Elsevier

Endocrine Practice

Volume 16, Issue 2, March–April 2010, Pages 244-248
Endocrine Practice

Case Report
Confirmation of Hypoglycemia in the “Dead-In-Bed” Syndrome, as Captured by a Retrospective Continuous Glucose Monitoring System

https://doi.org/10.4158/EP09260.CRGet rights and content

ABSTRACT

Objective

To report a case that substantiates the presence of hypoglycemia at the time of death of a young man with type 1 diabetes, who was found unresponsive in his undisturbed bed in the morning.

Methods

We describe a 23-year-old man with a history of type 1 diabetes treated with an insulin pump, who had recurrent severe hypoglycemia. In an effort to understand these episodes better and attempt to eliminate them, a retrospective (non-real-time) continuous subcutaneous glucose monitoring system (CGMS) was attached to the patient. He was found dead in his undisturbed bed 20 hours later. The insulin pump and CGMS were both downloaded for postmortem study.

Results

Postmortem download of the data in the CGMS demonstrated glucose levels below 30 mg/dL around the time of his death, with only a minimal counterregulatory response. This finding corresponded to a postmortem vitreous humor glucose of 25 mg/dL. An autopsy showed no major anatomic abnormalities that could have contributed to his death.

Conclusion

To our knowledge, this is the first documentation of hypoglycemia at the time of death in a patient with the “dead-in-bed” syndrome. This report should raise the awareness of physicians to the potentially lethal effects

of hypoglycemia and provide justification for efforts directed at avoiding nocturnal hypoglycemia. (Endocr Pract. 2010;16:244-248)

Section snippets

INTRODUCTION

The Diabetes Control and Complications Trial confirmed a threefold increase in severe hypoglycemia in patients with type 1 diabetes using intensive insulin therapy in comparison with conventional treatment (1). Nonetheless, intensive insulin therapy with a hemoglobin A1c goal of < 7.0% has been the standard of care for patients with type 1 diabetes, in an effort to prevent or minimize microvascular complications (2). More than 15 years after the initial report from that trial, the limiting

CASE REPORT

A 23-year-old man with a history of type 1 diabetes mellitus, which was being treated with an insulin pump, was found convulsing by his mother. She administered glucagon and called the emergency medical service (EMS). When they arrived in 5 minutes, his convulsions had stopped, and he had recovered enough to drink orange juice. After noting a finger-stick glucose level of 61 mg/ dL, the EMS took him to the emergency department. Three hours later, his laboratory glucose value was 224 mg/dL; the

DISCUSSION

Iatrogenic hypoglycemia, a common occurrence in the treatment of patients with type 1 diabetes, is a major limitation in the ability of these patients to attain target glycemic control (3). Of considerable concern is severe hypoglycemia, which may cause obtundation, seizures, coma, and death. Severe hypoglycemia is extremely worrisome in patients with hypoglycemia unawareness or hypoglycemia-associated autonomic failure (11). Nocturnal hypoglycemia is of substantial concern because patients may

CONCLUSION

Confirmation of the presence of hypoglycemia in the dead-in-bed syndrome implicates a pathologic process that can be the focus of interventions to minimize the risks of severe hypoglycemia in all patients with insulin-treated diabetes. Dietary and pharmacologic interventions have been disappointing in efforts to prevent nocturnal hypoglycemia (12). The introduction of real-time continuous glucose monitoring with alarms that signal the presence of glucose values below a specified level or rapid

DISCLOSURE

Dr. Tanenberg directs the East Carolina University Diabetes Research Center, which receives grant support from Medtronic MiniMed. He is also a principal investigator in the Star 3 Study (NCT00417989), sponsored by Medtronic Diabetes. The other authors have no multiplicity of interest to disclose.

ACKNOWLEDGMENT

We are grateful to Nancy Leggett-Frazier, RN, CDE, for her help with this patient, John Mastrototaro, PhD, who provided the CGMS postmortem processing, and to Mary Gilliland, MD, who supervised the autopsy. This case study was presented in part as a poster at the 17th Annual Meeting and Clinical Congress of the American Association of Clinical Endocrinologists; May 14-18, 2008; Orlando, Florida.

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