Endocrine Abstracts

Background: Non-islet-cell tumor hypoglycemia (NICTH) is a rare but severe complication of malignancy. NICTH has been related to the production of IGF II by tumours of mesenchymal or epithelial origin. It gives rise to frequent episodes of severe hypoglycemia and can have negative impact on quality of life. This case report describes a case of Non Islet cell tumor hypoglycemia due to hepatocellular carcinoma with hypoglycemia as the first presentation.

Clinical presentation: 34 years old male patient brought to the ER by ambulance as patient was found unresponsive with blood sugars of 30 mg/dl. Patient was started on dextrose infusion and regained consciousness. On history patient has been having episodes of headache and increased hunger and abdominal discomfort for the past 1 month duration. These episodes occurred thrice a week. He had noticed increase in size of abdomen, fullness and loss of appetite. Patient denied history of Alcohol or Drug use. He had no positive past medical/surgical/family history. On examination patient was cachexic, Abdomen non tender hepatomegaly and ascites. Cardiovascular and Respiratory system examinations were normal. Laboratory investigation of the patient revealed Hb 10.9 mg/dl, WBC-5.8(n- 67.6, l-19.7), PLT-363, LFT: AST-83, ALT-39, GGT-399, Alk phosphatase 278, Insulin-0.20 mIU/ml, C-peptide 0.68 ng/ml, creatinine 0.78, Hba1c-4.5, Insulin antibodies negative, Hepatitis B+ve. USG Abdomen revealed large heterogenous predominantly hyperechoic lesion of right lobe of liver with the possible thrombotic occlusion of right portal vein seen likely suggestive of neoplastic aetiology, ascites present. CT abdomen and pelvis reported hepatomegaly and large mass lesion involving right lobe of liver measuring 18.2 x 14.4 x 13.5 cm in size. The mass had invaded portal vein confluence and right branch of portal vein. Patient was subsequently evaluated for AFP-181500 IU/ml, IGF-1-36.74 ng/ml, CEA-0.50 ng/ml. The diagnosis of Hepatocellular carcinoma was made, Multidisciplinary team was formed, patient was treated for hypoglycemia with dextrose infusion and prednisolone 60 mg/day, planned for PET scan to check for metastasis, debulking/palliative care for relief from hypoglycemia.

Conclusion: NICTH is a rare condition and its incidence is unknown. It is more likely to develop in those with large tumor burden. The diagnosis can be confirmed by a combination of suppressed serum insulin levels and suppressed C peptide and growth hormone concentrations in the setting of hypoglycemia, along with elevated IGF-II levels. Initial treatment aims at maintaining euglycemia, managed with parenteral dextrose infusion. Identification of NICTH and complete tumor resection represents ideal management.