An article in the February 12 issue of the New England Journal of Medicine reports on an unusual cause for an outbreak of low blood sugar among men in Singapore: illegal use of sexual performance enhancement drugs that were contaminated with a diabetes drug.
Between January and May 2008, 149 men and one woman between 19 and 97 (mean age 51) were admitted to five public hospitals for unexplained low blood sugar. Similar cases were reported in media reports from Hong Kong. Seven Singaporean patients remained in a coma because of prolonged sugar starvation of the brain, and four subsequently died. The diabetes drug glyburide was found in blood and/or urine samples in 85% of cases; 30% admitted having used illegal sexual performance enhancers.
The contaminated products were a counterfeit version of the drug Cialis (meant for the treatment of genuine erectile dysfunction), and three purported herbal preparation (the affected brands included Power 1 Walnut and Santi Bovine Penis Erecting Capsule). All four preparations additionally contained Viagra in varying concentrations. Two herbal products contained traces of the weight loss drug sibutramine, a compound related to amphetamines.
The drug packaging mentioned names of non-existent overseas production facilities, so the source of the contamination with the diabetes drug could not be established.
The authors underline the risks that is known to be associated with purchasing drugs from unreliable providers or from online resellers. The clandestine use of impotence drugs as sexual performance enhancers seems to have provided a good illustration of this problem. They further call for more efforts by national and international health and law enforcement agencies to curb the manufacturing, international transport and sales of untrustworthy medication.

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Shih Ling Kao, Cheng Leng Chan, C.C. Tchoyoson Lim, Rinkoo Dalan, Daphne Gardner, Edward Pratt, Marilyn Lee, Kok Onn Lee. An Unusual Outbreak of Hypoglycemia. New England Journal of Medicine, 2009; 360: 734-736.   
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Fake impotence drugs linked to low blood sugar outbreak