Letters amounts of glucose, reacting to concen- trations as low as 0.05% (g/100 mb (2) ‘The intensity of color change crudely re- fects the amount of glucose present, to a maximum concentration of 2%, Placing a rop of the beverage in question on a strip of Tes-tape will rapidly reveal whether it contains sugar. The only known causes ofa false positive reaction are the presence of chlorine from cleans- ing agents or contamination with perox- ide-containing detergents (3). To gain some insight into the magnitude of the problem for our pa- tients, we conducted a survey of many establishments that serve fountain rinks, with an emphasis on fast-food chains, the source of most complaints from our patients. We tested 37 samples of diet colas ordered at 23 different loca- tions, mainly in central North Carolina, ‘over a period of several months. (Colas ‘were chosen for evaluation because these are often the only beverages available in fast-food restaurants) Because the nor- mal reaction of Tes-tape to a diet cola is completely negative, even a trace reac- tion was considered a positive response We expressed the data with the Mietti- nen exact confidence limits (4). Sixteen of 37 (43.2%) drinks tested positive for lucose, with a 95% confidence interval of 28.1% -59.4% (4). Of the 16 positive responses, 5 samples showed a markedly positive result of 2%. There are several possible expla nations for positive responses in our sur- vey. We did not investigate the source or sources of the error. However, we spec- ulate that any of the following possible events may have occurred. First, the manufacturer may have incorrectly filled the tanks. (It is important to note that wwe have never found even a trace pos- itive result in canned or bottled diet soft drinks.) Second, the counter per- son may have dispensed the wrong beverage. Third, the tanks may have been hooked up to the dispenser incor- rectly. Finally, because positive read- ings on the Tes-tape may also result from the presence of certain cleansing agents, we must also consider the pos- sibility that contamination of the bev- erage may have occurred if the dis- penser was not cleaned properly We were surprised by the magni- tude of the positive findings in our sur- vey. However, further anecdotal reports from patients and colleagues lead us to believe that our results are not atypical To determine the extent of this problem nationwide, investigation should be con- ducted in different locations. The varia- bles that might influence the positive re- sponse rate must also be assessed. References 1. Pennington JAT, Church HN: Bowes and Church's Food Values of Portions Commonly Used. L4th ed. New York, Harper & Row, 1985, p. 5 2. Feldman JM, Lebovitz FL: Tests for glyco- suria: an analysis of factors that cause mis leading results. Diabetes 22:115—21, 1973 3. Berger W: Test strip methods for estimat- ing glycosuria: uses and possible errors isch Med Wochenschr 98:2304—305, 1973 4. Mietinen OS: Comment, | Am Stat Assoc 69:380-82, 1974 Hypoglycemia Induced by Enalapril in Patient With Insulin Resistance and NIDDM Daw S.H. Bett, up logical cause of unexpected hypo- glycemia in an insulin-using pa- tient is usually found with an ad- equate patient assessment. On rare ‘occasions, no rational explanation can be found, Such a case is described in which, despite long-standing diabetic neuropa- thy, no previous severe hypoglycemia hhad occurred and in which retrospec- tively severe hypoglycemia was found and proved to be caused by using an angiotensin-converting enzyme (ACE) inhibitor. ‘A 65-yr-old thin black man had nnon-insulin-dependent diabetes mellitus (NIDDM) for 19 yr and had been using insulin for 18 yr. There was no history of diabetic ketoacidosis or severe hypogly- ceria. However, he had proliferative di- abetic retinopathy for which he had laser treatment, markedly symptomatic distal symmetrical polyneuropathy, autonomic neuropathy with impotence, limited Fro THE DepasrMent OF MEDICINE, THE UNIVERSITY OF ALABAMA AT BiRaNGii, SCHOOL OF Mepiane, Birinci, ALABAMA [ADDRESS CORRESPONDENCE AND REPRINT REQUESTS TO DaMIb S.H. Bu, wo, 1808 7mm AVENUE Sour, Univers Starion, Birwancitan, AL 35294 oa Daseres Cane, voune 15, wunen 7, Juv 1992joint mobility of diabetes, and a history of a cerebrovascular accident affecting the left side of his body. Proteinuria had recently been discovered. He had no ev- idence of ischemic heart disease or pe- ripheral vascular disease His diabetes was always poorly controlled. His HbA, levels over the pre- vious 5 yr had ranged between 15 and 16% (normal range 5.0-8,5%). Because he needed large doses of split-mixed in- sulin (1.5 U/kg) to achieve this poor control, it was likely that his poor control ‘was secondary to insulin resistance, ‘which had not been overcome with large doses of purified pork or human insulin, He had recently been discovered to have 2+ proteinuria and hypertension with a blood pressure of 160/90 mmHg and because of this was started on 5 ‘mg/day enalapril. On that visi, his HbA, was 13.4%, and a postprandial glucose ‘was 283 mg/dl (15,7 mM). Because of his ppoor glycemic control, his split-mixed insulin regimen was increased to a total of 130 U—an increase of 20%, Two weeks after his last clinic visit, his wife could not wake him for breakfast. The paramedics were called and he responded to 50 cc 50% dextrose and water. He was subsequently seen in the emergency room that day, and his insulin dose was reduced by 20%, and he was discharged home. Two days late, oon the reduced dose of insulin, he was unable to avoid chronic hypoglycemia, despite home glucose monitoring and taking extra calories. Because of this, he was admitted to the hospital for further evaluation and treatment. In the hospital, he became well controlled on a total insulin dose of 40 Uiday in a split-mixed regimen. After discharge, his blood glucose again began to drop, and he was finaly stabilized as an outpatient on 18 U/day NPH. His serum creatinine, cortisol, and thyroxine ‘were normal. We then realized that his decreased insulin needs coincided with the commencement of enalapril therapy. To confirm that enalapril had reduced his insulin resistance, the enalapril was withdrawn, and his insulin dose was not changed. At home, after 2 days, his blood glucose began to rise and when seen a5 an outpatient 1 wk later his fast ing blood glucose had risen to 349 mg/ percent (19.45 mM). Enalapril was rein- stated and his insulin dose was not changed. After 2 days at home, his blood glucose began co fall, and after 1 wk when checked as an outpatient, his 2-h postprandial blood glucose was 137 ‘mg/dl (7.6 mM). The enalapril was con- tinued and insulin dose was not changed Thus, in this case, enalapril caused a decrease in insulin resistance with a corresponding decrease in exoge- nous insulin requirements, Within 2 days of withdrawal of enalapril, the in- sulin resistance recurred with a corre- sponding increase in serum glucose level oon a fixed dose of insulin, Again, within 3 days after reinstitution of enalapril in- sulin resistance decreased with a corre- sponding decrease in serum glucose Thus, with withdrawal of and rechalleng- ing with enalapril, we confirmed that enalapril decreased this patient's insulin resistance, ‘ACE inhibitors are widely used to treat hypertension in diabetic patients ‘Their choice is based on the lack of effect ‘on potency, peripheral vascular disease, hyperlipidemia, and its protective effect on the kidney. In addition, unlike B-blockers, hypoglycemic symptoms are not masked and hypoglycemia is usually not induced (1). A further beneficial ef- fect is a decrease in insulin resistance ‘with potential improvement in glycemic control (2). However, the decrease in in- sulin resistance could potentially lead to hypoglycemia in the diabetic patient treated with insulin or oral hypoglyce- mics Hypoglycemic episodes with cap- topril have been described in three pa- tients on insulin and two receiving a sul- fonylurea G.4) and two people on a combination of sulfonylureas and biguanides (5). Enalapril-induced hypo- ‘glycemia in one patient on insulin and cone patient on sulfonylurea have been described (6). A mean decrease in fasting glucose was also described with enalapril in a comparative clinical trial involving enalapril, hydrochlorothiazide, and atenolol (7) None of these studies have clearly documented the effect of ACE inhibitors con insulin requirements by withdrawing the ACE inhibitor and rechallenging the patient with this medication. In addition, such a severe decrease in insulin resis- tance with a corresponding decrease in insulin needs has not been previously described Because ACE inhibitors decrease insulin resistance by ~10% (2), itis sur- prising that more cases of ACE inhibitor induced hypoglycemia have not been de- scribed, A possible reason for this is that ACE inhibitors are commonly used in combination with diuretics, which, by increasing insulin resistance, neutralize the effect of the ACE inhibitor. Similarly, it ACE inhibitors are used with a Be-blocker, a decrease in insulin resis- tance will again be compensated for by an increase in insulin resistance induced by the B-blocker (8) Thus, (0 the list of potential causes of severe hypoglycemia in the pa- tient with diabetes who requires insulin ot oral sulfonylureas should be added treatment with ACE inhibitors. References 1. Bell DSH: Hypertension in the person with diabetes. Am J Med Sci 297:228-32, 1989 2. Pollare T,Lithell H, Bere C: A compari- son of the effects of hydrochlorothiazide and captopril on glucose and lipid metab- olism in patients with hypertension, N Engl J Med 321:868-73, 1989 3, Fermiere M, Jachkar H, Richard JL, Bringer J, Orsetti A, Miaouze J: Captopril and in- ‘sulin sensitivity. Ann Inter Med 102:134— 35, 1985, 4. Arauz-Puchecoc, Ramirez LC, Rios JM, Raskin P: Hypoglycemia induced by angi= ‘rensin converting enzyme inhibitors in patients with non-insulin-dependent dia- Baseres Came, voune 15, nonmen 7, Jour 1997 3Letters betes receiving sulfonylurea therapy. Am J Med 89:811-13, 1990 5. Rett K, Wicklmayr M, Dietz GJ: Hypogly- cemia in hypertensive diabetic patients treated with sulfonylureas, biguanides and ‘captopril (Lewer). Lancet 319:1609, 1988 6. MeMurray J, Fraser DM: Captopril, enala- pril and blood glucose (Lete). Lancet 1:1035, 1986 7, Helgeland A, Strommer R, Hagelund CH, Treth $: Enalapril, atenolol and hydro chlorothiazide in mild to moderate hyper- tension: a comparative multi-center study in general practice in Norway. Lancet 1872-75, 1986 8, Lithell HO, Pollare 7, Berne C: Insulin sensitivity in newly detected hypertensive patients: influence of Captopril and other antihypertensive agents on insulin sensi- tivity and related biological parameters. J Cardiovasc Pharmacol 15:S46~52, 1990 Milk Allergy Masquerading as Insulin Allergy Daw S.H. Beu, 8 though with modem purified and A hhuman insulins the incidence of both local and systemic insulin al- lergy is decreased, these Teactions stil ‘occur (1). Substances other than insulins implicated as a cause of insulin allergy include impurities in the alcohol used to cleanse the injection site, protamine, and zinc (1). A case is described in which the allergy was caused by injected milk pro- tein ‘An 18 yr-old previously healthy white male showed the classic symptoms of diabetes and was admitted to his local hospital. His diabetes was controlled on insulin and he received survival-skill level diabetes education, During his hor pitalization, he felt well and had no al- lergic reactions to subcutaneously in- jected insulin ‘Alter his discharge from the hos- pital, his blood sugars rose dramatically and did not decrease with extra subcu- taneous injections. In addition, at the site ot is “cloudy” insulin injections bur not at his “clear injections,” he developed a ‘macular rash 2 h afier injection which lasted 36 h. Because of these dificuties, he sought help at our institution After arriving at the diabetes clinic his serum glucose was 453 mg/dl He was asked to give 5 U of regular row THe Scoot oF Mepicine, DeraRTMENT oF MeDicine, THE UNIVERSITY OF ALABAMA AT BiR- INGHAM, BIRMINGHAM, ALABAMA, [ADDRESS CORRESPONDENCE AND REPRINT REQUESTS TO DaMib S.H. BeuL, MB, 1808 7H AvENUE Sour, Bresncins, AL 35294 insulin subcutaneously. On producing his “insulins” it was discovered that he ‘was using two normal saline solutions; one was clear and the other had a cloudy appearance and obviously had been used to practice mixing insulin, He had de- cided not to purchase the human insulin that had been prescribed until the “insu- lins” that he had left the hospital with hhad been used and he had thus been injecting normal saline solutions. By con- tacting the hospital where he had been initiated on insulin 2 wk previously, it ‘was discovered that one vial of saline had been made to resemble NPH insulin by adding milk. ‘After treatment with split-mixed regular and NPH human insulin, his di- abetes was easily controlled and his skin lesions disappeared within 36 h. This case illustrates the need for clear discharge instructions to the patient with diabetes, especially those with a re- cent onset of diabetes and initiation of insulin therapy. References 1, Galloway JA, deShazo RP: The clinical use of insulin and the complications of insulin therapy. In Diabetes Mellitus: Theory and Practice. Ellenberg M, Rifkin H, Eds. 3rd ced. Chaps. 25, New Hyde Park, NY, Med. Exam, 1983, p. 519-38 336 Dasers Care, Voume 15, novmen 7, Ju 1992