Endo Case Challenge: A Cannabis User With Excessive Sweating and Syncope at Work

Marwa Saleem, MD; Ahmad Al Maradni, MD; Mahmoud Alsayed, MD; Ricardo Correa, MD, EdD


June 13, 2022

Physical Examination and Workup

The physical examination is unremarkable except for tachycardia (heart rate, 105 beats/min), elevated blood pressure (142/87 mm Hg), excessive sweating, and mild anxiety. The patient receives intravenous dextrose in the emergency department and is subsequently admitted to the hospital. The results of an initial biochemical workup, including measurement of serum morning cortisol, insulin-like growth factor 1, and metanephrines and a thyroid function test, are within normal limits.

Multiple attempts to wean the patient off intravenous dextrose are unsuccessful and are accompanied by a drop in his plasma glucose level to the mid-30s and then 40 mg/dL within a few hours. He is transferred to the intensive care unit for close blood glucose monitoring. Intravenous dextrose is stopped, and a 72-hour fasting protocol is initiated. After 28 hours of fasting, his fingerstick blood glucose level is 54 mg/dL (reference range, 70-100 mg/dL). A subsequent plasma glucose level is 47 mg/dL. Additional laboratory investigations show values of:

  • C-peptide level: 1.0 ng/mL (reference range, 0.5-2.0 ng/mL)

  • Insulin level: 3 µIU/mL (reference range [fasting], 5-15 µIU/mL)

  • Proinsulin level: 5 pmol/L (reference range, 3.6-22 pmol/L)

  • Insulin-like growth factor 2 (IGF-2) level: 400 ng/mL (reference range, 267-616 ng/mL)

  • Beta-hydroxybutyrate level: 4.7 mg/dL (reference range, 0.21-2.81 mg/dL)

The patient is given orange juice and a high-protein, low-carbohydrate meal.


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