Clinical Chemistry 58:6
1067–1077 (2012)
What Is Your Guess?
Cookie Lover’s Crash
James M. Kelley, James Watkins, and Petr Jarolim*
CASE DESCRIPTION
A 35-year-old man was brought by ambulance to the emergency department after a single-vehicle collision; he was
eating cookies while being extricated from the car. Upon arrival, his face was covered with purple icing. He was not
oriented to time or place, his speech was garbled, and he could not follow commands. Vital signs demonstrated
tachycardia and hypertension. He bore stigmata of anabolic steroid use: muscular hypertrophy, cutaneous striae,
and prominent veins. The patient absconded when he realized plasma chemistry tests had been ordered (Table 1).
Table 1. Laboratory and diagnostic results.
Test
Result
Reference interval
Point-of-care glucose, mg/dL
24
70–100
Central laboratory glucose, mg/dL
31
70–100
9
3–29
Insulin, IU/L
⬍0.1
C-peptide, ng/mL
Testosterone, pg/mL
8860
⬍0.1
Luteinizing hormone, IU/L
Chest radiograph
0.9–4.3
2220–6650
1.7–8.6
Rib fractures without pneumothorax
Computed tomography
No additional injuries noted
Urine toxicology screen
Unable to obtain
QUESTIONS
1. What was the cause of this patient’s low blood glucose concentration?
2. How did the patient’s clinical presentation (i.e., icing on his face, hypertrophied muscles, altered mental status)
correspond with the abnormal laboratory results?
3. What is the prevalence of doping among nonprofessional athletes?
The answers are on the next page.
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
* Address correspondence to this author at: Department of Pathology, Brigham
and Women’s Hospital, 75 Francis St., Boston, MA 02115. E-mail pjarolim@
partners.org.
Received November 28, 2011; accepted December 7, 2011.
DOI: 10.1373/clinchem.2011.180091
1067
What Is Your Guess?
ANSWERS
Normal insulin with undetectable C-peptide concentrations indicates exogenous insulin administration in
a bodybuilder (1 ). Insulin has anabolic functions that
inhibit breakdown and promote nutrient storage (2 ).
Pharmaceutical-grade insulin is available without
prescription, providing an easy-to-obtain performance enhancer (3 ). Although a urinary testosterone/
luteinizing hormone ratio ⱖ30 is a diagnostically sensitive marker for anabolic steroids (4 ), the combination of increased testosterone and undetectable luteinizing hormone in plasma suggests exogenous use. The
prevalence of doping in recreational athletes is estimated at up to 15% (5 ), making this scenario possible
in many hospitals.
Author Contributions: All authors confirmed they have contributed to
the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design,
acquisition of data, or analysis and interpretation of data; (b) drafting
or revising the article for intellectual content; and (c) final approval of
the published article.
Authors’ Disclosures or Potential Conflicts of Interest: No authors
declared any potential conflicts of interest.
References
1. Reverter JL, Tural C, Rosell A, Dominguez M, Sanmarti A. Self-induced insulin
hypoglycemia in a bodybuilder. Arch Int Med 1994;154:225– 6.
2. Rich JD, Dickinson BP, Merriman NA, Thule PM. Insulin use by bodybuilders.
JAMA 1998;279:1613.
3. Elkin SL, Brady S, Williams IP. Bodybuilders find it easy to obtain insulin to
help them in training. BMJ 1997;314:1280.
4. Perry PJ, MacIndoe JH, Yates WR, Scott SD, Holman TL. Detection of anabolic
steroid administration: ratio of urinary testosterone to epitestosterone vs the
ratio of urinary testosterone to luteinizing hormone. Clin Chem 1997;43:
731–5.
5. Bojsen-Moller J, Christiansen AV. Use of performance- and image-enhancing
substances among recreational athletes: a quantitative analysis of inquiries
submitted to the Danish anti-doping authorities. Scan J Med Sci Sports
2010;20:861–7.
News & Views
Direct-to-Consumer Cardiac Screening Tests:
User Beware
Christina M. Lockwood*
Cardiovascular disease (CVD) is the leading cause of
death in the US. Given the rising number of individuals
affected with CVD and its significant treatment costs,
prevention through recognition of risk factors and attenuation of modifiable behaviors is essential for improving outcomes and controlling the healthcare cost
burden. Accordingly, public health initiatives have increasingly focused on prevention strategies through
promotion of cardiovascular health. Therefore, it is not
surprising that private companies are attempting to
capitalize on consumer concerns about undetected
CVD through diagnostic test services.
Washington University School of Medicine, St. Louis, MO.
* Address correspondence to the author at: Washington University School of
Medicine Department of Pathology and Immunology, 660 S. Euclid Ave.,
Campus Box 8118, St. Louis, MO. Fax 314-454-5208; e-mail
[email protected].
1068 Clinical Chemistry 58:6 (2012)
Direct-to-consumer (DTC) cardiac screening tests
provide cardiovascular risk estimates and frequently
bypass medical professionals for interpretation and
follow-up. Companies directly advertise to the public
and offer services in corporate wellness programs and
community-based health-screening events, or through
their own facilities. A recent commentary in the Journal
of the American Medical Association by Lovett and Liang highlights some ethical considerations and professional guidelines surrounding cardiovascular risk assessment in the context of DTC testing (1 ). The
authors focus on carotid artery stenosis ultrasound, peripheral arterial disease ankle– brachial index, 1-time
atrial fibrillation electrocardiogram (ECG), abdominal
aortic aneurysm (AAA) ultrasound, hyperlipidemia,
high-sensitivity C-reactive protein (hs-CRP), and coronary calcium scoring with computed tomography
(CT) screenings. Each of the cardiac screening tests has
been critically evaluated by the American College of