Neuroglycopenic Syndromes

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Four more or less distinct neuroglycopenic syndromes (one of which is so rare that it will not be considered further here) can be recognized. They are not mutually exclusive, nor do they depend upon the ultimate cause of the hypoglycemia.

Acute Neuroglycopenia

This syndrome comprises a collection of vague symptoms such as feelings of alternating hot and cold, feeling unwell, anxiety, panic, inner trembling, unnatural feelings, blurring of vision, and palpitations, any or all of which may be accompanied by objective signs of facial flushing, sweating, tachycardia, and unsteadiness of gait. There is no particular order in which these features occur, nor are they constant. Nevertheless, patients on insulin therapy for diabetes, in whom they are common, rely upon them to warn of more severe neuroglycopenic impairment culminating in loss of consciousness. These patients can be taught to abort progression of symptoms by eating carbohydrate.

Many of the features of acute neuroglycopenia resemble those produced by adrenaline and consequently are often referred to as adrenergic.

Subacute Neuroglycopenia

This syndrome is more insidious and may go completely unrecognized unless or until the patient loses consciousness. Often, however, there is loss of spontaneous activity, impairment of cognitive function and the onset of somnolence that is more discernible to the bystander than to the patient and which, when it occurs de novo in an insulin-treated diabetic, is often referred to as 'hypoglycemia unawareness.'

Acute can proceed to subacute neuroglycopenia and both can progress to stupor or coma unless relieved by food or injection of glucagon. Even when this is not done, however, full recovery, under the influence of endogenous counter-regulatory mechanisms, is almost invariable and is the reason why treatment with insulin is so safe despite the potential dangers of hypoglycemia.

Chronic Neuroglycopenia

The third syndrome is exceedingly rare. It occurs only when the blood glucose concentration remains low, either due to the presence of an insulin-secreting tumor of the pancreas or overzealous treatment of diabetes with insulin for weeks or months on end. It is characterized by mental dysfunction resembling clinical depression, schizophrenia, or dementia, the symptoms of which are not relieved by restoring the blood glucose level to normal. Partial recovery may, however, take place over the ensuing months or years if the cause of the hypo-glycemia is remedied.

This condition might be confused with 'nonhypo-glycaemia' were it not for the fact that the blood glucose concentration is invariably low (<3.0mmoll_1) while the patient is fasting, does not rise normally in response to food, and evidence of underlying disease can always be found.

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