A Weightlifter With Palpitations, Tremors, and Confusion

Ricardo Correa, MD; Sri Harsha Tella, MD


January 11, 2021

In investigating this case, various endocrine conditions were ruled out, including a thyroid disorder, growth hormone deficiency, pheochromocytoma/paraganglioma syndrome, and adrenal insufficiency. He did not meet the criteria for insulinoma or true hypoglycemia because he did not demonstrate all of the Whipple triad. This was a challenging case because the patient presented with all the adrenergic and neuroglycopenic symptoms of hypoglycemia; however, his blood glucose and serum glucose levels did not support this.

Certain disorders and conditions can cause a discrepancy between capillary blood glucose levels and plasma glucose levels.[5,6,7,8] These patients present with a very low plasma glucose level, usually in the range of 20-30 mg/dL, without any symptoms. Causes in this group of patients can include the following:

Patients may occasionally hold the meter upside down and report incorrect readings. When a discrepancy is observed between glucometer readings and actual symptoms or signs, a different site may be punctured to get a blood drop for testing (ie, ear lobe).

Tarasova and colleagues[5] proposed that this condition should be called "artifactual hypoglycemia" instead of pseudohypoglycemia.[5] The term "artifactual" was introduced in 1961 to describe low glucose levels in a patient with chronic myelogenous leukemia due to increased glycolysis by leukocytes after delayed preparation of a venous blood sample.[9] This term has not yet been applied to guidelines.

None of the above conditions applied to the patient in this case because he never had a documented episode of hypoglycemia (blood glucose level < 70 mg/dL).


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