Endocrine Abstracts

Ms T. B. is a 72-year-old retired teacher referred with asymptomatic hypoglycemia found on screening for diabetes with fasting plasma glucose 1.8 mmol/l, HbA1 c 23 mmol/mol (4.3%). On repeated questioning, denies any symptoms of neuroglycopenia or autonomic activation even after prolonged fasting. Her only symptom is a 1.5 kg weight gain over the past 6 months.

Social: Ms. T.B. is a nonsmoker and nondrinker. She is divorced, with 2 children. On the basis of her own extensive research, she believes that she should not be vaccinated for COVID-19 and has, accordingly, not done so. Says she distrusts pharmaceutical industry and most doctors.

Drugs: Current medications: zopiclone and cannabis p.r.n. for insomnia. No drug adverse events reported.

Past medical history: Remote episode of nephrolithiasis tought to be due to primary hypercalciuria (Ca, PTH mid-range). No features suggestive of NET, MEN1 or diabetes.

Family: Nil significant. No NET, no MEN, no nephrolithiasis, no diabetes or family members in health care.

Physical examination: 43 kg well-looking woman. No significant findings.

Laboratory investigations: Morning cortisol (0944): 205 nmol/l, short synacthen 305 →891 nmol/l Fasting plasma glucose: 2.5 mmol/l Insulin: 31 (13-161) pmol/l C-peptide: 503 (298-2350) pmol/l Proinsulin: 83.8 (<18.8) pmol/l Plasma ß-OH-butyrate: 0.17 (0.00-0.42) mmol/l, urinary ketones -ve Sulphonylurea drug screen: not available

Imaging: Radiology recommended triphasic CT, declined by patient in favour of MRCP. 3.3 cm enhancing solid mass in the pancreatic tail and complex septated cyst in the pancreatic head, probably a sidebranch IPMN. Mild central intrahepatic and extrahepatic bile duct dilatation probably due to the mass effect of the cystic mass in the pancreatic head.

Surgery: Distal pancreatic resection with splenectomy. Declines more extensive surgery.

Pathology: 3.3 cm G3 PNET (Ki67 27%) with 2 of 5 regional lymph nodes showing evidence of metastatic spread.

Follow up post op: HbA1 c risen from 23 (4.3%) to 38 mmol/mol (5.6%). Fasting glucose risen from 1.8, 2.5 to 6.0 mmol/l. Repeat MRI suggestive of numerous, small intra-heaptic metastases Declines further follow-up, investigation, or treatment.