SUN-618 A Rare Case of Hypoglycemia with Combination of Insulin and Non-Insulin-Mediated Etiologies, Implication for Institutional Protocol

Abstract Disclosure: R. Ozturk: None. S. Ramadan: None. A. Usman: None. Z. He: None. Background: Proper assessment of hypoglycemia in patients without diabetes can be challenging in a busy hospital ward. The interpretation of the biochemical data can be confusing if not placed in accurate context. We present here a difficult management of hypoglycemia case in a patient without diabetes. Case Description: An 87-year-old female with a history of hypothyroidism is hospitalized for sepsis. She has had unexplained hypoglycemic episodes with neuroglycopenic symptoms for the previous 6 months. She does not have the diagnosis of diabetes and has not had any gastrointestinal surgery. Her liver and thyroid function were normal. Random cortisol was 25.5 µg/dL. Hypoglycemia persisted despite sepsis being treated. Laboratories obtained while glucose <55 mg/dL after multiple attempts showed proinsulin 11.3 pmol/L ( 0-10 ), insulin 15 uIU/mL ( 2.6-24.9 ), and C-peptide 3.8 ng/mL ( 1.1-4.4 ). Beta-hydroxybutyric acid level was 0.7 mg/dL ( 0.2-2.8 ). The patient received 1 mg of glucagon iv and glucose increased from 42 mg/dL to 55 mg/dL. An abdomen CT for sepsis assessment reported unremarkable pancreas. Diazoxide was started, and oral intake encouraged while insulin antibody results were still pending. Patients hypoglycemic episodes improved after 2 days, and the patient was discharged to rehabilitation with outpatient endocrinology follow up. She continued to receive antibiotic treatment. The patient returned 5 days later with hypoglycemia, hypothermia, generalized rash, and altered mental status. Insulin antibodies that were sent during the previous admission resulted in elevated levels of 8.7 uU/mL ( <5 ). Patient was started on high dose of glucocorticoids with octreotides and IV Dextrose infusion. Patient could not tolerate oral intake due to lack of appetite and altered mental status, tube feeds were not within goals of care. The course was complicated by severe acute kidney injury. Unfortunately, patient did not improve and family changed code status to comfort measures only. Patient passed away after 2 weeks. Conclusion: This case highlights the complexity of diagnoses and treatment of this unique case of hypoglycemia. A major challenge in diagnosis was that the patient had frequently received treatment for hypoglycemia before the blood draw. Etiology of hypoglycemia is likely multifactorial with both insulin and non insulin-mediated etiologies. In addition, robust institutional protocol is crucial to expedite the diagnosis process. Presentation: Sunday, July 13, 2025