Virginia Via Research Day Book 2026

Medical Resident Research Case Reports

15 TIME CRITICAL CTA IN MESENTERIC ISCHEMIA DESPITE CKD: A CASE BASED ARGUMENT FOR IMAGING-FIRST TRIAGE IN A PATIENT WITH ACUTE ON CHRONIC ISCHEMIA

Quinta Odondi, MD; Jun Huh, MD; Kimberly Bird, MD; Akshay Duddu, MD Corresponding author: quinta.odondi@lpnt.net

Sovah Health - Danville, Danville, Virginia

to the ED. This patient was not diabetic; however, upon checking blood sugar on arrival to the ED, it was found to be less than 20. She was given an amp of D50, and blood sugar improved to 49 within 30 minutes. After the first D50 patient was alert and able to hold simple conversations. She was given a 2nd amp of D50 and blood sugar improved to 65. The patient was started on D10W infusion. Blood sugar improved to 90. However, in less than 2 hours, the patient was unconscious again, and blood sugar was less than 20, even with D10 W infusing through a properly working IV. Another D50 was given again. Per family, the patient had no access to any insulin. She was not on any oral anti-diabetic medication and had no access to any. She was however, on metoprolol. Lactic acid was elevated and continued to trend up, was 9 then 12.5, then 14, even on adequate IV hydration. Blood culture was negative, Chest x-ray did not show any infiltrates, CT chest /abdomen/pelvis showed no acute findings. UA was ordered but not sent (may be difficult to obtain in dialysis patient). The patient was afebrile throughout. WBCs was 13.72, and procalcitonin was 103.9. On arrival to the ED, nursing did a Sepsis

screen which was negative. Hemoglobin A1c was 4.1, again reaffirming that she was not diabetic. Beta hydroxy butyrate was 1.11. She was empirically treated with IV antibiotics. Total Cortisol level was appropriately elevated, 150 prior to hydrocortisone. She became hypotensive and progressed to shock state. She received hydrocortisone and was started on norepinephrine to maintain MAP above 65. Ammonia level was less than 10. Comments: This case emphasizes the critical role of renal gluconeogenesis especially during acute illness and possible role of continuous glucose monitoring in acute care settings. In ESRD patients, the loss of this mechanism creates a more likely predisposition to severe, refractory and recurrent hypoglycemia in acute illness, even in the absence of exogenous insulin use or diabetes.

Context: Hypoglycemia is plasma glucose level below 70 mg/dL. Level 3 hypoglycemia refers to glucose below 54 mg/dL, often including associated neurological symptoms. Severe hypoglycemia, especially in the setting of non-diabetic patients where it is least anticipated, can be life-threatening. This case highlights the underrecognized contribution of renal gluconeogenesis with maintaining euglycemia and the vulnerability of end-stage renal disease (ESRD) patients to severe hypoglycemia despite not having diabetes. In addition, it raises the question of whether continuous glucose monitoring (CGM) could possibly play a meaningful role in acute care setting for early intervention. Report of case: This is a case of an 80-year old female with ESRD who experienced level 3 hypoglycemia refractory to standard therapy. The patient was brought to the ED for altered mental status; she was unconscious. The family had called EMS because patient was lethargic. Upon EMS’ arrival, blood sugar was 38 and she was given two oral glucose tablets which improved blood sugar to 48. The patient was given 2 more oral glucose tablets en route prior

Table of Contents

146 Edward Via College of Osteopathic Medicine (VCOM)