Johns Hopkins pediatric endocrinology fellow Joseph Heinemann discusses a case of an unexpected cause of hypoglycemia in a patient with type 1 diabetes. In this case, a 15-year-old boy with celiac disease, type 1 diabetes and hyperthyroid disease went to a Johns Hopkins emergency department with symptoms that included weight loss, hypoglycemia, drinking excessively and frequent urination. In this video, Heinemann talks about the evaluation and treatment plans for this patient.
Hi, my name is Doctor Joseph Heineman. I'm a pediatric endocrine fellow here at the Johns Hopkins Children's Center. I would like to speak to you today about an interesting case of an unexpected cause of hypoglycemia in a patient with type one diabetes. Type one diabetes is an autoimmune disorder that affects the pancreatic beta cells leading to inadequate insulin production and elevated blood glucose. Having an elevated blood sugar typically leads to urinating and drinking excessively. In addition to the risk of developing life threatening complications over time, treatment for type one diabetes involves insulin injections several times a day with the goal of maintaining target blood sugars. Type one diabetes is a known risk factor for the development of additional autoimmune diseases. Our case involves a fifteen-year-old boy with type one diabetes, autoimmune hypothyroidism and celiac disease who came to the Johns Hopkins emergency room, complaining of weight loss, urinating and drinking excessively as well as recurrent hypoglycemia or low blood sugars. Review of his medical records showed a previously extensive work up including evaluation of his adherence to insulin domaine as well as testing for Addison's disease. Addison's disease is a rare autoimmune disorder that leads to the autoimmune attack of the adrenal glands and development of adrenal insufficiency, a life threatening disorder and known cause of hypoglycemia. He had passed an AC T H stimulation test to test the choice for evaluation of adrenal insufficiency. Only six months prior. During that evaluation, practitioners speculated that the patient had been surreptitiously injecting himself with extra insulin which would have accounted for an unexplained hypoglycemia. Our team was concerned that despite previously reassuring testing, he could not rule out an evolving process. Therefore, the decision was made to repeat the AC T H stimulation test this time, he failed the test. He was diagnosed with adrenal insufficiency and started on treatment with good effect. However, the story doesn't end there. Additional blood test was sent confirming the cause of adrenal sufficiency. Several days later, the rest of the blood bur came back and unexpectedly showed the adrenal sufficiency was due to a process occurring at the level of the pituitary gland which sits in the brain hormone testing confirmed he had panhypopituitarism. He had lost production of many of the hormones produced in the pituitary gland, including growth hormone, hormones of puberty and houla hormones that stimulate the adrenal gland and the thyroid gland. The next step of course was to get an MRI of the brain which confirmed the presence of brain tumor in the area of the pituitary gland. He underwent successful treatment of the brain tumor with the pediatric oncology team and continues to follow the with the pediatric endocrinology team for multiple hormone deficiencies. What I hope people take away from this case is that low blood sugars in individuals with type one diabetes is a common occurrence. It's a known risk of being treated with insulin. However, when low blood sugars occur, frequently are severe or unexplained. Additional evaluation is needed. Additionally, there exists a concept of premature closure, premature closure occurs when a clinician makes a diagnosis prematurely and stops collecting additional information. This can lead to missing potentially life threatening disorders. In order to prevent premature closure, it's important for clinicians to be aware of how the results of specific tests may change over the course of the disease and when it may be appropriate to repeat specific testing. In this case, the decision was made to repeat the ach stimulation test leading to the appropriate diagnosis and life saving treatment. Thank you so much for listening.