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Nutrition. 2014 Sep;30(9):1090-2. doi: 10.1016/j.nut.2014.01.007. Epub 2014 Feb 15.

Refractory hypoglycemia and subsequent cardiogenic shock in starvation and refeeding: report of three cases.

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Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan. Electronic address:
Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
Medical Education Center, Osaka University Graduate School of Medicine, Osaka, Japan.
Department of Pediatrics, Takarazuka City Hospital, Hyogo, Japan.
Laboratory of Cardiovascular Disease, Novel, Non-invasive and Nutritional Therapeutics (CNT), Graduate School of Medicine, Osaka University, Osaka, Japan.



Although starvation is associated with high in-hospital mortality, its related cardiac complications are not sufficiently understood. The aim of this study was to determine the clinical course and pathogenesis of cardiac complications in malnourished patients.


We reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac complications in starvation.


This report concerns three patients, respectively suffering from anorexia nervosa, esophageal carcinoma, and Parkinson's disease. Their ages ranged from 18 to 70 y, body mass index was 11.5 ± 1.5 kg/m2 (mean ± SD), and the main symptom was coma. The average blood glucose level was 15.7 ± 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypoglycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 ± 4 mg/dL and 10 ± 9.1 μEq/L, respectively). Levels of serum potassium, phosphate, and magnesium were almost normal at admission. The main cardiac complications included Takotsubo cardiomyopathy and cardiac arrest. All patients survived as a result of intensive treatment.


Repetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding.


Hypoglycemia; Hypophosphatemia; Hypotriglyceridemia; Refeeding; Starvation; Takotsubo cardiomyopathy

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