Volume 72, Issue 7, August–September 2025, 501599Author links open overlay panel, , , , , Abstract

A 51-year-old man with a past medical history of chronic alcoholism was admitted for a planned fasting test due to suspected hypoglycemia. Despite previous evaluations by cardiology and neurology revealing no evident etiology, his syncopal episodes were suspected be associated with inconsistent hypoglycemic episodes. During his hospital admission, the patient experienced several syncopal episodes with associated seizures, which, at the time, were not related to hypoglycemia. This led to further investigation, including the exclusion of other causes, such as a possible autonomic dysfunction. Neurology consequently expanded the assessment, identifying subtle signs of mild parkinsonism and symptoms suggestive of a REM sleep disorder, which shifted the diagnostic suspicion.

This case underscores the importance of considering other clinical conditions when evaluating hypoglycemia, especially when classic symptoms are absent or inconsistently presented, and an endocrinological origin has been ruled out.

Resumen

Se trata de un varón de 51 años con antecedentes de alcoholismo crónico, que ingresa de manera programada para realizar un test de ayuno por sospecha de hipoglucemia. Aunque los estudios previos por parte de cardiología y neurología no mostraron causas evidentes, se sospechaba que los síncopes podían estar relacionados con hipoglucemias que no se presentaban de forma consistente. Durante su ingreso, el paciente sufrió varios episodios sincopales con convulsiones asociadas, en ese momento sin relación con hipoglucemia, lo que llevó a descartar otras etiologías, entre las que se encontraba un posible trastorno autonómico. Esto hizo que neurología ampliara el estudio, observando signos sutiles de parkinsonismo y clínica sugestiva de un trastorno del sueño REM que reorientaron la sospecha diagnóstica. Este caso resalta la importancia de considerar otras entidades clínicas en el abordaje de la hipoglucemia cuando los síntomas clásicos están ausentes o se manifiestan de forma inconsistente, especialmente tras haber descartado un origen endocrinológico.

Section snippetsCase description

The patient, a 51-year-old caucasian male, was admitted to the Endocrinology and Nutrition Department for a scheduled 72-h fasting test. He had an alcohol use disorder (daily intake of 1–2 l of beer since the age 20), with variable abstinence periods for which he remained on 250 mg of disulfiram daily. From a nutritional point of view, he was overweight according to his BMI (26.1 kg/m2). His personal and family medical history was otherwise unremarkable, apart from alcoholism. The patient had

Management

Hypoglycemia in individuals without DM is a relatively rare condition,1 with its prevalence evaluated in only a limited number of small-scale studies.2, 3, 4, 5 Diagnosing its origin can sometimes be challenging. To identify hypoglycemia, the presence of Whipple's triad is usually required: symptoms associated with hypoglycemia, a low plasma glucose concentration (<55 mg/dL in subjects without diabetes), and symptom improvement upon normalization of blood glucose levels.6, 7, 8 Evidence of the

Areas of uncertainty

Alpha-synucleinopathies arise from the accumulation of a protein called alpha-synuclein in the central nervous system (CNS). Normally present in the human brain, alpha-synuclein plays essential roles, such as regulating neurotransmitter release at nerve endings. However, when this protein misfolds, it forms insoluble aggregates that disrupt its proper functioning. These disorders are representative of a spectrum of conditions, including Parkinson's Disease, MSA, and Dementia with Lewy Bodies.16

Clinical practice guidelines

The diagnostic process for hypoglycemia should start with a detailed medical history, including dietary habits, alcohol consumption, drugs and a history of any GI surgical procedures. If Whipple's triad is confirmed, glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, sulfonylureas, and anti-insulin antibodies should be measured during hypoglycemic episodes.21

Following the diagnostic algorithm (Fig. 1), a 72-h fasting test may be conducted to identify the underlying cause. If this

Conclusions and recommendations

Investigating hypoglycemia in individuals without diabetes can sometimes be challenging, as the root cause often goes beyond endocrinology and may represent just one part of a more complex syndrome affecting the patient. In light of this, a collaborative, multidisciplinary approach is highly valuable. By involving multiple clinical specialties, the diagnostic process becomes more thorough, increasing the chances of accurately identifying the underlying cause. Teamwork ultimately benefits the

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