Hypoglycemia with Severe Lactic Acidosis

A fifty-seven-year-old South African female, of Indian descent, with end-stage renal failure and on regular hemodialysis, was admitted in June 2016. She presented with one-day history of back pain, mild abdominal pain, nausea and vomiting. Initial investigations showed blood glucose less than 1 mmol with lactic acid 13.27 mmol/L. She was not a diabetic, but her husband was a diabetic on metformin. Despite extensive investigation, the cause of hypoglycemia and life-threatening lactic acidosis was not immediately identified. She received Glucagon and intravenous dextrose and had no hypoglycemia during admission. She was discharged after four days in good condition. Metformin level was sent to an outside laboratory, and revealed a highly elevated level. She admitted that she might have confused her husband's metformin with paracetamol, which tablets look similar.