Whipple Triad Its Limitations in Diagnosis and Management of Hypoglycemia as a Co-morbidity in Covid-19 Diabetics and Diabetes Mellitus in General- A Review
International Journal of Diabetes and Endocrinology
Volume 5, Issue 2, June 2020, Pages: 23-26
Received: Feb. 25, 2020;
Accepted: Apr. 10, 2020;
Published: May 29, 2020
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Adegbenga Bolanle Ademolu, Medicine Department, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
In 1938 Allen Oldfather Whipple (1881-1963) an American surgeon invented a triad of two clinical and one laboratory parameter to give the Whipple triad which had been in clinical use for decades and beneficial to perhaps millions of people worldwide with hypoglycemia as health challenges. The Whipple triad is characteristically presence of hypoglycemic symptoms, documentation of low blood sugar at the time of hypoglycemic symptoms, and reversal of these symptoms when the blood glucose level is restored to normal. Of note is the fact that over the years Whipple triad had been invaluable in diagnosing hypoglycemia in diabetics, but we should not lose sight of this singular fact that though good and useful for diagnostic purposes, Whipple triad has it's limitations as a diagnostic tool. With Corona virus disease 2019 (COVID 19) pandemic caused by severe acute respiratory distress syndrome coronavirus 2 (SARS CoV-2) affecting the immunosuppresed including diabetics, knowing the limitation of the diagnostic tool for diagnosing the hypoglycemia, a lifelong challenging issue in diabetics is a proactive way of recognizing a possible additional co-morbidity that if not recognized may further put the COVID-19 diabetic patient at risk. Though the issue of hypoglycemia in infected diabetic patient with COVID 19 has not been a major issue for now worldwide, the fact that asymptomatic carrier of COVID 19 diabetic patient could develop hypoglycemia makes it an important issue to be borne in mind by physicians. A google search was conducted in English by typing in the words Whipple, hypoglycemia, diabetes, probable hypoglycemia in pubmed. A literature review was done going through relevant articles. The limitations to Whipple triads were found in hypoglycemia with reversible neurological damage, hypoglycemia with irreversible neurological sequelae, hypoglycemia unawareness and in patients with rebound hypoglycemia. Similarly, Whipple triad limitation of application was found in unconscious patient from other causes other than hypoglycemia. Further limitations were also found in probable symptomatic hypoglycemia and in symptomatic hypoglycemia. Whipple triad has its limitation in medical practice which may be diverse and this have to be borne in mind by the clinician for a holistic approach to patient management especially during this COVID-19 pandemic and thereafter. The question to be addressed in the future remains of all hypoglycemic episodes occurring annually worldwide in diabetic and non diabetic subjects, how many can Whipple triad diagnose? In other words what is the sensitivity, specificity and predictive value of Whipple triad?
Adegbenga Bolanle Ademolu,
Whipple Triad Its Limitations in Diagnosis and Management of Hypoglycemia as a Co-morbidity in Covid-19 Diabetics and Diabetes Mellitus in General- A Review, International Journal of Diabetes and Endocrinology. Special Issue: Hypoglycemia in Diabetes.
Vol. 5, No. 2,
2020, pp. 23-26.
Copyright © 2020 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/
) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Dr Chloe Roy. Allen Oldfather Whipple. Life in the fastlanelast update May 24, 2019.
Allen Oldfather Whipple. The surgical therapy of hyperinsulinism. J Internat Chir3: 237-276 (1938).
Marco Cascella; Michael Rajnik; Arturo Cuomo; Scott C. Dulebohn; Raffaela Di Napoli. Features, Evaluation and Treatment Coronavirus (COVID-19).
Lei Fang, George Karakiulakis, *Michael Roth. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet Respiratory Medicine Volume 8, ISSUE 4, Pe21, April 01, 2020.
Auer RN. Hypoglycemic brain damage. Metab Brain Dis. 2004 Dec; 19 (3-4): 169-75.
Roger F Butterworth. Hypoglycemic Encephalopathy. American Society for Neurochemistry.1999.
Nana Esi Kittah et al. MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia.., European Journal of Endocrinology, 2017.
Philip E. Cryer, Lloyd Axelrod, Ashley B. Grossman, Simon R. Heller Victor M. Montori, Elizabeth R. Seaquistet al. Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, Volume 94, Issue 3, 1 March 2009, Pages 709–728.
Martín-Timón I, Del Cañizo-Gómez FJ. Mechanisms of hypoglycemia unawarenessand implications in diabetic patients. World J Diabetes. 2015; 6 (7): 912–926. doi: 10.4239/wjd.v6.i7.912.
Samson WK, Stein LM, Elrick M, et al. Hypoglycemia unawareness prevention: Targeting glucagon production. Physiol Behav. 2016; 162: 147–150. doi: 10.1016/j.physbeh.2016.04.012.
Bakatselos SO. Hypoglycemia unawareness. Diabetes Res Clin Pract. 2011 Aug; 93 Suppl 1: S92-6. doi: 10.1016/S0168-8227(11)70020-1.
Andreas Fritsche, Michael Stumvoll, Hans U. Häring, John E. Gerich Reversal of Hypoglycemia Unawareness in a Long-Term Type 1 Diabetic Patient by Improvement ofβ-Adrenergic Sensitivity after Prevention of Hypoglycemia. The Journal of Clinical Endocrinology & Metabolism, Volume 85, Issue 2, 1 February 2000, Pages 523–525.
Kalra S, Mukherjee JJ, Venkataraman S, et al. Hypoglycemia: The neglected complication. Indian J Endocrinol Metab. 2013; 17 (5): 819–834. doi: 10.4103/2230-8210.117219.
M Hassan Murad, Fernando Coto-Yglesias, et al. Drug-Induced Hypoglycemia: A Systematic Review. The Journal of Clinical Endocrinology and Metabolism March 200994 (3): 741-5.
Sharifi-Razavi A, Karimi N, Rouhani N, COVID 19 and Intra cerebral hemorrhage: Causative or Coincidental, New Microbes and New Infections.
Javier Morales, MD, a Doron Schneiderb. Hypoglycemia. The American Journal of Medicine, Vol 127, No 10 A, October 2014.
Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care. 2013; 36 (5): 1384–1395.
International Hypoglycaemia Study Group*. Minimizing Hypoglycemia in Diabetes. Diabetes Care 2015 Aug; 38 (8): 1583-1591.
Philip Mathew; Deepu Thoppil. Hypoglycemia. Treasure Island (FL): Stat Pearls Publishing, 2020 Jan.
D. Clayton et al. Hypoglycemia. / Can J Diabetes 37 (2013) S69eS71.