The ackee tree is native to Jamaica, where it produces a fruit that is commonly eaten. The unripened fruit contains hypoglycins, a group of toxins that produce vomiting (Jamaican vomiting sickness), central nervous system sedation, and seizures. In addition, hypoglycins inhibit hepatic gluconeogenesis and may contribute to hypoglycemia. Epidemics of hypoglycin-mediated hypoglycemia have occurred only during times of famine, when poor nutrition and the increased eating of unripened fruit are perhaps more commonplace. Ackee is available in the United States in canned form, but only the unripe, fresh fruit is associated with hypoglycemia.
The sympathetic nervous system mediates glucose autoregulation partly through the release of epinephrine, which prevents the release of insulin and elevates blood glucose levels. This mechanism explains the role of epinephrine in the counterregulatory response to hypoglycemia. b-adrenergic antagonists interfere with both of these effects, potentially resulting in hypoglycemia through excessive insulin release while preventing the development of the typical autonomic response to hypoglycemia.12!3 andl4 In addition, caffeine has been demonstrated to enhance patients' awareness of hypoglycemic events, theoretically because of its ability to induce neuroglycopenia.15
An increased incidence of neonatal hypoglycemia during the first day of life has been reported many times in those whose mothers had received b-adrenergic antagonists.16 Neonates may also demonstrate characteristic radiographic findings on computed tomography resulting from hypoglycemia ( Table 184.:3.)17
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