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https://doi.org/10.11613/BM.2020.010802

An unconscious man with profound drug-induced hypoglycaemia

Toon Schiemsky ; Laboratory Medicine, University Hospitals Leuven; Department of cardiovascular Medicine, University of Leuven, Leuven, Belgium
Guy Vundelinckx ; Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Belgium
Kathleen Croes ; Laboratory medicine, AZ Groeninge Hospital, Kortrijk, Belgium
Joris Penders ; Laboratory medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
Koen Desmet ; Laboratory Medicine, University Hospitals Leuven; Department of cardiovascular Medicine, University of Leuven, Leuven, Belgium
Steven Pauwels ; Laboratory Medicine, University Hospitals Leuven; Department of cardiovascular Medicine, University of Leuven, Leuven, Belgium
Pieter Vermeersch orcid.org/0000-0001-7076-061X ; Laboratory Medicine, University Hospitals Leuven; Department of cardiovascular Medicine, University of Leuven, Leuven, Belgium

Abstract

Introduction: Hypoglycaemia has been reported as an unusual complication of tramadol use and in a few cases of tramadol poisoning, but the
exact mechanism is not known.
Case description: An ambulance crew was dispatched to an unconscious 46-year old man. A glucometer point-of-care measurement revealed a
profound hypoglycaemia (1.9 mmol/L). Treatment with intravenous glucose was started and the patient was transported to the hospital. The patient
had several episodes of pulseless electrical activity requiring cardiopulmonary resuscitation in the ambulance and upon arrival in the hospital.
Despite continuous glucose infusion the hypoglycaemia was difficult to correct during the next few hours and the patient developed hypokalaemia.
Further investigation to identify the cause of hypoglycaemia revealed that insulin and C-peptide were inappropriately raised. A toxicological investigation
revealed the presence of tramadol and its metabolites in lethal concentrations. Also acetaminophen, ibuprofen and lormetazepam were
present. Ethanol screening was negative (< 0.1 g/L) and no sulfonylurea were detected. The patient developed multiple organ failure, but eventually
recovered.
What happened: The hypoglycaemia was caused by inappropriate stimulation of insulin secretion in a patient intoxicated with tramadol. The
sudden hypokalaemia was caused by a massive intracellular shift of potassium in response to the hyperinsulinemia, triggered by the intravenous
administration of glucose.
Main lesson: To our knowledge, we are the first to document a significant rise in endogenous insulin production in a hypoglycaemic patient presenting
with tramadol intoxication. Our observation suggests that hyperinsulinemia could be the cause of the hypoglycaemia associated with tramadol
use.

Keywords

hypoglycaemia; tramadol; insulin; poisoning

Hrčak ID:

234150

URI

https://hrcak.srce.hr/234150

Publication date:

15.2.2020.

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