Metformin-Associated Lact...

A 53-year-old woman from a nursing home was brought to the emergency department (ED) due to dizziness, weakness, and light-headedness persisting since morning. Emergency services recorded her low blood sugar of 34 mg/dL, prompting dextrose administration. She regularly took metformin for diabetes (850 mg, twice daily). She denied other symptoms. Her medical history included type II diabetes, hypertension, prior stroke, and CKD stage 3a. She also had thrombotic thrombocytopenic purpura and received rituximab. On arrival, she was tachypneic and diaphoretic with vital signs showing low blood pressure and high pulse. Her glucose was 91 mg/dL. Clinical exam showed residual weakness from her stroke. Labs indicated severe acute kidney injury (creatinine 6.6 mg/dL, eGFR 8.51 mL/min/1.73 m2), high potassium (6.7 mmol/L), and severe metabolic acidosis (lactate 20 mmol/L). Notable findings included low acetaminophen, normal HbA1c, and insulin levels. ICU and nephrology consults were made, and the patient received prompt hemodialysis in the ED, after which her parameters improved, obviating further dialysis.