Insulinoma masquerading as a loss of consciousness in a teenage girl: case report and literature review

Novel Use of Dasiglucagon, a Soluble Glucagon Analog, for the Treatment of Hyperinsulinemic Hypoglycemia Secondary to Suspected Insulinoma: A Case Report

INTRODUCTION

Hyperinsulinemic hypoglycemia is the most common cause of persistent hypoglycemia in children and adults. In adolescents and adults, hyperinsulinemic hypoglycemia is most frequently caused by an insulin-producing tumor.

CASE PRESENTATION

A 17-year-old, previously healthy male presented with recurrent and severe episodes of hypoglycemia. Diagnostic evaluation was consistent with hyperinsulinemic hypoglycemia, and an insulinoma was suspected. Multiple imaging studies and surgical exploration failed to identify a lesion. Over the course of months, the patient was found to be refractory to conventional medical interventions.

CONCLUSION

Upon approval from the US Food and Drug Administration and the Institutional Review Board, the patient was treated with dasiglucagon, a novel soluble glucagon analog, under a single-patient Investigational New Drug. The patient has tolerated the medication and has been able to achieve appropriate glycemic control.

Insulinoma in childhood: a retrospective review of 22 patients from one referral centre

Background

Insulinomas are very rare in childhood with sparse knowledge on the clinical aspects and the presence of Multiple Endocrine Neoplasia type 1 (MEN1).

Methods

We conducted a retrospective review of patients diagnosed with insulinoma between 1995 and 2021, presenting to one referral centre in Russia. Clinical, biochemical, genetic, imaging and histological data were collected. In addition, follow-up and family data were obtained.

Results

A total of twenty-two children aged 5 to 16 years were identified. The median (range) gap between the first hypoglycaemia symptoms and diagnosis was 10 (1-46) months. Twelve children (55%) were misdiagnosed to have epilepsy and were treated with anticonvulsants before hypoglycemia was revealed. Contrast enhanced MRI and/or CT were accurate to localize the lesion in 82% (n=18). Five patients (23%) had multiple pancreatic lesions. All children underwent surgical treatment. The median (range) diameter of removed tumors was 1.5 (0.3-6) cm. Histopathological studies confirmed the presence of insulinoma in all cases. Immunohistochemical studies revealed G2 differentiation grade in 10 out of 17 cases. Two patients were diagnosed with metastatic insulinoma. One of them had metastases at the time of insulinoma diagnosis, while the other was diagnosed with liver metastases eight years after the surgery. Eight children (36%) were found to carry MEN1 mutations, inherited n=5, de novo n=1, no data, n=2. Children with MEN1 had significantly higher number of pancreatic tumors compared to sporadic cases. All of them developed additional MEN1 symptoms during the following 2-13 years. In the five patients with inherited MEN1, seven family members had hitherto undiscovered MEN1 manifestations.

Conclusions

In this large cohort of children with rare pediatric insulinomas, MEN1 syndrome and G2 tumors were frequent, as well as hitherto undiscovered MEN1 manifestations in family members. Our data emphasize the need of genetic testing in all children with insulinoma and their relatives, even in the absence of any other features, as well as the importance of a prolonged follow-up observation.

Case report - Selective internal radiation therapy (SIRT) in a patient with hyperinsulinemic hypoglycemia due to a metastatic insulinoma with late onset of endocrine activity

Insulinomas are the most common functioning pancreatic neuroendocrine tumors (NET), which can lead to hyperinsulinemic hypoglycemia. In advanced metastatic stages of the disease, the prognosis is poor. Patients with hormonally active insulinomas primarily present with features of neuroglycopenia. Transformation from a nonfunctional to a functional NET is rare. Here, we present a case of a 59-year-old male adult with a metastatic insulinoma and late onset of endocrine activity. Besides medical treatment with Diazoxide and small frequent feedings, continuous intravenous glucose application was eventually required to avoid hypoglycemia. Furthermore, we show that selective internal radiation therapy (SIRT) can be an effective therapeutic approach for symptom reduction in advanced metastatic disease.

Recurrent Hypoglycemia in Baby with Insulinoma: A Case Report

BACKGROUND: Insulinoma is a functional neuroendocrine tumor in the pancreas that can cause hypoglycemia due to endogenic hyperinsulinism. Insulinoma is a rare case with an incidence of 1–4 cases per million people each year. Insulinoma can occur at various ages and mostly occurs in adults with a predominance in women. CASE REPORT: A baby boy aged 1 month 23 days was referred from Prof. Dr. W. Z. Johannes Hospital with the chief complaint was seizures. The results of the examination of blood glucose levels at Sanglah Hospital were 28 mg/dl. There were some episodes of normal blood glucose level in the patient after having some doses of glucose infusion therapy. However, it was only for a while, the blood glucose level came back low and induced the symptoms of the seizure (neuroglycopenia). The seizures stopped after having anticonvulsant therapy and blood glucose levels within normal limits. These symptoms were consistent with the Whipple triad in insulinoma. The patient has an elevated insulin level (92 IU/ml). Computed tomography scan of the abdomen with contrast showed a mass in the caudal part of the pancreas. The patient underwent a partial pancreatectomy. Histomorphology features showed pancreatic neuroendocrine tumors without metastases. Immunohistochemical results of Ki-67 showed well-differentiated neuroendocrine tumors grade 2. CONCLUSION: Based on clinical, physical examination, laboratory, and radiology findings, the patient was diagnosed with recurrent hypoglycemia due to insulinoma and improved with partial pancreatectomy.

Acanthosis nigricans: To be or not to be afraid

Acanthosis nigricans (AN), a skin disorder with high prevalence, represents a dermatological condition with esthetic implications, but otherwise mild symptoms. For any clinician, it is in fact the tip of the iceberg, leading him/her to investigate what lies beneath the surface, since AN points to a systemic problem or disease: metabolic disorder (most frequently), endocrine syndrome, medication side effects, malignancy, and genetic factors. Sometimes, it is the first observed sign of a malignancy or of diabetes mellitus, especially in patients with chronic metabolic disorder; therefore, it is not to be taken lightly. The present review summarizes the information in literature regarding the etiopathogenesis of AN. We propose a new classification that aims to better organize the different types of AN, with implications on the extent and urgency of the investigation plan, as well as various therapeutic algorithms. Therapy options are also presented, both systemic treatments that target the underlying disease, and local ones for esthetic reasons.

Multiple endocrine neoplasia type 1 presenting with concurrent insulinoma and prolactinoma in early-adolescence

Background

Multiple Endocrine Neoplasia Type 1 (MEN1) is a rare autosomal dominant disease that generally presents with primary hyperparathyroidism. However, initial presentation may vary and continued reevaluation of etiology of symptoms is required for appropriate diagnosis.

Case Presentation

Twelve year old female presented with altered mental status that self-resolved and hypoglycemia. Laboratory evaluation revealed pituitary dysfunction with central hypothyroidism and adrenal insufficiency in the setting of hyperprolactinemia. Macroadenoma was confirmed on imaging. Despite medical treatment of pituitary hormone disorders, she continued to have significant hypoglycemia and further workup revealed hyperinsulinism. Insulinoma was identified and confirmed by endoscopic ultrasound. Hypoglycemia resolved after laproscopic enucleation of the insulinoma.

Conclusion

Children presenting with one endocrine tumor should be investigated for other potential endocrine tumors. Multiple imaging modalities may be required to confidently identify neuroendocrine tumors for appropriate surgical intervention.