Endocrine Abstracts

A 76 year-old male was admitted to hospital after an episode of dysarthria and right upper limb weakness. On initial assessment by the pre-hospital team, a capillary blood glucose of 2.9 mmol/l was found and symptoms and signs resolved upon correction with intravenous (IV) 10% dextrose. The patient reported a six month history of episodic episodes of tremors, diaphoresis and fatigue, without loss of consciousness. Occurring mostly late in the morning when he skips breakfast and resolves after eating. No weightloss. Past medical history includes ischemic heart disease, needing CABG 15 years ago, and dyslipidaemia. Drug history includes aspirin, atorvastatin and perindopril. No history of impaired glucose metabolism or diabetes mellitus from past medical visits or biochemical tests. No signs of hereditary endocrine disease in patient or relatives. On clinical assessment, the patient was hemodynamically stable with no abnormal systemic findings and a BMI of 27 kg/m². Initial blood test were all normal - including thyroid function tests, random morning cortisol (512 nmol/l), random glucose of 4.8 mmol/l and Hba1 c of 5.2%. CT brain was normal. The patient was kept as an inpatient for a fasting test giving the clinical history of Whipple’s triad. 5 hours into the fast, the patient complained of lethargy and sweating, his capillary blood glucose was 2.5 mmol/l and urgent bloods during the hypoglycaemic episodes were taken - C-peptide, insulin, pro-insulin, Beta-hydroxybutyrate, plasma glucose, insulin antibodies and urine for sulphonylurea screen. Hypoglycaemia was corrected with oral agents and patient’s symptoms resolved. Biochemical evaluation was in keeping with endogenous hyperinsulinemia (Table 1). A CT of the pancreas showed a 2.4 × 1.5 cm lesion at the body-tail junction of the pancreas with no signs of nodal involvement or metastasis. A 68-Ga-DOTA scan was also done, showing a focus of increased tracer uptake at the known pancreatic site, in keeping with a pancreatic neuroendocrine tumour (insulinoma). Chromogranin A was taken (108.38 ng/ml, normal <108). The patient underwent spleen-preserving distal pancreatectomy as curative intent. Histology showed a Grade II pancreatic endocrine tumour, R0, TNM: pT2 pNX with a Ki-67 index of 3%. He was doing well and with complete resolution of symptoms. A repeat CT scan 3 months post-op showed successful removal of the lesion with no signs of recurrency.