116 - hypoglycemia causes list

Recently there was a question in the medical sciences paper of the UPSC prelims examination conducted on 18 may 2008 regarding hypoglycemia. Let us look into this question. The question was as follows :

Which of the following conditions is associated with hypoglycemia?

a- VIPoma

b- Phaeochromocytoma

c- Fibrosarcoma

d- Glucaganoma

The answer is : c . fibrosarcoma . surprised ? I was too , but this is the answer , because all the other three do not cause hypoglycemia and only fibrosarcoma causes hypoglycemia. Check out the tumors that cause hypoglycemia and also all the other causes that cause hypoglycemia. I know it is an exhaustive list but read once so that atleast a few of them will remain in ur brain .

Extrapancreatic Tumors

• Mechanisms
• Increased utilization by large or active tumor
• Cachexia and depletion of glycogen reserves
• Insulin-like peptides, especially IGF-II (Doege-Potter syndrome)
• Inhibited hepatic gluconeogenesis or glycogenolysis
• Blunted counterregulatory hormone responses
• Autoimmune (see below)
• Tumors associated with hypoglycemia
• Benign and malignant mesothelioma
• Neurofibroma
• Fibrosarcoma
• Rhabdomyosarcoma
• Leiomyosarcoma
• Liposarcoma
• Sarcomatous dysembryoma
• Reticulum cell sarcoma
• Hemangiopericytoma
• Spindle cell sarcoma
• Pseudomyxoma peritonei (Rosenfeld syndrome)
• Hepatoma (Nadler Wolfer Elliott syndrome)
• Adrenal carcinoma (Anderson syndrome)
• Non-islet pancreatic carcinoma
• Hypernephroma
• Adenocarcinomas of prostate, colon, bile duct, breast, stomach
• Simple fibroma
• Leukemia
• Lymphomas and Hodgkin's disease
• Multiple myeloma
• Wilms' tumor
• Apudoma
• Carcinoid tumors
• Pheochromocytoma (especially after removal)
• Melanoma
• Teratoma
• Neuroblastoma
• Paraganglioma

Causes of Transient Neonatal Hypoglycemia

• Prematurity
• Intrauterine growth retardation
• Smaller of twins
• Severe infant respiratory distress syndrome
• Maternal toxemia
• Perinatal asphyxia
• Critical illness

Starvation, Inadequate Intake Or Absorption

• Fasting, e.g. preoperative
• Severe malnutrition
• Kwashiorkor
• Anorexia nervosa
• Pyloric stenosis
• Vitamin B6 (pyridoxine) deficiency
• Biotin deficiency
• Hypomagnesemia
• Diarrhea
• Renal glycosuria
• Combined intestinal monosaccharide transport defect

Major Organ Failure & Critical Illness

• Congestive heart failure
• Cyanotic congenital heart disease
• Renal failure, especially chronic
• Dialysis
• Central nervous system disorders
• Head trauma
• Stroke
• Severe encephalopathies
• Hypothalamic tumor
• Liver disorders
• Severe acute hepatitis due to infection or toxins
• Chronic liver failure
• Reye's syndrome
• HELLP syndrome (hemolysis, elevated liver enzymes, thrombocytopenia)
• Chronic pancreatitis
• Sepsis
• Hypothermia
• Malignant hyperthermia

Hyperinsulinism

• Hypoglycemia due to endogenous insulin
• Congenital hyperinsulinism
• Transient neonatal hyperinsulinism
• Due to maternal factors
• Maternal diabetes
• Erythroblastosis fetalis
• Excessive intravenous glucose during labor
• Maternal sulfonylurea
• Sympathomimetic tocolytic agents (e.g. ritodrine)
• Due to infant factors
• Intrauterine growth retardation
• Perinatal asphyxia
• Idiopathic transient hyperinsulinism
• Iatrogenic
• Malposition of umbilical catheter
• Focal congenital hyperinsulinism
• Paternal SUR1 mutation with clonal loss of heterozygosity of 11p15
• Paternal Kir6.2 mutation with clonal loss of heterozygosity of 11p15
• Diffuse congenital hyperinsulinism
• Autosomal recessive forms
• SUR1 mutations
• Kir6.2 mutations
• Autosomal dominant forms
• Glucokinase gain-of-function mutations
• Hyperammonemic hyperinsulinism (glutamate dehydrogenase gain-of-function mutations)
• Loss of heterozygosity of 11p15 (Beckwith-Wiedemann syndrome)
• Donohue syndrome (leprechaunism)
• Acquired tumors and hyperplasias of pancreatic beta cells
• Islet cell adenoma
• Islet cell carcinoma
• Multiple endocrine adenomatosis syndrome
• Pluriglandular syndrome of islet, pituitary, parathyroid hyperplasia
• Autoimmune insulin syndrome
• Reactive hypoglycemia (postprandial hypoglycemia syndrome)
• Dumping syndrome
• Drug induced hyperinsulinism
• Oral hypoglycemic agents, especially Sulfonylureas
• Treatment of diabetes
• Treatment of diabetes insipidus
• Ingestion by child
• Aspirin overdose
• Acetaminophen overdose
• Pentamidine
• Quinine
• Disopyramide
• Bordetella pertussis vaccine or infection
• Hypoglycemia due to exogenous (injected) insulin
• Insulin self-injected for treatment of diabetes
• Excessive insulin dosage or accelerated absorption
• Excessive activity
• Inadequate food or delayed or decreased absorption
• Alcohol
• Drugs which contribute synergistically
• Development of concurrent disease
• Acquired endocrinopathies
• Renal, cardiac or liver failure
• Factitious & malicious insulin injection
• Insulin self-injected surreptitiously (e.g., Munchausen syndrome)
• Munchausen by proxy
• Insulin tolerance test for pituitary or adrenergic response assessment
• Treatment of hyperkalemia
• Insulin potentiation treatment (cancer quackery)
• Insulin-induced coma for depression or psychosis treatment (insulin shock)

Hormone Deficiencies

• Cortisol
• Addison's disease (acquired adrenal destruction)
• ACTH deficiency
• ACTH unresponsiveness
• Congenital adrenal hypoplasia
• Congenital adrenal hyperplasia
• Growth hormone
• Isolated growth hormone deficiency
• Laron dwarfism (GH unresponsiveness)
• Epinephrine and catecholamines
• Adrenomedullary unresponsiveness
• Glucagon
• Combined deficiencies
• Congenital hypopituitarism (various causes)
• Psychosocial deprivation syndrome (hypothalamic)
• Thyroid hormone (depresses GH and ACTH)

Metabolic Defects

• Defective glycogenolysis or glycogen accumulation
• Glucose-6-phosphatase deficiency (glycogenosis type I, von Gierke dis)
• Pseudoglycogenosis type I
• Amylo-1,6-glucosidase (debrancher) deficiency (glycogenosis type III)
• Hepatic phosphorylase deficiency (glycogenosis type VI)
• Hepatic phosphorylase kinase deficiency (glycogenosis type IXb)
• Glycogen synthase deficiency (glycogenosis type 0)
• Galactose-1-phosphate uridyl transferase deficiency (galactosemia)
• Defects of gluconeogenesis or substrate supply
• Fructose-1,6-diphosphatase deficiency
• Isovaleric acidemia
• Hypoalaninemia
• Phosphoenolpyruvate carboxykinase deficiency
• Pyruvate carboxylase deficiency (Leigh syndrome)
• Fructose-1-phosphate aldolase deficiency
• Defects of mitochondrial beta-oxidation and fatty acid metabolism
• Systemic carnitine deficiencies
• Enzyme deficiencies
• Carnitine palmitoyltransferase I
• Carnitine palmitoyltransferase II
• Carnitine acyltransferase
• Butyryl CoA dehydrogenase
• Hydroxymethylglutaryl CoA lyase
• Methylcrotonyl CoA carboxylase
• Medium chain acyl CoA dehydrogenase
• Short chain acyl CoA dehydrogenase
• Long chain acyl CoA dehydrogenase
• Multiple acyl CoA dehydrogenase (glutaric aciduria type II)
• Long-chain 3-hydroxyacyl-CoA dehydrogenase
• Short-chain 3-hydroxyacyl CoA dehydrogenase
• Carnitine/acylcarnitine translocase
• Enoyl CoA hydratase
• Ketothiolase
• Succinyl CoA:acetoacetate transferase
• Defects of amino acid metabolism
• Maple syrup urine disease
• Methylmalonic acidemia
• [[hydroxy-methylglutaric aciduria]]
• Tyrosinosis
• Phenylketonuria
• Propionic acidemia
• Miscellaneous metabolic defects
• Defective type I glucose transporter in brain
• Methylglutaconic aciduria
• Sucrosuria
• Glycerol intolerance
• Rare variants of galactose intolerance
• Other rare or poorly defined congenital metabolic defects

Drugs And Toxic substances

• Insulin, antidiabetic agents (see above)
• Drugs associated with hypoglycemia alone
• Ethanol
• Beta blockers, e.g. propranolol
• Salicylates
• Acetaminophen
• Acetazolamide
• Aluminium hydroxide
• Chloroquine
• Chlorpromazine
• Cimetidine, ranitidine
• Diphenhydramine, other antihistamines
• Propoxyphene
• Disopyramide
• Doxepin
• Golytely (in distal intestinal obstruction syndrome of cystic fibrosis)
• Imipramine
• Indometacin
• Isoxsuprine
• Insulin-like growth factor 1
• Lidocaine
• Lithium
• Pentamidine
• Propranolol, nadolol, labetalol, metoprolol
• Orphenadrine
• Oxytetracycline
• Quinine, quinidine
• Perhexiline
• Ritodrine
• Haloperidol
• Chelating agents (BAL and EDTA)
• THAM
• Colchicine
• Para amino benzoic acid, para-amino salicylic acid
• Cholestyramine added during glucocorticoid therapy (reduces absorption)
• Drugs which lower glucose in diabetics
• Enalapril and captopril
• Coumarin
• Phenylbutazone
• Antihistamines
• Sulfa antibiotics, including SMX/TMP (especially in renal failure)
• Monoamine oxidase inhibitors
• Medicines not available in U.S.
• Azapropazone, buformin, carbutamide, cibenzoline, cycloheptolamide, glibornuride, gliclazide, mebanazine, metahexamide, perhexiline, sulphadimidine, sulphaphenazole, Nigerian cow urine medicine
• Environmental toxins
• Amanita phalloides toxin
• Abractylis gummifera (Mediterranean plant)
• Hypoglycin from unripe Ackee fruit (Jamaican vomiting illness)
• Parathion
• Vacor rat poison

Idiopathic And Miscellaneous

• Ketotic hypoglycemia
• Identifiable hormone and enzyme deficiencies
• Idiopathic
• Idiopathic hypoglycemias, etiologies undetermined
• Autoimmune
• Antibodies to insulin
• Antibodies to insulin receptor
• Stimulating antibodies to islet cells
• Thyrotoxicosis (extremely rare)
• Infection
• Mumps
• Varicella
• Pertussis
• Measles
• Malaria
• Extreme exercise
• Artifactual
• In vitro glucose consumption after blood drawing
• Leukemic WBC's may consume glucose in vitro
• Polycythemia of infancy (RBCs consume glucose in vitro)
• Inaccuracies of blood drop strips
• Inherent variation inaccuracy at low end
• Inadequate drop
• Excessive wiping
• Short time interval

Reactive, Functional, Postprandial, Etc.

• Prediabetes (both categories controversial & may not be valid)
• Juvenile diabetes (rare, anecdotal reports)
• Adult onset diabetes (in early stages)
• After intravenous glucose load
• Abrupt discontinuation of parenteral nutrition or i.v. glucose
• After exchange transfusion with ACD preserved blood in neonate
• Alimentary (rapid jejunal emptying with exaggerated insulin response)
• Post fundoplication for gastroesophageal reflux
• Post gastrectomy dumping syndrome
• Short bowel syndrome
• Idiopathic gastrointestinal motility disturbance
• Alternate day growth hormone therapy
• Idiopathic reactive or postprandial hypoglycemia (hypoglycemia documented at time of symptoms: rare)
• Idiopathic postprandial syndrome (hypoglycemia never documented: common)