True seizures as a presentation of spontaneous fasting hypoglycemia

 

Could this be the first reported case?

A 38-year-old woman, mother of four children, was quite well up to 1 year ago, when she started to suffer from recurrent attacks of headache, fatigue and lack of concentration. She sought medical advice & received non-specific treatment.

Four months ago, her husband described an attack of tonic-clonic convulsions, which she suffered at 5 o'clock a.m. The emergency consultation revealed low blood sugar ~44 mg/dl, she was rescued with I.V. glucose. The condition recurred at first nightly ~ "Dawn time" but later on became at any time. They sought medical advice many times & underwent laboratory investigations, which revealed high fasting insulin & C-peptide (we are not sure that the measurement was during the attack of hypoglycemia or not), other investigations were normal. She also had undergone imaging including C.T abdomen & pelvis with contrast with pancreatic protocol which revealed no sizable pancreatic masses or focal lesions. Also, she underwent MRI, PET-CT scan, and endosonography, all revealed nothing. Because of the persistence of symptoms & increased its intensity, she underwent further study with Gallium PET-CT which revealed nothing.  When we saw the patient, she was depressed more or less overweight, with little acanthosis nigricans. We are attributing the depression to her prolonged suffering, prolonged ICU admission & investigations, and it may be in part due to neuropsychiatric manifestations of recurrent hypoglycemia.

Fasting hypoglycemia typically presents with subacute neuroglycopenic symptoms because the blood glucose drops gradually. This slow decline allows the brain to partially adapt to it, often bypassing or blunting the sharp, rapid autonomic fight-or-flight warning symptoms.

We considered insulin resistance as a cause, and have started a regimen including (1) re-assurance, (2) regular programmed exercise, (3)dietary regulation ("fractionated, low glycemic index food"), and (4) small doses of insulin sensitizers.

There was a dramatic response & the patient is happy now at home, Serving her family.

Can you remember the smile of the patient & her husband in our grand meeting?!

All praises & thanks to our great Lord.