White fat, factitious hyperglycemia, and the role of FDG PET to enhance understanding of adipocyte metabolism

The development of a hybrid PET/CT led to the recognition of the enhanced glycolysis in brown fat. We report a previously unrecognized mechanism for altered fluorodeoxyglucose (FDG) biodistribution with diffuse white adipose tissue uptake. This occurred during a restaging scan for cervical cancer following administration of insulin in the setting of measured hyperglycemia. The patient's blood sugar normalized, but she experienced symptoms and signs of hypoglycemia. A subsequent history indicated that the patient received intravenous high-dose vitamin C just prior to arrival. Ascorbic acid is a strong reducing agent and can cause erroneous false positive portable glucometer readings. Accordingly, it is likely the patient was euglycemic on arrival and was administered FDG during a period of insulin-induced hypoglycemia. Prominent diffuse white adipose tissue, gastric mucosal, myocardial, and very low hepatic and muscle activity were observed. The case provides insight into the metabolic changes that occur during hypoglycemia and the potential danger of relying on portable glucometer readings. We discuss the potential biological basis of this finding and provide recommendations on the avoidance of this complication.