Faculty Bibliography

OBJECTIVE: To describe a patient with kidney insufficiency from diabetes treated with glyburide, who presented with prolonged and recurrent hypoglycemia unresponsive to large intravenous doses of glucose, which was treated successfully with intravenously administered octreotide, and to review the therapeutic options for hypoglycemia. METHODS: We present a case report of a 66-year-old man with diabetes causing chronic kidney disease, who was treated with orally administered glyburide, 7.5 mg twice a day. He initially presented to another hospital because of hypoglycemia and was treated with intravenously administered glucose and discharged. The next day, his family brought him to our emergency department because of recurring low blood glucose levels and symptoms of sweating, fever, and nightmares. Laboratory tests revealed a blood glucose level of 33 mg/dL and a creatinine concentration of 6.2 mg/dL. RESULTS: The patient was treated with a 5% dextrose and, subsequently, a 10% dextrose infusion without any sustained improvement. The blood glucose level remained low despite the additional administration of 3 ampules of 50% dextrose in water. The patient was given a bolus of octreotide (50 mug subcutaneously) 14 hours after his second presentation. He received another 50-mug dose of octreotide 6 hours later. After this bolus, the hypoglycemia resolved, and he no longer required intravenous administration of glucose to maintain euglycemia. CONCLUSION: Patients with diabetes and kidney disease frequently have persistent and difficult-to-treat hypoglycemia, unresponsive to conventional therapy. Octreotide is an effective and safe treatment for patients with refractory hypoglycemia attributable to sulfonylureas

Computerized axial tomography (CAT) was used to study 39 patients with known thyroid disease and 14 patients with primary hyperparathyroidism. In all, CAT was performed only when information that was required for diagnosis or therapy was not available from other less expensive techniques. The greatest value was found in the evaluation of cryptic symptoms or structures in the neck after surgery for thyroid cancer, the assessment of the extent of thyroid cancer, the localization of aberrant thyroid tissue, the etiology of unexplained recurrent laryngeal nerve paralysis and the identification and delineation of mediastinal goiter. In six of 14 patients undergoing neck exploration for primary hyperparathyroidism CAT correctly localized the site of the enlarged parathyroid glands including one mediastinal parathyroid adenoma and one patient with two parathyroid adenomas