin Invest 42:497-787, 1964. 4. Kedes LH, Field JB: Hypothermia. N Engl J Med 271-'785-787, 1964. 5. Freinkel N, Singer DL, Arky RA, et al: Alcohol hypoglycemia. J of Clin Invest 42-.1112-1133, 1963. 6. Freinkel N, Metzger BE, Harris E, et al: Hypothermia of hypoglycemia. N Engl J Med 287:841-845, 1972. 7. Panerai AE, et al: Hypoglycemia and inhibition of insulin secretion by 2-deoxy-d-glucose in rats with hypothalamic lesions. Pharmacol Res Commun 7-'133-141, 1975. 8. Sheehan HL, Summers VK: Treatment of h y p o p i t u i t a r y coma. Brit Med J 1-.1214-1215, 1952. 9. Kudzma DJ: Treating alcohol induced hypoglycemia. Hospital Physician, 1975, p 35.

Volume 5 Number 8 Page 595

Hypothermia--a sign of hypoglycemia.

Hypothermia may occur in association with hypoglycemia, and indeed may be the only sign. Two cases are presented. In one, the patient presented with h...
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