AN UNCOMMON CAUSE OF HYPOGLYCEMIA. S. Agresta 1 , B. Springgate 1 ; 1 Tulane, New Orleans, LA (Tracking ID #75148) LEARNING OBJECTIVES: 1. Recognize ethanol ingestion as an important cause of sustained hypoglycemia. 2. Provide appropriate treatment for ethanol-induce hypoglycemia. CASE INFORMATION: A 37 year-old man presented after a syncopal episode. Seven months earlier he was diagnosed with alcoholic liver disease. On presentation, he was tremulous and diaphoretic. The remainder of the physical exam was normal. An initial blood glucose was 30 mg/dL. He received one ampule of intravenously D50. Twenty minutes later the symptoms returned. His glucose was 28. Despite additional intravenous dextrose, his glucose continued to drop to between 30 and 40 mg/dl. His AST was 175 U/L, ALT 73 U/L, Hgb A1C 4.6%, and C peptide 15.5 ng/mL (nl). Drug and ethanol screens were negative. After two days of continuous dextrose-containing intravenous fluids, his blood glucose level returned to normal. IMPLICATIONS/DISCUSSION: Alcohol-induced hypoglycemia is an important but infrequently diagnosed sequella of ethanol ingestion. Symptoms are precipitated by a period of fasting followed by ingestion of alcohol. Ethanol inhibits the normal hepatic gluconeogenesis response to starvation-induced hepatic glycogen depletion. As this inhibition may be gradual, hypoglycemic symptoms may develop slowly. Patients may not demonstrate acute alcohol toxicity at the time of presentation. 1 Continuous intravenous glucose is required to prevent recurrent hypoglycemia and to replete hepatic glycogen stores. Chronic alcoholics may also have inhibition of pituitary ACTH, creating a hypo-cortisolemic state, exacerbating the hypoglycemia. surpassed those of the squamous cell type. The general locations of adenocarcinoma metastasis are lymph nodes and liver, and occasionally lung and bone. We report a case of adenocarcinoma of the esophagus with leptomeningeal carcinomatosis. A 56 year old thin white male presented with dysphagia, and a 40 pound weight loss over six months. He also had nausea, vomiting, abdominal pain, rectal bleeding, and diplopia during this period. On exam, he was alert and oriented. He had sluggish reaction of his left pupil, diplopia on downward gaze, guaiac positive stool, and a microcytic anemia (MCV 61). Esophagogastroduodenoscopy showed a mass that extended from the 28th cm of the esophagus to the 37th cm including the GE junction. Whole body CT scan showed an isodense mass in the foramen of Monro, midesophageal thickening, multiple hepatic lesions, and celiac lymphadenopathy. Brain MRI showed leptomeningeal carcinomatosis surrounding the pons and multiple cranial nerves. The patient received urgent whole brain radiation. Upon completion of radiation an Ommaya reservoir was suggested for intrathecal methotrexate. However, his overall quality of life deteriorated rapidly and he chose to receive hospice care. IMPLICATIONS/DISCUSSION: Metastatic sites for esophageal cancer typically involve the liver and lymph nodes and rarely lung and bone. Direct CNS involvement is an extremely rare occurrence. On identification of the leptomeningeal carcinomatosis our patient was able to undergo whole brain radiation to prevent any immediate risk of herniation, but given the extent of his disease his prognosis was extremely poor. The reasons why this adenocarcinoma spread to involve the CNS are unclear, and further study needs to be undertaken. As esophageal adenocarcinoma becomes more common, this type of presentation may be seen more frequently, and clinicians should be aware of this. week. The test took place at 6 AM with an ambient temperature of 75F. At the end of the test the patient collapsed complaining of``complete muscle failure''. He was found to be hypotensive and tachycardic. The patient's history was significant for the use of an herbal supplement called Energel. He had been taking this consistently for the past month to try improve his performance time. Laboratory results initially revealed severe rhabdomyolysis with a creatinine kinase (ck) of 11,000. Acute renal failure secondary to pigment-induced ATN was demonstrated by a serum creatinine (cr) of 2.4 mg/dl and urine positivity for myoglobin. The patient's ck peaked at 240,000 during his hospital course. After 8 days his ck was 45,000 and his cr returned to normal. IMPLICATIONS/DISCUSSION: Energel is a herbal supplement that contains Ma Huang. Ma Huang is the Chinese version of Ephedra which grows in many parts of the world and is used predominantly as a stimulant. Ephedra alkaloids are structurally similar to ephedrine and pseudoephedrine. They stimulate both alpha and beta-adrenergic receptors as well as release norepinephrine from storage sites. Each tablet of Energel contains 330 mg of Ma Huang extract, which is 6% (19.8 mg) of Ephedra. The dose is 2 gelcaps a day. Our patient took this dose. The FDA has banned the sale of Ephedra in large amounts (over 24 mg a day and does not recommend taking this product in small amounts for more than 7 consecutive days. Our patient was taking 40 mg a day for 30 days. Ephedra has caused 17 deaths and hundreds of serious side effects including stroke, myocardial infarction and seizures in previously healthy young adults. To this date there have been no reported cases of rhabdomyolysis associated with Ma Huang. This is an extremely important health concern since Ephedra, in its many forms, is readily available in unscrutinized and easily obtainable health supplements.