Endocrine Abstracts

Case history: A 30-year-old Ugandan male, now living in UK, presented to A&E with confusion and agitation. Capillary blood glucose was 0.9 mmol/l and he was commenced on intravenous Dextrose. During blood donor screening in Uganda, he was told that he had a blood-borne infection. He had gross hepatomegaly on examination. During admission, he experienced repeated episodes of hypoglycaemia despite increased dietary intake of carbohydrates and continuous infusions of 5%-10% Dextrose. He also required rescue treatment with 20% intravenous Dextrose.

Investigations: INR: 1.3 (0.8–1.2), bilirubin: 18 μmol/l (0–21), ALP: 574 U/l (30–130), ALT: 71 U/l (<50). CT Chest/Abdomen/Pelvis: Gross hepatomegaly with innumerable low density lesions and associated intrahepatic duct dilation. Suspicious for cholangiocarcinoma with liver metastases. MRI Liver: Massive occupation of the liver by multiple confluent solid lesions. Differentials were epithelioid haemangioendothelioma, hepatocellular carcinoma, cholangiocarcinoma and metastases. HBsAg: Reactive, Anti-HBe IgG: Reactive, HBeAg: Negative, Anti-HBc IgG: Reactive, Anti-HBc IgM: Negative. Profile consistent with persistent HBV-infection. Alphafetoprotein >250 413.0 KU/l (<7.4). Ultrasound-Guided Liver Biopsy: Hepatocellular carcinoma of fibrolamellar type. Random cortisol: 402 nmol/l. During a hypoglycaemic episode, blood glucose: 2.4 mmol/l, insulin: 6 pmol/l (18–173), C-peptide: 528 pmol/l (370–1470). IGF binding protein-3: 3.6 mg/l (3.5–7.6), IGF-1: 6.6 nmol/l (10.0–32.5).

Treatment: Dexamethasone 2 mg BD was commenced and was up-titrated to 8 mg BD but to no avail. Glucagon infusion was started at 0.1 mg/hour and was up-titrated to 0.3 mg/h with no improvement. Recombinant Human Growth Hormone 3 mg subcutaneous OD was then commenced and was titrated to 6 mg OD and hypoglycaemia resolved. He was weaned off Dextrose and Glucagon infusions and was discharged on Growth Hormone injection. He was also started on Tenofovir for HBV-infection and chemotherapy was being considered by tertiary centre HCC team. However, he was readmitted 2 weeks later with worsening ascites, generalised oedema and acute kidney injury. Unfortunately he died after being palliated.

Conclusion: Non-islet cell tumour hypoglycaemia is a rare but serious complication of malignancy. The management strategy is multi-pronged and involves correction of hypoglycaemia and treatment of the underlying malignancy. If hypoglycaemia persists despite increasing caloric intake and intravenous dextrose, other adjunct therapy like glucocorticoids, glucagon infusion and growth hormone should be considered. In this case, hypoglycaemia was resistant to initial treatment and required all these measures sequentially to correct hypoglycaemia. Unfortunately the underlying tumour was at an advanced stage and the patient could not survive.