Endocrine Abstracts

A 68-year-old lady presented to hospital with several weeks’ history of paroxysmal symptoms including sweating, pre-syncope and syncope. She also had 2 months history of weight loss. She was a chronic heavy smoker, but did not drink any alcohol and did not take any regular medications.

On examination, she appeared cachectic and had a non-tender palpable liver. There were no signs of decompensated chronic liver disease. Her bedside capillary blood glucose was 0.9 mmol/l (NR 3.8–6.1).

Laboratory investigations showed hepatitic picture of deranged LFTs (ALP 383, ALT 50, GGT 635, and Bilirubin 15). Abdominal ultrasound and staging CT scans confirmed heterogenous solid masses in right lobe suggestive of liver metastasis.

Further tests revealed a high AFP level of >1 000 μg/l (NR <5.8). Her hepatitis screen and auto-immune profile were normal. Her lab glucose was 1.2 mmol/l. Her insulin, C-peptide and IGF1 concentrations were undetectable, but her serum IGF2 level was high at 102 nmol/l (NR 0–10). Her liver biopsy confirmed high-grade hepatocellular carcinoma.

Unfortunately, her hypoglycaemia was resistant to continuous IV-dextrose infusion and she continued to have frequent hypoglycaemic episodes with seizures and brain damage. She became too unwell and deemed unfit for surgical intervention or any other treatment for debulking the tumour size. She gradually deteriorated and eventually passed away.

This case illustrates a rare cause of hypoglycaemia as a paraneoplastic phenomenon due to high IGF2 secretion by the tumour cells. Treating hypoglycaemia in such cases can be challenging as they tend to be severe and resistant to glucose replacement. Several other treatment options have been tried in some case reports, but nothing proven to be effective.