Recurrent episodes of hypoglycemia induced by moxifloxacin
A 66-year-old male, known diabetic for last 1 year was hospitalized with pain in right upper quadrant of abdomen for 20 days and breathlessness at rest for 5 days. No written reports of blood sugar levels were available with patient at the time of admission. On verbal enquiry, he reported that blood sugars were always below 140 mg%. His blood sugars were well-controlled on medical nutrition therapy (diet with low glycemic index). He had never taken any anti-diabetic drugs. During this admission, blood investigations revealed fasting blood sugar of 142 g/dl, white blood cell count of 12700/c.mm, platelets of 48000 lacs/c.mm. Renal profile showed blood urea nitrogen of 33.4 mg/dl, creatinine of 1.7 mg/dl, sodium of 129 meq/l, and potassium of 3.9 meq/l. Liver function tests revealed total bilirubin level of 6.6 mg/dl, direct bilirubin level of 5.8 mg/dl, alanine amino-transferase level of 75 u/l, aspartate amino-transferase level of 103 u/l, alkaline phosphatase level of 202 u/l, total protein level of 5.8 g/dl and albumin level of 2.9 g/dl. Hepatitis B surface Antigen (HBsAg) and anti Hepatitis C virus (HCV) were negative. Chest X-ray revealed right mid zone pneumonia and ultrasound abdomen was normal. Urine routine revealed 10-12 pus cells/high power field and later urine culture grew Escherichia coli. He was empirically started on i.v. moxifloxacin (400 mg) at admission and was managed symptomatically. Twenty four hours later i.v. cefepime/tazobactum combination was also added based on urine culture sensitivity report. After 16 h of hospitalization patient developed tremors, sweating and was found to have blood glucose level of 58 mg/dl. He was administered 10% dextrose intravenously, which relieved his symptoms. The patient had repeated episodes of hypoglycemia for subsequent 3 days (blood glucose levels 77, 44, 54 mg/dl) despite regular administration of intravenous 10% dextrose. Moxifloxacin was discontinued after 3 days, after it was suspected to cause the hypoglycemia. After stopping moxifloxacin, his blood sugar levels increased after 24 h and he developed hyperglycemia (blood sugars-273, 324, 298 mg/dl) and required insulin treatment. The patient was discharged on recovery after 10 days of hospitalization. At 1 month follow-up, his liver function tests and kidney function tests were normal. He continued to require insulin for glycemic control even 1 month after his discharge. His last blood sugars level was 115 mg% with insulin.