High-dose Vitamin-C Induced Prolonged Factitious Hyperglycemia in a Peritoneal Dialysis Patient

A Case Report

Olivier Lachance; François Goyer; Neill K. J. Adhikari; Marie-Hélène Masse; Jean-François Bilodeau; François Lamontagne; Marc-André Leclair

Disclosures

J Med Case Reports. 2021;15(297) 

In This Article

Case Presentation

A 73-year-old non-diabetic (HbA1c 5.7%) white man with end-stage renal disease on peritoneal dialysis was admitted with diarrhea, fever, and hypotension. At home, the patient was on automated nocturnal peritoneal dialysis (6 × 2 L × 2.5% over 8 hours) with 2 L of icodextrin as a daytime dwell. Physical examination was unremarkable except for abdominal distension. Sepsis due to peritonitis was suspected, and he received intravenous fluids, vasopressors, and broad-spectrum antibiotics. Blood cultures grew Salmonella spp. The patient continued to receive peritoneal dialysis, with three daytime exchanges of 2.5% or 4.25% dextrose and one night exchange of icodextrin. The patient had some urine output at baseline but became anuric following hospital admission.

The patient consented to participation in the LOVIT trial 18 hours after admission to the ICU. Before the first dose of study drug, he received subcutaneous insulin due to sepsis-associated hyperglycemia. Capillary blood glucose was monitored with the Accu-Chek Inform II glucometer (F. Hoffmann-La Roche Ltd.). On hospital day 5, he received intravenous insulin for worsening hyperglycemia, after which he became unconscious. A blood sample sent to the core laboratory and tested using a hexokinase assay showed severe hypoglycemia (1.7 mmol/L; normal > 4 mmol/L). Insulin was discontinued, 50% dextrose was administered, and his cognitive status normalized.

After unblinding, research staff confirmed that he had been receiving vitamin C. He was discharged to the ward on hospital day 10. An ascorbic acid level of 568 μmol/L (normal range: 30–114 μmol/L) was measured using a spectrophotometric dinitrophenylhydrazine assay 5 days after discontinuing vitamin C therapy, on hospital day 11, and important differences between blood glucose measured by the core laboratory and point-of-care glucometers persisted until hospital day 12 (Figure 1). Following this event, the LOVIT trial protocol was amended to mitigate the risk of factitious hyperglycemia. The patient was discharged home without any apparent sustained harm.

Figure 1.

Glucose values from glucometer and core laboratory assay before, during, and after vitamin C administration. Note that core laboratory measurements were not available between day 2 and day 5

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