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Zhu G, Xie L, Hu X. Diagnosis of pancreatic focal nesidioblastosis assisted by dual‑nuclide tracer positron emission tomography/computed tomography: A case report. Exp Ther Med 2024; 27:42. [PMID: 38125355 PMCID: PMC10731402 DOI: 10.3892/etm.2023.12330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Nesidioblastosis is a rare cause of hyperinsulinemic hypoglycemia in adults and its clinical features are similar to those of insulinoma with recurrent hypoglycemic attacks. The present study reports the case of a 48-year-old man who visited the Affiliated Hospital of Zunyi Medical University (Zunyi, China) with a 5-year history of recurrent hypoglycemic symptoms such as dizziness and palpitations. Abdominal magnetic resonance imaging (MRI) showed a mass of ~1.2x1.0 cm in the head of the pancreas, which was suspected to be an insulinoma. For confirmation, the patient underwent both fluorine-18-fluorodeoxyglucose (18F-FDG) and gallium-68-labeled 1,4,7,10-tetraazacyclododecane-1,4,7,10-teraacetic acid-d-Phel-Tyr3-Thr8-OC (68Ga-DOTATATE) positron emission tomography/computed tomography (PET/CT), which showed a moderately increased uptake of 18F-FDG but no uptake of 68Ga-DOTATATE in the corresponding lesion. The patient subsequently underwent surgery to remove the lesion, which was pathologically confirmed as a pancreatic nesidioblastosis. This case showed that nesidioblastosis should be considered a differential diagnosis for insulinoma and that dual nuclear tracer PET/CT imaging is helpful for differentiating between the two. If conventional imaging techniques such as ultrasound, CT and MRI cannot identify the cause of hypoglycemia in future cases, dual-nuclide tracer PET/CT imaging should be considered.
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Affiliation(s)
- Guangwen Zhu
- Department of Endocrinology, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, Guizhou 563000, P.R. China
| | - Liting Xie
- Department of Gynaecology, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, Guizhou 563000, P.R. China
| | - Xianwen Hu
- Department of Nuclear Medicine, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou 563003, P.R. China
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Thapa S, Kaur K, Yadav GK, Kumari D, Phulware RH. Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)/Nesidioblastosis as the underlying cause of recurrent hypoglycemia in a diabetic adult. Autops Case Rep 2023; 13:e2023451. [PMID: 38034512 PMCID: PMC10687782 DOI: 10.4322/acr.2023.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/05/2023] [Indexed: 12/02/2023]
Abstract
Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), without previous bariatric surgery, is a rare form of hypoglycemia in adult patients and is associated with nesidioblastosis. Adult-onset nesidioblastosis in diabetic patients is rare and histologically identical to "non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)". Nesidioblastosis is rare in adults and clinically and biochemically mimics Insulinoma. In the literature, there have only been four cases of adult nesidioblastosis that followed diabetes mellitus. We report a case of nesidioblastosis in a 36-year-old diabetic female presenting with dizziness, sweating, and palpitations for three years. Selective non-invasive techniques failed to detect a tumor. Based on the pursuit of an insulinoma, a distal pancreatectomy specimen was received at our laboratory, and a diagnosis of nesidioblastosis was made. She is currently on follow-up with a favorable outcome. The definitive diagnosis of nesidioblastosis is made on a histological basis. The preferred form of treatment is pancreatic surgical resection. Nesidioblastosis should be taken into consideration in cases where diabetes transforms into hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Samikshya Thapa
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Kirandeep Kaur
- All India Institute of Medical Sciences, Department of Endocrinology, Rishikesh, Uttarakhand, India
| | - Gajendra Kumar Yadav
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Divya Kumari
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Ravi Hari Phulware
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Second MAFA Variant Causing a Phosphorylation Defect in the Transactivation Domain and Familial Insulinomatosis. Cancers (Basel) 2022; 14:cancers14071798. [PMID: 35406570 PMCID: PMC8997416 DOI: 10.3390/cancers14071798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/25/2022] [Accepted: 03/30/2022] [Indexed: 12/21/2022] Open
Abstract
Adult-onset familial insulinomatosis is a rare disorder with recurrent, severe hypoglycemia caused by multiple insulin-secreting pancreatic tumors. The etiology was unclear until the variant p.Ser64Phe in the transcription factor MAFA, a key coordinator of β-cell insulin secretion, was defined as the cause in two families. We here describe detailed genetic, clinical, and family analyses of two sisters with insulinomatosis, aiming to identify further disease causes. Using exome sequencing, we detected a novel, heterozygous missense variant, p.Thr57Arg, in MAFA’s highly conserved transactivation domain. The impact of the affected region is so crucial that in vitro expression studies replacing Thr57 have already been performed, demonstrating a phosphorylation defect with the impairment of transactivation activity and degradation. However, prior to our study, the link to human disease was missing. Furthermore, mild hyperglycemia was observed in six additional, heterozygote family members, indicating that not only insulinomatosis but also MODY-like symptoms co-segregate with p.Thr57Arg. The pre-described MAFA variant, p.Ser64Phe, is located in the same domain, impairs the same phosphorylation cascade, and results in the same symptoms. We confirm MAFA phosphorylation defects are important causes of a characteristic syndrome, thus complementing the pathophysiological and diagnostic disease concept. Additionally, we verify the high penetrance and autosomal dominant inheritance pattern.
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Doi S, Yamada T, Kito Y, Obara S, Fujii Y, Nishimura T, Kato T, Nakayama H, Tsutsumi M, Okamura R. Adult-Onset Focal Nesidioblastosis With Nodular Formation Mimicking Insulinoma. J Endocr Soc 2022; 6:bvab185. [PMID: 35024540 PMCID: PMC8743044 DOI: 10.1210/jendso/bvab185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Indexed: 11/21/2022] Open
Abstract
Nesidioblastosis is defined as the neoformation of the islets of Langerhans from the pancreatic ductal epithelium and is recognized as the most common cause of hyperinsulinemic hypoglycemia in infants. We herein report an extremely rare case of adult-onset focal nesidioblastosis with the unusual feature of hyperplastic nodular formation. A 55-year-old woman was admitted to our hospital for a tumor detected in the body of the pancreas by magnetic resonance imaging screening. Laboratory examinations showed a high insulin level in the blood. Contrast-enhanced computed tomography and the selective arterial calcium injection test suggested the presence of multiple insulinomas in the body and tail of the pancreas, and, thus, the patient underwent distal pancreatectomy. A histopathological examination of the tumor in the body of the pancreas showed the nodular hyperplasia of islet-like cell clusters. In addition, many small intralobular ductules and islet cells appeared to be budding from the proliferating ductal epithelium, forming “ductuloinsular complexes”. No other abnormal lesion was detected in the remainder of the pancreas. The histopathological diagnosis was focal nesidioblastosis. The patient has remained free of the recurrence of hypoglycemic episodes for more than 31 months. The present case of rare adult-onset focal nesidioblastosis with hyperplastic nodular formation was preoperatively identified as an apparent pancreatic tumor mimicking insulinoma. Nesidioblastosis and insulinoma need to be considered in cases of hyperinsulinemic hypoglycemia, even in adult patients.
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Affiliation(s)
- Shunsuke Doi
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takatsugu Yamada
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yoshinori Kito
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Shinsaku Obara
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Yusuke Fujii
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Takao Nishimura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Tatsushi Kato
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Hiroyuki Nakayama
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
| | - Masahiro Tsutsumi
- Department of Pathology, Saiseikai Chuwa Hospital, Nara 633-0054, Japan
| | - Ryuji Okamura
- Department of Surgery, Yamatotakada Municipal Hospital, Nara 635-8501, Japan
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Lopes AA, Miranda AC, Maior MS, de Mello RV, Bandeira FA. Nesidioblastosis Associated with Pancreatic Heterotopia as a Differential Diagnosis of Hypoglycemia: A Literature Review and Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922778. [PMID: 32624567 PMCID: PMC7360359 DOI: 10.12659/ajcr.922778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Male, 32-year-old Final Diagnosis: Nesidioblastosis Symptoms: Hypoglycemia Medication:— Clinical Procedure: Distal pancreatectomy • magnetic resonance image • selective arterial calcium stimulation test with hepatic venous sampling Specialty: Endocrinology and Metabolic
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Affiliation(s)
- Aline A Lopes
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Ana C Miranda
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Marcelo S Maior
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Roberto V de Mello
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Francisco A Bandeira
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
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Shen Y, Song X, Ren Y. Insulin autoimmune syndrome induced by exogenous insulin injection: a four-case series. BMC Endocr Disord 2019; 19:148. [PMID: 31883520 PMCID: PMC6935495 DOI: 10.1186/s12902-019-0482-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Insulin autoimmune syndrome (IAS) is a rare cause of hypoglycemia and is characterized by the presence of insulin autoantibodies. Patients with IAS usually complain of hypoglycemia without any previous insulin received. Glucocorticoids and immunosuppressants are used to treat IAS. CASE PRESENTATION We report four patients with diabetes who were diagnosed with non-classical IAS and describe the treatment of these patients. Moreover, the differential diagnosis with hyperinsulinism is discussed. CONCLUSION High levels of insulin autoantibodies, as well as hyperinsulinemic hypoglycemia, are found in patients with diabetes mellitus and prior exogenous insulin exposure. This situation that we classified as non-classical IAS should be attached importance to.
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Affiliation(s)
- Yimin Shen
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
- Zhejiang University School of Medicine, Zhejiang, 310058 China
| | - Xiaoxiao Song
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
| | - Yuezhong Ren
- Department of Endocrinology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, 310009 China
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Total pancreatectomy for the management of refractory post-gastric bypass hypoglycemia. Dig Dis Sci 2015; 60:1505-9. [PMID: 25344909 DOI: 10.1007/s10620-014-3408-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/15/2014] [Indexed: 12/19/2022]
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Kriger AG, Smirnov AV, Kalinin DV, Glotov AV, Berelavichus SV, Konyaeva GI, Lebedeva AN, Karel'skaya NA, Tsygankov VN. [Nesidioblastosis (diagnosis, surgical treatment)]. Khirurgiia (Mosk) 2015:16-29. [PMID: 26978464 DOI: 10.17116/hirurgia20151016-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Nesidioblastosis (NB) is rare disease with organic hyperinsulinism syndrome and caused by diffuse hyperplasia and/or hypertrophy of pancreatic islands of Langerhans. MATERIAL AND METHODS The results of surgical treatment of 3 patients with NB are presented. In all patients the diagnosis was suspected at the preoperative stage and confirmed by histological examination later. Herewith in 2 patients NB was combined with insulinoma. All patients underwent corpora-caudal pancreatectomy. RESULTS In postoperative period one patient hadn't episodes of hypoglycemia for the entire follow-up period (5 months), in another patient hypoglycemic states occurred at 1.5 months after surgery. The third patient required pancreatic head extirpation at 11 days after surgery due to persistent severe course of organic hyperinsulinism. In immediate postoperative period in the same patient hyperinsular hypoglycemia was observed that pointed on extrapancreatic source of insulin secretion. However contrast-enhanced CT did not reveal any formations. CONCLUSION Thus, corpora-caudal pancreatectomy is preferable as surgical treatment. Results of surgical management can provide a complete regression of the symptoms, but do not guarantee absence of recurrence and even any changes in frequency and severity of hypoglycemic states.
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Affiliation(s)
- A G Kriger
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Smirnov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - D V Kalinin
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Glotov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - S V Berelavichus
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | | | - A N Lebedeva
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - N A Karel'skaya
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - V N Tsygankov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
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