Endocrine Abstracts

Hypoglycaemia is a common and potentially life threatening presentation to Emergency Departments across the UK.It is often a result of medications for treatment of diabetes but other differentials include rarer reactive and fasting causes.This case report describes a 69 year old man who initially presented with right upper quadrant pain and weight loss which then lead to a diagnosis of inoperable hepatic sarcoma. He later presented with hypoglycaemia and Whipples triad in the context of no circulating oral hypoglycaemic agent and fasting biochemistry that was not supportive of the role of insulin in the genesis of the hypoglycaemia: insulin <1.0IU/l, c-peptide <0.1 nmol/l and glucose 2.0 mmol/l. Short synacthen test was normal. IGF2: IGF1 ratio was 14.7, supporting evidence of ‘Big’ IGF2 over production. IGF2 excess in the context of hypoglycaemia and known malignancy confirmed a diagnosis of non-islet cell tumour hypoglycaemia. In this case, the patient’s tumour had grown extensively by time of diagnosis and was inoperable due to both size and location in the caudate lobe of the liver. His case was further complicated by admissions with Moraxella and E.coli bacteraemia; likely stemming from the tumour as no other was source found on imaging. Despite initial treatment with once daily steroids he had multiple near-fatal hypoglycaemic episodes requiring inpatient monitoring. Growth hormone treatment was felt to be contra-indicated due to concern over tumour growth. Ultimately, a regime of twice daily steroids at supra-physiological dose and regular carbohydrate intake was used to maintain glycaemic and symptomatic control. Although rare, the exact incidence of non-islet cell tumours causing hypoglycaemia is unknown and they are often diagnosed late. Treatment options are limited, however if surgical resection is possible, hypoglycaemia can be fully resolved. There is limited evidence base for other therapeutic options such as glucocorticoids, recombinant growth hormone and glucagon.