Early hemodialysis in pediatric metformin overdose with severe lactic acidosis and recurrent hypoglycemia: a case report and literature review.

Background: Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication of metformin overdose. This case highlights uncommon features such as recurrent hypoglycemia and emphasizes the role of early, repeated hemodialysis in recovery. Case presentation: A healthy 17-year-old female ingested 51 grams of metformin and presented with vomiting, hypotension, severe lactic acidosis, and hypoglycemia. Early vasopressors and sequential hemodialysis were crucial; minimal response after the first session improved markedly after a prolonged second session. She fully recovered with ICU and psychiatric care. Conclusion: Metformin associated lactic acidosis typically presents with severe metabolic derangements and organ dysfunction; however, hypoglycemia remains an uncommon but important manifestation, likely related to impaired gluconeogenesis and glycogenolysis. This case underscores the importance of early recognition and aggressive management, including prompt vasopressor support and repeated hemodialysis, which can be lifesaving even in severe presentations. A holistic approach to prognostication integrating clinical judgment, dynamic patient assessment, and timely therapeutic intervention rather than reliance on isolated laboratory values is essential to optimize outcomes and minimize long term complications.