Hypoglycemia is defined as random blood sugar equal to or lower than 60mg/dl. The most common cause is medications such as sulfonylurea, biguanides and insulin. Other causes include liver disease, certain tumors, kidney disease, severe infections and starvation. It can be a very common presentation in elderly patients with altered mental status who are on polypharmacy. Investigating recurrent hypoglycemia can be a challenge. Whilst the obvious focus is to rule out an underlying endocrine etiology, a thorough history and recognition of factitious cause is important and worth bearing in mind. This can be difficult to diagnose and often, can only be ruled out by extensive investigations and exclusion of other causes . Patients with clinical hypoglycemia unawareness are at high risk of severe hypoglycemia that requires thirdparty assistance. Hypoglycemia is less frequent in type 2 diabetes than it is in type 1. Populationbased data indicate that the overall event rate for severe hypoglycemia (requiring the assistance of another individual) in insulintreated type 2 diabetes is approximately 30 percent of that in type 1 diabetes (35 versus 115 episodes per 100 patientyears). In this case a young non diabetic female presented to ED in a state of altered mental status with recurrent hypoglycemia, the cause for which was thought to be sepsis and ultimately diagnosed as fulminant hepatic failure. In fulminant hepatic failure there as altered mental status with coagulopathy in setting of acute liver disease. Neurotoxins like ammonia and glutamine with cytokines produce cytogenic and vasogenic effects which leads to cerebral oedema and thus altered sensorium. Patient presents in a state of hepato cellular dysfuction, encephalopathy and cerebral oedema, infections or multi organ failure. The case emphasizes the importance of appropiate history taking and correct differential diagnosis establishment in order to achieve good outcome of a patient with fulminant hepatic failure.

Keywords: Hypoglycemia; Diabetes; Hepatic Failure; Altered Sensorium.