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(10) A Case of Pseudo Hypoglycemia in a Patient with Leukocytosis


Authors:

Michael A. Weintraub, MD – Internal Medicine Resident, Thomas Jefferson University Hospital

Deepika Nandiraju, MD – Fellow in training, Thomas Jefferson University hospital

Monika Shirodkar, Md – Associate Professor of Clinical Medicine, Thomas Jefferson University Hospital

Michael A. Weintraub, MD – Internal Medicine Resident, Thomas Jefferson University Hospital

Abstract:

Objective : Hypoglycemia is most convincingly documented by Whipple’s triad: symptoms of hypoglycemia, low plasma glucose and relief of symptoms after treatment. Pseudo hypoglycemia is a condition which is associated with an artifactually low glucose concentration in the absence of classic signs and symptoms. We present a case of pseudo hypoglycemia where leukocytosis played a role in lowering venous glucose.

Methods :

A 65-year-old male with a history of gout was admitted for evaluation of hematuria. Labs during his admission revealed a venous blood glucose of 43mg/dl. Point of care glucose checks were not ordered on admission as the patient was not diabetic. The patient no hypoglycemia symptoms and received no anti hyperglycemic medications. He had an HbA1c of 6.2%. He was hemodynamically stable with no signs of infection. The only other lab abnormality noted was a leukocytosis of 95 thousand/µL. Point of care glucose checks were ordered with meals and at bedtime.  Subsequent venous blood glucose next day was reported as 27 mg/dL, patient remained asymptomatic and his corresponding point of care glucose was 92 mg/dL. A close evaluation of the case revealed delay in the venous sample analysis. Immediate processing of sample revealed a normal glucose (90mg/dL) that correlated with the simultaneous point of care glucose. Repeat testing with quick processing of the sample clarified that low venous blood glucose level was due to in vitro glucose consumption by leukocytes between the time of the blood draw and sample analysis

Results : NA

Discussion :

Pseudo hypoglycemia is not a clinical syndrome rather a result of artifactually low glucose concentration. Although there are case reports in the literature, the phenomenon is under-recognized. Causes of pseudo hypoglycemia differ based on the method of glucose measurement. Low capillary blood glucose is seen in situations with decreased perfusion, such as in patients with peripheral vasoconstriction in hypovolemic shock, Raynaud’s disorder. Decreased perfusion leads to increased glucose uptake by peripheral tissues. In contrast, low venous blood glucose levels can be observed in leukemia or polycythemia vera where high nucleated cell counts cause increased glycolysis. Waldenstrom macroglobulinemia has also been reported to generate falsely low venous blood glucose readings due to interference of the proteins with the lab test. Pseudo hypoglycemia should be considered in asymptomatic patients with low blood glucose levels before initiating an extensive work up.

Conclusion : Pseudo hypoglycemia should be considered in asymptomatic patients with low venous blood glucose values, which do not correlate with point of care glucose values. 

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