SAT-556 - An Etiology Too Far: Piperacillin-Tazobactam Induced Hypoglycemia with Adrenal Insufficiency and Hemodialysis

Hypoglycemia is a rare but recognized adverse effect of certain antibiotics, including beta lactam antibiotics, particularly in patients with renal impairment. Just the use of beta lactam antibiotics may not be enough to cause hypoglycemia, however. We present a case of severe, recurrent hypoglycemia temporally associated with piperacillin-tazobactam administration in a patient with newly diagnosed adrenal insufficiency and end-stage renal disease on hemodialysis.
35 year old male with a history of ESRD on hemodialysis, Chagas disease, prior strongyloides infection, and remote polysubstance use disorder presented to the hospital with shortness of breath. On admission, he was found to have acute hypoxemic respiratory failure secondary to volume overload. His respiratory distress worsened during the admission, requiring transfer to the medical ICU. Imaging revealed right lower lobe opacities and he received empiric antibiotics with piperacillin-tazobactam, cefepime, and vancomycin. During that admission, while receiving piperacillin–tazobactam and vancomycin, he developed recurrent hypoglycemia to 20–50 mg/dL. Endocrinology was consulted and recommended stopping the piperacillin–tazobactam; the hypoglycemia resolved. A cortisol was not drawn and patient discharged.
He was readmitted a few months later with acute hypoxemic respiratory failure due to pulmonary edema. His course was complicated by altered mental status, bradycardia, seizures, and cardiac arrest, requiring intubation, vasopressors, and temporary transvenous pacing. Again, while receiving piperacillin–tazobactam for suspected pneumonia, he developed persistent hypoglycemia, below 55 mg/dL requiring continuous dextrose infusion. Endocrinology was consulted for refractory hypoglycemia. Piperacillin–tazobactam was discontinued after which hypoglycemia resolved and the patient maintained euglycemia off dextrose infusion. Piperacillin–tazobactam was restarted by the primary team and the patient again developed hypoglycemia which, again, resolved with discontinuation of piperacillin–tazobactam. Evaluation revealed adrenal insufficiency with low morning cortisol (3.1 µg/dL), inadequate cosyntropin stimulation (peak 9.1 µg/dL), and elevated ACTH (66.2 pg/mL), consistent with primary adrenal insufficiency. Abdominal imaging was unremarkable, and pituitary MRI showed no mass. The patient was started on hydrocortisone replacement and did well afterwards.
Recurrent hypoglycemia temporally linked to piperacillin–tazobactam across separate hospitalizations strongly supports a drug-induced etiology. Underlying adrenal insufficiency and ESRD likely increased vulnerability during critical illness. Clinicians should recognize piperacillin–tazobactam as a potential cause of hypoglycemia in patients with renal failure, particularly when episodes are recurrent.

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