Part I MCQs (One Best Type)

1. Pakistan Society Of Chemical PathologistsDistance Learning Programme In Chemical Pathology(DLP-2)Lesson No 10Hypoglycaemiain Neonates and Adults By Brig Aamir IjazMCPS, FCPS, FRCP (Edin)Professor of Pathology / Consultant Chemical PathologistAFIP Rawalpindi

2. Part IMCQs (One Best Type)

3. b. Drugs Q.1: The commonest cause of Hypoglycaemia in adults is:a. Antibodies to insulin receptorsb. Drugsc. Glucagon Deficiencyd. Insulinomae. Malaria

5. e. Tailoring his treatment to reduce risk Q 2.A 62 years male who is a known diabetic treated with sulfonylureas complains of attack of sweating, tremors and headache. He could not get his blood test done during this attack but these symptoms were relieved with some sweet thing. As per recent guidelines which of the following is the best strategy for his management:a. Documentation of Whipple's triad b. Frequent lab measurement of glucosec. Investigations like insulin and C-peptided. Reassurance of patiente. Tailoring his treatment to reduce risk

6. No need to demonstrate Whipple`s triad in diabetics. • Ignoring such symptoms in diabetics can be dangerous. • Hypoglycaemia in diabetics, may be documented or undocumented, should be taken as an urgent issue • Some modification of treatment should be advised to avoid untoward incidence while patient is driving etc. Hypoglycaemia in Diabetics

7. c. Artificial Q 3: A 36 years male who is NOT a known diabetic has been referred to you for the investigation of Hypoglycaemia from Bone Marrow Transplant Centre (BMTC). Plasma Glucose report from your lab has been 2.83 mmol/L (51 mg/dl) on one occasion. He had absolutely no symptoms of hypoglycaemia. On further inquiry you found out that this is a patient of acute myeloid leukaemia (AML) currently in relapse. Please note the sample of this patient was received in a plain tube from BMTC.What is the most probable cause/type of Hypoglycaemia in this patient?a. Antibioticsb. Anti-mitoticsc. Artificial d. Hyperkalaemiae. Insulinoma.

8. High TLC can be an important cause of increased utilization of glucose • Sample collected in plain tube i.e. serum without a preservative (e.g. NaF) can also lead to in vitro decrease in glucose concentration Artefactual or artificial Hypoglycaemia

9. b. Documented symptomatic hypoglycaemia Q 4: A 24 years old male who is a known patient of type 1 diabetes mellitus (DM), reports occurrence of attack of hypoglycaemia with blood glucose 2.66 mmol/L (48 mg/dl) (measured on a glucometer). He measured glucose due to onset of sweating and headache. Which of the following category the patient belongs to?a. Asymptomatic hypoglycaemiab. Documented symptomatic hypoglycaemiac. Probable symptomatic hypoglycaemiad. Psuedohypoglycaemiae. Severe hypoglycaemia

10. Classification of Hypoglycaemia in Dabetics Slides courtesy Dr SabihaWaseem

12. e. Male (72 years) with impaired renal function on getifloxacin for the treatment of severe sepsis Q 5 :In an Intensive Care Unit following FIVE patients are being nursed. Their salient clinical and lab features are given. Which of these patients is at the greatest risk of hypoglycaemia:a. A male (46 years) known patient of type 2 DM on insulin therapy (10 units TDS) with target glycaemic level according to the latest recommendations (140-180 mg/dl or 8 -10 mmol/L)b. Female (25 years) with severe sepsis on cephalosporinsc. Female (39 years) with impaired renal function on beta-blockers due to hypertensiond. Male (34 years) on mechanical ventilator and caphalosporins due to road traffic accident.e. Male (72 years) with impaired renal function on getifloxacin for the treatment of severe sepsis

13. A. Ill or medicated individual 1. Drugs : Insulin or insulin secretagogue, Sulphonylures, Alcohol/Ethanol Others : Beta blockers, , Salicylates, quinine, indomethacin, Lithium, getifloxacin • Critical illnesses : Hepatic, renal, or cardiac failure, Sepsis (including malaria), predisposing illness, hospitalized patients 3. Hormone deficiency :Cortisol, Glucagon and epinephrine (in insulin- deficient, diabetes mellitus), hypopituitarism/ Addison’s disease • Non-islet cell tumor hypoglycemia (NICTH) B. Seemingly well individual 5. Endogenous hyperinsulinism: Insulinoma, Islet hyperplasia/ nesidioblastosis, Post - gastric bypass hypoglycemia, Insulin autoimmune hypoglycemia (Antibody to insulin, Antibody to insulin receptor), Insulin secretagogue, severe exercise 6. Accidental, surreptitious, or malicious hypoglycemia Causes of hypoglycemia in adults

14. c. Glycogen Q 6 :In a healthy full term neonate, who has born about one and a half hours ago, blood glucose level is 2.38 mmol/L (43 mg/dl). Which of the following is the most important source of maintenance of plasma glucose in this baby?a. Amino acidsb. Glycerolc. Glycogen d. Lactatee. Maternal blood glucose

15. a. Glucose-6-phosphatase Q 7 :A 28 days neonate has hepatomegaly and following abnormal lab findings:• Fasting Plasma Glucose: 1.0 mmol/L (18 mg/dl)• Serum Triglycerides: 5.88 mmol/L (516 mg/dl)• Serum Uric Acid: 432 μmol/L (7.32mg/dl)• Plasma Lactic Acid: Increased• Urinary ketones: +++Which of the following enzymes of glycogen metabolism is most likely effected in this neonate: a. Glucose-6-phosphatase b. Glycogen debrancherc. Glycogen synthased. Liver phosphorylasee. Liver phosphorylase kinase

17. c. Galactose-1-phosphate uridyltransferase Q 8 :An infant develops attacks of hypoglycaemia strongly related with dietary milk (both with breast milk and cow milk). His urine is positive for reducing substance but negative for glucose (by strip) and ketone bodies.Which of the following enzymes is most commonly deficient in these types of infants? a. Epimeraseb. Galactokinasec. Galactose-1-phosphate uridyltransferased. Glycogen synthasee. Lactase

19. e. Soy-based infant formulas Q 9 :The infant mentioned in question No 8 above has been referred to you for dietary advice. Which of the following dietary options is the best for this infant? a. Galactose free milk b. Lactose-free infant formulac. Low calcium milkd. Non-fat dry milk e. Soy-based infant formulas

20. Now it is said that Lactose Free Milk is NOT safe in children with galactossaemia • Soy-based infant formula is safer. Dietary milk in Galactossaemia

21. b. Defects in the metabolism of fatty acids Q 10 :The most common disorders that can cause Sudden Unexpected Infant Death due to hypoglycaemia are:a. Branched chain amino acids disordersb. Defects in the metabolism of fatty acids c. Methylmalonicacidemiasd. Propionic acidemiase. Urea cycle disorders

23. Medium chain acyl CoA dehydrogenase deficiency (MCAD) is the most common inborn error of fatty acid oxidation that impairs the body's ability to break down medium-chain fatty acids into acetyl-CoA. • This condition may lead to cellular energy shortage and cause severe clinical events such as hypoketotic hypoglycemia, Reye syndrome and sudden death Sudden Infant Death Due To Hypoglycemia

24. Part IIShort Answer Questions:

25. Q. 11: No authentic classification or typing system of Hypoglycaemia is in vogue. Please answer following related questions:a. Give any ONE system of classifying Clinical Hypoglycaemia in non-diabetics.b. Write TWO points regarding merits and/or demerits of this classification system.

26. Postabsorptiveor fasting hypoglycemia • Postprandial or reactive hypoglycemia Traditional Classification

27. Simple • Classify most patients into their respective category • Valid for healthy and ill individuals and patients on medication. Merits of Traditional Classification

28. Patients with an insulinoma, typically have fasting hypoglycemia, but they may suffer postprandial hypoglycemia • Gastric bypass patients, typically have postprandial hypoglycemia, but may have symptoms when fasting. Demerits of Traditional Classification

29. A. Hypoglycemia in Ill or medicated individual 1. Drugs Insulin or insulin secretagogue Certain antibiotics 2. Critical illnesses Hepatic, renal, or cardiac failure Sepsis (including malaria) 3. Hormone deficiency Cortisol Glucagon and epinephrine 4. Nonislet cell tumor Clinical Classification of Hypoglycemia

30. B. hypoglycemia in seemingly well individual 1. Endogenous hyperinsulinism • Insulinoma • Functional β-cell disorders (nesidioblastosis) • Noninsulinomapancreatogenous hypoglycemia • Post gastric bypass hypoglycemia • Insulin autoimmune hypoglycemia • Insulin secretagogue • Other 2. Accidental, surreptitious, or malicious hypoglycemia Clinical Classification of Hypoglycemia(Cont)

31. This etiological classification is based on clinical condition with more emphasis on role of medication in causing hypoglycaemia especially in ill patients. • This classification helps in planning the diagnostic workup which would be more elaborated in healthy individuals with documentation of Whipple triad. Merits of Clinical Classification

32. Q. 12: A 31 year non-diabetic female has been brought in A & E of a hospital in semi-conscious state. Her blood glucose measured on glucometer was 2.1 mmo/L (38 mg/dl). She was given intravenous glucose to which she responded well. Her blood sample was drawn before giving glucose for ascertaining the cause of hypoglycaemia. Casualty Medical Officer (CMO) later on found out that her husband is a known patient of type 2 DM and regularly takes sulfonylureas. She, however, denied any intake of medicine but CMO referred the case to local police for the investigation of attempted suicide.a. Name TWO hormonal tests you can perform in the blood sample of this patient to find/rule out the cause of hypoglycaemia in this patient. How can these two tests be helpful?b. How can you confirm / rule out surreptitious use of sulfonylureas in this patient?

33. Serum insulin and Serum C peptide Rationale • If patient is having high serum insulin and very low serum C-peptide in presence of hypoglycaemia, the cause is exogenous insulin administration. • Since sulfonylureas stimulate insulin secretion (insulin secretagogues), endogenous insulin production results in equimolar rise in C peptide concentration. • So inappropriately normal levels of insulin and C peptide in presence of hypoglycaemia points towards factitious hypoglycaemia by sulfonylureas TWO hormonal tests to find/rule out the cause of hypoglycaemia

34. Detection of sulfonylureas and its metabolites in the urine and plasma of this patient. Following methods can be used: • High-performance liquid chromatography (HPLC) • Capillary electrophoresis (CE) • Liquid chromatography tandem mass spectrometry (LC/MS/MS) Confirmation of surreptitious use of sulfonylureas

35. Non Islet Cell Tumour Hypoglycemia (NICTH) Q. 13: A 45 year male has recently been diagnosed a soft tissue tumour 6 cm in diameter found in the mediastinum (non-bronhogenic) on imaging. Histopathological diagnosis is awaited. He has history of attacks of severe hypoglycaemia on several occasions with low serum Insulin and beta-hydroxy butyrate levels.a. What is the most probable pathological diagnosis?b. Please write the name of ONE substance produced from the tumour cells which is most likely the cause of Hypoglycaemia in this patient. How it causes hypoglycaemia? Big IGF-2

36. Non Islet Cell Tumour Hypoglycemia (NICTH) Slides courtesy Dr Nudrat Khan (QAMC Bwp)

37. Nonisletcell tumors of mesenchymal, vascular (eg,hemangiopericytoma), or epithelial cell types. • Usually located in the chest and in the retroperitoneal region  Nature and Location

38. Tumoraloverproduction of IGF-2, Incompletely processed big IGF-2, rarely IGF-1 Stimulate insulin receptors Increased glucose utilizatization mostly in skeletal muscles Hypoglycaemia (mostly fasting) Pathogenic Mechanism

39. Insulin- LOW • C-peptide-LOW • Beta hydroxybutyrate concentration–LOW • The plasma glucose response to glucagon administration- normal or near normal unless there has been extensive tumoral replacement of hepatic tissue, resulting in low hepatic glycogen stores • High serum IGF-II and big IGF-II Biochemical Findings

40. Q. 14: A 51 year male complains of documented attacks of hypoglycaemia 4-5 hours after meals. His insulin levels were high but a 72-hour fast could not provoke hypoglycaemia. Imaging studies fail to localize a lesion in pancreatic beta cells. Histopathological studies show nesidioblastosis. What is the most probable pathological diagnosis in this patient? Non InsulinomaPancreatogenousHypoglycemia Syndrome (NIPHS)

41. It is likely that tumourcells cannot process the augmented amounts of pro-insulin-like growth factor-II (pro-IGF-II) synthesised, resulting in a substantial release of ‘big’-IGF-II into the circulation. ‘ • Big’-IGF-II competes with the mature IGF-II and IGF-I for binding to IGF-binding proteins (IGFBPs). • ‘Big’-IGF-II, at the tissue level will rise inducing a strong insulin-like effect via the insulin receptors, increased glucose utilization by the tumor and causing hypoglycaemia. Big- IGF-II causing hypoglycemia in NICTH

42. Non InsulinomaPancreatogenousHypoglycemia Syndrome (NIPHS)Versus Insulinoma Slides courtesy Dr Nudrat Khan (QAMC Bwp)

44. Q. 15: A 32 years female who is a known patient of type 1 DM presents with progressive weakness, fatigue, poor appetite, and weight loss and menstrual irregularities. Her DM is well-controlled for many years but suddenly she developed a marked decrease in insulin requirements and increased frequency of hypoglycaemic episodes.   What is the most probable pathological diagnosis in this patient? Addison Disease or Autoimmune polyglandular syndrome type 2

45. Type 1 DM is an autoimmune disease in 80% of patients • So in this patient it is essential to rule out involvement of other features related to an autoimmune phenomena, most important of which is Addison disease. • If remains un-diagnosed, hypocortisolism can be life threatening. Addison Disease or Autoimmune polyglandular syndrome type 2

46. Suggestive symptoms e.g. weakness, fatigue, poor appetite, and weight loss • Menstrual irregularities can be due to Addison alone or due to hypogonadism • Decreased insulin requirement may be due to decrease in a diabatogenic hormone i.e. cortisol • Hypoglycaemia is a feature of Addisons disease. Points in Favour of Addison Disease or Autoimmune polyglandular syndrome type 2

47. Younger age of the patient • Given symptoms appear in CKD when it is very advance i.e. in ESRD • Menstrual problems cannot be explained until it is ESRD • Patient has well controlled DM • There can be reduced insulin requirement but attacks of hypoglycaemia is rare. (Good thinking of participants who chose this cause and should always be kept in mind in DM. But ignoring Addison Disease can be a patient safety issue and safety can never be compromised Points Against CKD or Nephropathy

48. Q. 16: A 7 months child is admitted in an Intensive Care Unit. He has vomiting, encephalopathy and seizures. He is thin and undernourished He has marked hypoglycaemia (plasma glucose: 1.61 mmol/L or 29 mg/dl). Screening tests for Inborn Errors of Metabolism are negative. Serum Insulin and Serum Cortisol levels are lower and higher than normal, respectively. Write THREE non-metabolic causes which can cause hypoglycaemiain this child.

49. Transient neonatal hypoglycemia • Hyperinsulinemia • Islet cell hyperplasia • Insulinoma 3. Inherited metabolic disorders including • Glycogen storage diseases • Galactosemia • Hereditary fructose intolerance • Fatty acid B-oxidation defects 4. Non-metabolic causes • Prematurity • Small-for-dates • Endocrine disorders • Starvation • Drugs • Ketotic hypoglycemia • Rye Syndrome Causes of Hypoglycemia in Childhood

50. Q. 17: In this lesson we have seen a wide range of conditions leading to hypoglycaemia in children and adults with or without DM. Suppose as a consultant Chemical Pathologist you are requested to provide brief guidelines on Hypoglycaemia. Please prepare a small document with threshold Plasma Glucose levels to be used for the diagnosis and treatment of hypoglycaemia in various clinical settings.