A Weightlifter With Palpitations, Tremors, and Confusion

Ricardo Correa, MD; Sri Harsha Tella, MD

Disclosures

January 11, 2021

Discussion

In patients without diabetes, true hypoglycemic episodes are characterized by the Whipple triad of low plasma glucose, concurrent symptoms of hypoglycemia, and resolution of symptoms when the glucose level returns to normal.[1] Adrenergic symptoms of hypoglycemia are the first to appear and typically include palpitation, tremors, anxiety, and sweating. Adrenergic symptoms appear at blood glucose ranges of 40-60 mg/dL. Thereafter, if blood glucose continues to decrease, neuroglycopenic symptoms appear. These include confusion, syncope, seizure, and coma.[2]

The term "clinical pseudohypoglycemia" is used when patients—typically those with personality or other psychological disorders—report relief of hypoglycemia symptoms after eating despite having a blood glucose level within the normal range. Pseudohypoglycemia broadly falls under two categories: (1) normal blood glucose with hypoglycemia symptoms and (2) discrepancy between fingerstick and serum blood glucose levels. The first group includes patients with a personality disorder or other psychiatric disorder, including addiction problems, which lead to hypoglycemic symptoms that are relieved after eating. However, these patients do not manifest the typical Whipple triad. They have no evidence of blood glucose levels < 70 mg/dL during a symptomatic hypoglycemic episode. The patient in this case falls into this category.

The patient had a past medical history of personality disorder. He did not provide detailed information about his psychiatric illness, the treatment that was administered, or why that treatment was discontinued. He was fixated on fitness and achieving a "macho" look and was possibly using androgenic steroids along with other supplements, although laboratory tests did not confirm this suspicion.

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