Refractory Hypoglycemia in a Woman With Cirrhosis and a Large Pelvic Mass: A Case Report.

Recurrent severe hypoglycemia is a life-threatening condition that may cause altered mental status, metabolic encephalopathy, and loss of protective airway reflexes, particularly in patients with multiple comorbidities and recent changes in glucose-lowering therapy. We report a woman in her 60s with hypertension, chronic obstructive pulmonary disease requiring home oxygen at 2 L/min, atrial fibrillation treated with rivaroxaban, heart failure with reduced ejection fraction of 35%, obesity, and a reported recent diagnosis of type 2 diabetes mellitus. She presented after weakness and a witnessed fall while exiting the shower, without reported loss of consciousness or seizure activity. Although insulin had been prescribed approximately two weeks earlier, she had never obtained or used it. Her initial point-of-care glucose was 69 mg/dL (3.8 mmol/L), followed during hospitalization by recurrent values below 20 mg/dL (below 1.1 mmol/L). Despite repeated dextrose administration, the patient developed progressive somnolence and impaired airway protection requiring endotracheal intubation and intensive care. Management included an initial continuous 10% dextrose infusion, subsequent 5% or 10% dextrose infusions, and repeated 50% dextrose boluses. Head computed tomography (CT) showed no acute intracranial abnormality. Chest and abdominal imaging demonstrated cardiomegaly, pleural effusions, ascites, anasarca, and cirrhotic liver morphology. Pelvic CT and ultrasonography identified a 16.2 × 12.3 × 11.9 cm left adnexal mass concerning a neoplasm. Cancer antigen 125, inhibin A, inhibin B, and insulin-like growth factor binding protein 2 were elevated; however, these findings were nonspecific. Magnetic resonance imaging (MRI) was not completed because the patient declined conventional MRI owing to severe claustrophobia. No biopsy, resection, or histopathologic diagnosis was obtained during hospitalization; the available records documented plans for outpatient open MRI and gynecologic-oncology evaluation but did not specify a separate reason for deferring tissue diagnosis. A complete biochemical critical sample during hypoglycemia, including paired plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, cortisol, screening for insulin secretagogues, and insulin-like growth factor measurements, could not be confirmed, and the available records did not explain why it was not obtained during a qualifying episode. The hypoglycemia was therefore considered likely multifactorial. Poor oral intake, critical illness, and impaired hepatic glycogen storage and gluconeogenesis from cirrhosis were plausible contributors. A tumor-related mechanism remained possible but was not biochemically or pathologically confirmed. The patient was ultimately transitioned from intravenous dextrose to oral glucose supplementation, experienced her final documented hypoglycemic episode on hospital day 34, and was discharged on hospital day 36 for outpatient primary care, endocrinology, hepatology, and gynecologic-oncology evaluation.