Endocrine Abstracts

Case presentation: A 43 year old female patient presented to the Emergency Department (ED) after a seizure episode in which the patient was confused, with repetitive movements of her upper limbs touching the left side of her face. This episode lasted 5 minutes, and the patient was confused for 45 minutes following this. Her mother telephoned an ambulance, and on arrival of the paramedics, her capillary glucose was found to be 1.5 mmol/l. The severe hypoglycaemic episode was treated with intravenous 250 ml 10% glucose × 2, and the patient was brought to ED for assessment. The ED team referred her for endocrine review. A short synacthen test was performed which was normal with a time 0 cortisol of 325 and 30 minute cortisol 560. Three overnight fasting insulin C peptides were sent which showed mild hypoglycaemia each morning with inappropriately elevated insulin and C peptide, consistent with endogenous insulin excess. A CT abdomen was reported as normal appearances of the pancreas. An MRI head was normal. The patient was reviewed by the neurology team- seizure due to hypoglycaemia. An MRI pancreas subsequently revealed a pancreatic lesion and the patient was referred to the regional neuroendocrine Multidisciplinary Team (MDT) for review. She underwent an ultrasound guided biopsy of the pancreatic lesion which confirmed an insulinoma. The biopsy appears to have had a therapeutic benefit by removing some of the culprit cells because the patient’s hypoglycaemic episodes have reduced following the biopsy. The patient has been referred to the pancreatic surgical team to consider surgical removal of the lesion or interventional radiology guided ablation. If her hypoglycaemic episodes re occur, she will be commenced on diazoxide pending definitive surgical or interventional radiology guided ablation management.

Learning point: This case demonstrates the importance of biochemical investigation for unexplained hypoglycaemia in patients without diabetes, as the initial CT imaging showed normal pancreatic appearances, but the raised insulin C peptide biochemical result confirmed endogenous insulin excess which prompted further imaging with an MRI pancreas. The MRI pancreas was able to identify a pancreatic lesion. The patient had a therapeutic benefit from the biopsy, and has been referred for definitive management with surgical excision of the pancreatic insulinoma or ablation. The patient had previous surgery for an incisional hernia repair, and therefore may opt for ablation due to increased technical difficulty of the surgery which is being discussed with the pancreatic surgical team.