Endocrine Abstracts

Introduction: Urgent conditions, as first symptom of endocrine disease, are rather rare in a hospital emergency department. Emergency medicine doctors work in difficult conditions, often under time pressure, they must also be guided by the likelihood of linking symptoms to the disease. Unfortunately, this makes it difficult to diagnose rare diseases. Therefore, without criticising doctors of other specialties, we would like to present our patient’s long journey from the emergency department to an effective operation.

Case: A 33-year-old woman was brought to a hospital emergency department in a district hospital due to an acute psychotic episode. In the absence of a response to the treatment, she was transported to a psychiatric hospital, where initially her condition improved slightly. Unfortunately, in the further course convulsions appeared and with suspected state of epilepsy she was transported to the neurology department, where despite intensive pharmacotherapy and mechanical ventilation her condition did not improve. A dramatic improvement occurred when the consultant internist ordered blood glucose control (29 mg/dl) and subsequently glucose infusion. In the endocrinology ward during the hunger test, hypoglycaemia was found, but with not very high insulin levels, which did not allow unambiguous diagnosis of insulinoma. In the gastrology clinic, extended imaging diagnostics with MRI and an EUS were performed combined with a biopsy of the 29×15 mm “nodula” adjacent to the head of the pancreas. However, the result of the biopsy did not confirm the diagnosis of insulinoma. Meanwhile, the patient ‘disappeared” from observations of endocrinologists from the first hospital, but after 2 months “was found” in a clinic of endocrinology 400 km away. In this time the values of insulin and C peptide during spontaneous hypoglycaemia met the criteria for insulinoma diagnosis, which was also confirmed by the histopathological examination after surgical removal of the nodule. The patient in good general condition remains under the control of the endocrinology clinic. From the psychotic episode in the hospital emergency department 105 days have passed to the operation and from the first discrete symptoms 13 months.

Conclusion: Diagnosis of insulinoma in department of emergency is practically impossible, However, adherence to the principle of blood glucose testing in each patient in department of emergency probably slightly shortens the path to proper diagnosis and effective treatment.