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Elghobashy M, Gama R, Sulaiman RA. Investigation and Causes of Spontaneous (Non-Diabetic) Hypoglycaemia in Adults: Pitfalls to Avoid. Diagnostics (Basel) 2023; 13:3275. [PMID: 37892096 PMCID: PMC10606153 DOI: 10.3390/diagnostics13203275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Although adult spontaneous (non-diabetic) hypoglycaemia is rare, its recognition is important for the preventative or curative treatment of the underlying cause. Establishing Whipple's triad-low blood glucose, neuroglycopaenia and resolution of neuroglycopaenia on increasing blood glucose levels to normal or above-is essential to verify hypoglycaemia. Awareness that hypoglycaemia may occur in severely ill patients is important for its prevention. Further investigation in such cases is unnecessary unless another cause of hypoglycaemia is suspected. Patients are often asymptomatic and normoglycaemic at review. Their history of medication, self-medication, access to hypoglycaemic drugs, alcohol use and comorbidity may provide aetiological clues. The investigation involves obtaining blood samples during symptoms for laboratory glucose measurement or provoking fasting or postprandial hypoglycaemia as directed by symptoms. If confirmed, insulin, c-peptide, proinsulin and beta-hydroxybutyrate are analysed in hypoglycaemic samples. These will classify hypoglycaemia due to non-ketotic hyperinsulinaemia, non-ketotic hypoinsulinaemia and ketotic hypoinsulinaemia, and direct investigations to identify the underlying cause. There are, however, many pitfalls that may mislabel healthy individuals as "hypoglycaemic" or misdiagnose treatable or preventable causes of spontaneous hypoglycaemia. Clinical acumen and appropriate investigations will mostly identify hypoglycaemia and its cause.
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Affiliation(s)
- Maiar Elghobashy
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
| | - Rousseau Gama
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
- School of Medicine and Clinical Practice, Wolverhampton University, Wolverhampton WV1 1LY, UK
| | - Raashda Ainuddin Sulaiman
- Department of Medical Genomics, Center for Genomic Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
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2
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Fottner C, Ferrata M, Weber MM. Hormone secreting gastro-entero-pancreatic neuroendocrine neoplasias (GEP-NEN): When to consider, how to diagnose? Rev Endocr Metab Disord 2017; 18:393-410. [PMID: 29256148 DOI: 10.1007/s11154-017-9438-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neuroendocrine neoplasms of the digestive system (GEP-NEN) represent a heterogeneous group of malignancies with various clinical presentation and prognosis. GEP-NENs can potentially affect all organs of the gastrointestinal tract; characteristically they share the biological property to produce and secrete peptides and neuroamines. About 30% of GEP-NENs are hormonally active and can cause specific clinical syndromes. The clinical presentation mainly depends on the primary site of the tumor and its functionality. Because of the wide spectrum of clinical symptoms and their misperceived rarity, diagnosis of GEP-NENs is often delayed for years and tumors are detected first in an advanced stage. Early identification of a specific hormonal syndrome can significantly impact tumor diagnosis and treatment, moreover the preoperative management of NEN hormonal release avoids potential life threatening hormonal crisis. However, GEP-NEN diagnostic work-up is challenging, it requires a multidisciplinary team and needs particular experience; standardized protocols and clinical experience are essential for a proper endocrine diagnostic work-up. In addition to the biochemical diagnostic, further radiologic and endoscopic imaging modalities are required moreover, somatostatin-receptor based functional imaging, using either Octreotide-scintigraphy or novel PET-based techniques with specific isotopes like Ga68-DOTA-octreotate, plays an important role for the detection of the primary tumor as well as for the evaluation of the tumor extent.
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Affiliation(s)
- Christian Fottner
- Schwerpunkt Endokrinologie und Stoffwechselerkrankungen, I. Medizinischen Klinik und Poliklinik; ENETS center of excellence, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstrasse 1, 55101, Mainz, Germany.
| | - Martina Ferrata
- Schwerpunkt Endokrinologie und Stoffwechselerkrankungen, I. Medizinischen Klinik und Poliklinik; ENETS center of excellence, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstrasse 1, 55101, Mainz, Germany
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Matthias M Weber
- Schwerpunkt Endokrinologie und Stoffwechselerkrankungen, I. Medizinischen Klinik und Poliklinik; ENETS center of excellence, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstrasse 1, 55101, Mainz, Germany
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Vezzosi D, Bennet A, Grunenwald S, Caron P. Hypoglycémies chez le sujet non diabétique : quand faut-il réaliser une épreuve de jeûne et comment l’interpréter ? Presse Med 2016; 45:588-94. [DOI: 10.1016/j.lpm.2016.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/21/2016] [Accepted: 04/13/2016] [Indexed: 11/29/2022] Open
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Employing in vitro analysis to test the potency of methylglyoxal in inducing the formation of amyloid-like aggregates of caprine brain cystatin. Amino Acids 2014; 47:135-46. [DOI: 10.1007/s00726-014-1848-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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Abstract
Hyperinsulinemic hypoglycemia is the most common cause of persistent hypoglycemia in children and adults. The diagnosis of hyperinsulinemic hypoglycemia relies on the evaluation of the biochemical profile at the time of hypoglycemia, however, contrary to common perception, plasma insulin is not always elevated. Thus, the diagnosis must often be based on the examination of other physiologic manifestations of excessive insulin secretion, such as suppression of glycogenolysis, lipolysis and ketogenesis, which can be inferred by the finding of a glycemic response to glucagon, and the suppression of plasma free fatty acids and beta-hydroxybutyrate concentrations during hypoglycemia.
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Affiliation(s)
- Diva D De León
- Division of Pediatric Endocrinology, Children's Hospital of Philadelphia, Philadelphia, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
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Agin A, Charrie A, Chikh K, Tabarin A, Vezzosi D. Fast test: Clinical practice and interpretation. ANNALES D'ENDOCRINOLOGIE 2013; 74:174-84. [DOI: 10.1016/j.ando.2013.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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7
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Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, Kobayashi M, Hanazaki K. Diagnosis and management of insulinoma. World J Gastroenterol 2013; 19:829-37. [PMID: 23430217 PMCID: PMC3574879 DOI: 10.3748/wjg.v19.i6.829] [Citation(s) in RCA: 215] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 11/12/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
Insulinomas, the most common cause of hypoglycemia related to endogenous hyperinsulinism, occur in 1-4 people per million of the general population. Common autonomic symptoms of insulinoma include diaphroresis, tremor, and palpitations, whereas neuroglycopenenic symptoms include confusion, behavioural changes, personality changes, visual disturbances, seizure, and coma. Diagnosis of suspected cases is based on standard endocrine tests, especially the prolonged fasting test. Non-invasive imaging procedures, such as computed tomography and magnetic resonance imaging, are used when a diagnosis of insulinoma has been made to localize the source of pathological insulin secretion. Invasive modalities, such as endoscopic ultrasonography and arterial stimulation venous sampling, are highly accurate in the preoperative localization of insulinomas and have frequently been shown to be superior to non-invasive localization techniques. The range of techniques available for the localization of insulinomas means that blind resection can be avoided. Intraoperative manual palpation of the pancreas by an experienced surgeon and intraoperative ultrasonography are both sensitive methods with which to finalize the location of insulinomas. A high proportion of patients with insulinomas can be cured with surgery. In patients with malignant insulinomas, an aggressive medical approach, including extended pancreatic resection, liver resection, liver transplantation, chemoembolization, or radiofrequency ablation, is recommended to improve both survival and quality of life. In patients with unresectable or uncontrollable insulinomas, such as malignant insulinoma of the pancreas, several techniques should be considered, including administration of ocreotide and/or continuous glucose monitoring, to prevent hypoglycemic episodes and to improve quality of life.
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 2011; 34:e61-99. [PMID: 21617108 PMCID: PMC3114322 DOI: 10.2337/dc11-9998] [Citation(s) in RCA: 316] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence-Based Laboratory Medicine Committee of the American Association for Clinical Chemistry jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (HbA(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of HbA(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA.
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9
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2011; 57:e1-e47. [PMID: 21617152 DOI: 10.1373/clinchem.2010.161596] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence Based Laboratory Medicine Committee of the AACC jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (Hb A(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of Hb A(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892-1508, USA.
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Musshoff F, Hess C, Madea B. Disorders of glucose metabolism: post mortem analyses in forensic cases–part II. Int J Legal Med 2010; 125:171-80. [DOI: 10.1007/s00414-010-0510-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 08/24/2010] [Indexed: 11/24/2022]
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Izumiyama H, Gotyo N, Fukai N, Ozawa N, Doi M, Yoshimoto T, Arii S, Hirata Y. Glucose-responsive and octreotide-sensitive insulinoma. Intern Med 2006; 45:519-24. [PMID: 16702744 DOI: 10.2169/internalmedicine.45.1523] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Insulinoma is the most common cause of fasting hypoglycemia resulting from autonomous insulin hypersecretion. We describe herein a unique case with paradoxical hypoglycemic episodes induced by hyperglycemia. A 55-year-old female had repeated hypoglycemic episodes after meal or during increased physical activity. Although fasting (10 hr) failed to provoke hypoglycemia, oral glucose tolerance test (GTT) caused an exaggerated insulin response (885 microU/ml) at 30 min, followed by hypoglycemia (36 mg/dl) after 90 min. Moreover, intravenous GTT also induced an exaggerated insulin response (>2900 microU/ml) at 10 min, followed by hypoglycemia (34 mg/dl) after 40 min. Although MRI and CT scan of the abdomen failed to detect any mass lesions in the pancreas, Octreoscan revealed increased radioactive uptake around the pancreatic head region. Treatment with a daily injection of octreotide (100 microg) alleviated her hypoglycemic episodes. At surgery, two islet cell adenomas were identified in the pancreas and resected. Postoperatively, she was free from hypoglycemic episodes after meal. Postoperative oral and intravenous GTT did not induce hypoglycemia. Thus, this is a very rare case of glucose-responsive and octreotide-sensitive insulinoma in whom GTT and octreotide proved to be a useful provocation and treatment for hypoglycemic episodes.
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Affiliation(s)
- Hajime Izumiyama
- Department of Clinical and Molecular Endocrinology, Tokyo Medical and Dental University Graduate School, Yushima
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12
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Abstract
Spontaneous hypoglycaemia is not a diagnosis, but a manifestation of a disease process. It is important to recognize spontaneous hypoglycaemia, as treatment may be preventative or curative. It is equally important to avoid mislabelling healthy individuals as having hypoglycaemia as this may have a negative impact on the quality of life and use of scarce health-care resources.
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Affiliation(s)
- M J Griffiths
- Department of Clinical Chemistry, New Cross Hospital, Wolverhampton, West Midlands
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Czupryniak L, Strzelczyk J, Drzewoski J. Diagnostic difficulties in long-standing insulinoma with near-normal plasma insulin levels. J Endocrinol Invest 2005; 28:170-4. [PMID: 15887865 DOI: 10.1007/bf03345362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Insulinoma tumors are often difficult to detect, as the symptoms largely precede occurrence of a visualized tumor. We report the case of an insulinoma patient with long delayed diagnosis and marked adaptation to extreme hypoglycemia. The patient with a 7-yr history of seizures was found to have plasma glucose concentration during a starvation test as low as 16 mg/dl, with no clinically significant symptoms and concomitant normal plasma insulin levels: 10-30 microIU/ml. All attempts to localize a tumor with repeated abdominal ultrasound examinations or computed tomography scanning were unsuccessful. The patient did not tolerate the introduced oral treatment with diazoxide. Once it had become technically available, endoscopic ultrasonography of the pancreas was performed. It revealed a 10 mm tumor in the pancreatic head. The tumor was subsequently removed surgically. During the operation plasma insulin concentration rose almost 15-fold, which confirmed the insulin-secreting character of the growth. Microscopic examination revealed benign insulinoma, with partially trabecular structure. One month after the operation the patient had normal plasma glucose values of 60-120 mg/dl, but she constantly complained of excessive thirst, which occurred soon after the operation and slowly subsided in the following weeks. In conclusion, the present report demonstrates that insulinoma should be considered and searched for in every case of hypoglycemia associated with normal insulin levels. It also confirms the essential role of endoscopic ultrasonography in the diagnosis of insulin-secreting tumors.
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Affiliation(s)
- L Czupryniak
- Department of Gastroenterology and Metabolic Diseases, Medical University of Lodz, Barlicki University Hospital, Lodz, Poland.
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Gama R, Teale JD, Marks V. Best practice No 173: clinical and laboratory investigation of adult spontaneous hypoglycaemia. J Clin Pathol 2003; 56:641-6. [PMID: 12944543 PMCID: PMC1770066 DOI: 10.1136/jcp.56.9.641] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2003] [Indexed: 11/04/2022]
Abstract
Adult spontaneous hypoglycaemia is not a diagnosis per se but a manifestation of a disease. Although rare, it is important to identify spontaneous hypoglycaemia and its causes because treatment may be preventative or curative. Hypoglycaemia can occur as an epiphenomenon in many serious diseases. It is sufficient to recognise the disease's association with hypoglycaemia and then take appropriate action to prevent the recurrence of hypoglycaemia. In investigating apparently healthy individuals, common pitfalls to avoid are: failure to recognise subacute neuroglycopenia clinically; failure to document hypoglycaemia adequately during symptoms; failure to measure pancreatic hormones, counter-regulatory hormones, and ketones in hypoglycaemic samples; failure to recognise pre-analytical and analytical limitations of laboratory assays; and failure to abandon obsolete and inappropriate investigations. Providing these caveats are met, appropriate laboratory and radiological investigations will almost always uncover the cause of spontaneous hypoglycaemia.
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Affiliation(s)
- R Gama
- Clinical Chemistry, New Cross Hospital, Wolverhampton, West Midlands WV10 0QP, UK.
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Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Clin Chem 2002. [DOI: 10.1093/clinchem/48.3.436] [Citation(s) in RCA: 603] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AbstractBackground: Multiple laboratory tests are used in the diagnosis and management of patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially.Approach: An expert committee drafted evidence-based recommendations for the use of laboratory analysis in patients with diabetes. An external panel of experts reviewed a draft of the guidelines, which were modified in response to the reviewers’ suggestions. A revised draft was posted on the Internet and was presented at the AACC Annual Meeting in July, 2000. The recommendations were modified again in response to oral and written comments. The guidelines were reviewed by the Professional Practice Committee of the American Diabetes Association.Content: Measurement of plasma glucose remains the sole diagnostic criterion for diabetes. Monitoring of glycemic control is performed by the patients, who measure their own plasma or blood glucose with meters, and by laboratory analysis of glycated hemoglobin. The potential roles of noninvasive glucose monitoring, genetic testing, autoantibodies, microalbumin, proinsulin, C-peptide, and other analytes are addressed.Summary: The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are of minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Thorn 530, 75 Francis St., Boston, MA 02115
| | - David E Bruns
- Department of Pathology, University of Virginia Medical School, PO Box 800214, Charlottesville, VA 22908
| | - David E Goldstein
- Department of Child Health, University of Missouri School of Medicine, 1 Hospital Dr., Columbia, MO 65212
| | - Noel K Maclaren
- Weill Medical College of Cornell University, 1300 York Ave., Suite LC-623, New York, NY 10021
| | - Jay M McDonald
- Department of Pathology, University of Alabama at Birmingham, 701 S. 19th St., Birmingham, AL 35294
- Veterans Administration Medical Center, Birmingham, AL 35233
| | - Marian Parrott
- American Diabetes Association, 1701 Beauregard St., Alexandria, VA 22311
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Wagner B, Ludwig C, Riedl M, Niederle B, Cejna M, Vierhapper H, Waldhäusl W, Roden M. Severe chronic hypoglycemia in a lean, young woman. Pancreas 2000; 21:97-9. [PMID: 10881939 DOI: 10.1097/00006676-200007000-00058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- B Wagner
- Department of Internal Medicine III, University of Vienna, Austria
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Abstract
PURPOSE To characterize neuroglycopenic symptoms in the clinical presentation of patients with insulinomas. SUBJECTS AND METHODS Patients with histologically confirmed islet cell adenomas or carcinomas were identified at a single institution. Patient symptoms and clinical features of the insulinomas were obtained by retrospective medical record review with special attention to neuroglycopenic and autonomic symptoms. RESULTS Of the 59 patients, 51% were female. Patients' ages ranged from 17 to 79 years (median 55) at the time of surgery. The interval from the onset of symptoms to diagnosis ranged from 1 month to 30 years (median 24 months). Most patients were diagnosed within 1 to 5 years (53%). Prior diagnoses included neurologic disorders (64%), especially seizure disorders (39%); 7 (12%) patients were treated with antiseizure medications. All patients had neuroglycopenic symptoms including confusion (83%) and personality change or bizarre behavior (64%). Amnesia for hypoglycemia was common (41%). Autonomic symptoms (83%) were usually diaphoresis (69%) or tremulousness (24%). Food ingestion relieved symptoms in 71% of patients; 39% reported weight gain. CONCLUSIONS Despite improving diagnostic techniques, the diagnosis of an insulinoma is often delayed. Careful inquiry about neuroglycopenic symptoms from patients and persons who know them well is necessary whenever hypoglycemia due to endogenous hyperinsulinemia is a clinical consideration. A history of neuroglycopenic symptoms should suggest the diagnosis of hypoglycemia associated with a hyperinsulinemic state.
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Affiliation(s)
- A M Dizon
- Department of Endocrinology, Cleveland Clinic Foundation, Ohio 44195, USA
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18
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Verrotti A, Fusilli P, Pallotta R, Morgese G, Chiarelli F. Hypoglycemia in childhood: a clinical approach. J Pediatr Endocrinol Metab 1998; 11 Suppl 1:147-52. [PMID: 9642653 DOI: 10.1515/jpem.1998.11.s1.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A child with hypoglycemia presents very frequently an urgent diagnostic and therapeutic challenge. The main causes of hypoglycemia and the clinical approach and laboratory investigations are reviewed underlining that the relationship between the hypoglycemic event and the last meal can aid in diagnosis, in particular for metabolic diseases. Only a correct and precise diagnosis can allow adequate and appropriate treatment and prevention of future hypoglycemic events.
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Affiliation(s)
- A Verrotti
- Department of Pediatrics, University of Chieti, Italy
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Beccaria L, Bosio L, Burgio G, Paesano PL, Del Maschio A, Chiumello G. Multiple insulinomas of the pancreas: a patient report. J Pediatr Endocrinol Metab 1997; 10:309-14. [PMID: 9388825 DOI: 10.1515/jpem.1997.10.3.309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Whereas there is general agreement about the biochemical diagnosis of hyperinsulinism, the value of imaging to differentiate diffuse from focal pancreatic lesions is still a matter of debate. We describe a case of multiple adenomas of the pancreas in an eleven year-old boy. The source of hyperinsulinism was detected by pancreatic ultrasound examination and confirmed by MRI as a single adenoma of the pancreas. These radiological exams did not identify three other pancreatic adenomata. Our report outlines the difficulties in anatomically localizing the source of excessive insulin secretion in cases of hyperinsulinemic hypoglycemia.
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Affiliation(s)
- L Beccaria
- Pediatric Department, Scientific Institute H San Raffaele, University of Milan, Italy
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