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Koceva A, Krajnc M. Insulinoma Unmasked: A Continuous Glucose Monitoring-Fueled Journey. Curr Oncol 2024; 31:5452-5461. [PMID: 39330031 PMCID: PMC11431697 DOI: 10.3390/curroncol31090403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 09/05/2024] [Accepted: 09/12/2024] [Indexed: 09/28/2024] Open
Abstract
Insulinomas are rare functional neuroendocrine tumors that are usually indolent and small. Due to their rarity, there is often a delay in disease recognition and diagnosis, and small tumor size makes their localization challenging. Glucose monitoring and dietary modification with or without pharmacotherapy are crucial during diagnostics, and surgery is the only definite treatment. Continuous glucose monitoring (CGM) systems can be a valuable tool in managing insulinoma patients. We present three patients with confirmed endogenous hyperinsulinemic hypoglycemia undergoing tumor localization, medical treatment, and surgery while wearing a CGM system. By accurately depicting glucose fluctuations, CGM can help prevent hypoglycemia, decrease hypoglycemia unawareness, track hypoglycemia frequency, aid in medical therapy dose titration, and confirm a cure after surgery.
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Affiliation(s)
- Andrijana Koceva
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia
| | - Mitja Krajnc
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia
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2
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Perez JA. Glucose Disorders. Prim Care 2024; 51:375-390. [PMID: 39067965 DOI: 10.1016/j.pop.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Glucose disorders are the most common endocrine condition in the primary care setting. The conditions overlap and are better viewed as a spectrum rather than discrete entities. Multiple treatment agents are now available for diabetes mellitus which include long-acting and short-acting insulins and medications targeting the various pathways of diabetes including liver gluconeogenesis, increasing peripheral insulin sensitivity, stimulating pancreatic insulin production, eliminating glucose renally, decreasing carbohydrate gastrointestinal absorption, and targeting the body's incretin system. Various endocrine conditions can cause secondary hyperglycemia or hypoglycemia. Medications and physiologic stress can affect glucose levels. Genetic syndromes causing enzyme deficiencies underlie a small portion of glucose disorders.
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Affiliation(s)
- Juan A Perez
- Department of Family and Community Medicine Residency Program, Penn State Health-St. Joseph Hospital, 145 N. 6th Street, 2nd floor, Reading, PA 19601, USA.
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3
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Karamanolis NN, Kounatidis D, Vallianou NG, Alexandropoulos K, Kovlakidi E, Kaparou P, Karampela I, Stratigou T, Dalamaga M. Paraneoplastic hypoglycemia: An overview for optimal clinical guidance. Metabol Open 2024; 23:100305. [PMID: 39185033 PMCID: PMC11342107 DOI: 10.1016/j.metop.2024.100305] [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: 07/15/2024] [Revised: 07/28/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024] Open
Abstract
Paraneoplastic hypoglycemia, also known as non-islet cell tumor hypoglycemia (NICTH), is a rare but critical condition occurring in patients with different types of malignancy. This condition is commonly linked to tumors producing insulin-like growth (IGF) factors, particularly IGF-2 and its precursors, which disrupt glucose homeostasis and lead to excessive glucose consumption. The diagnosis typically involves documenting symptomatic hypoglycemia and ruling out other potential causes. Essential diagnostic tools include imaging studies and laboratory tests, specifically measuring IGF-2 levels and the IGF-2:IGF-1 ratio. Treatment strategies for NICTH are multifaceted and may include surgical resection of the tumor if feasible, pharmacological interventions such as corticosteroids to suppress IGF-2 production, or supportive measures to manage acute hypoglycemic episodes. Novel therapeutic approaches targeting IGF-2, such as monoclonal antibodies or siRNA, are also being explored and hold promise for future treatment options. This review aims to enhance understanding of paraneoplastic hypoglycemia, focusing on its pathogenesis and diagnosis, to guide optimal medical treatment.
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Affiliation(s)
- Nikolaos Nektarios Karamanolis
- 2th Department of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Hippokratio General Hospital, 11527, Athens, Greece
| | - Dimitris Kounatidis
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527, Athens, Greece
| | - Natalia G. Vallianou
- First Department of Internal Medicine, Sismanogleio General Hospital, 15126, Athens, Greece
| | - Konstantinos Alexandropoulos
- 2th Department of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Hippokratio General Hospital, 11527, Athens, Greece
| | - Eleni Kovlakidi
- 2th Department of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Hippokratio General Hospital, 11527, Athens, Greece
| | - Pinelopi Kaparou
- 2th Department of Internal Medicine, Medical School, National & Kapodistrian University of Athens, Hippokratio General Hospital, 11527, Athens, Greece
| | - Irene Karampela
- Second Department of Critical Care, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Theodora Stratigou
- Department of Endocrinology and Metabolism, Evangelismos General Hospital, 10676, Athens, Greece
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece
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4
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Mitteer LM, States L, Bhatti T, Adzick NS, Lord K, De León DD. Hyperinsulinemic Hypoglycemia Due to an Insulinoma in a 2-Year-Old Child. JCEM CASE REPORTS 2024; 2:luae161. [PMID: 39286518 PMCID: PMC11402795 DOI: 10.1210/jcemcr/luae161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Indexed: 09/19/2024]
Abstract
Insulinomas are rare insulin-secreting tumors that most commonly affect adults. A 26-month-old child presented to her local emergency department with severe hypoglycemia. Initial workup was consistent with hyperinsulinemic hypoglycemia. Over the course of 10 months, multiple therapies for hyperinsulinism (HI) were trialed without significant benefit. Genetic testing for genes associated with HI was negative. At age 35 months, the patient was transferred to our center for further treatment. She underwent several imaging tests that revealed a lesion on her pancreas concerning for an insulinoma. The patient underwent surgical intervention to enucleate the lesion. Histopathological review of the specimen confirmed a benign, well-circumscribed insulinoma. A postoperative fasting test proved the patient was cured and she was discharged without the need for further glucose monitoring.
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Affiliation(s)
- Lauren M Mitteer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Lisa States
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tricia Bhatti
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and Perelman School Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - N Scott Adzick
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Surgery, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Katherine Lord
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Diva D De León
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Congenital Hyperinsulinism Center, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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5
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Adelmeyer J, Schauer CM, Kann PH. Spontaneous hypoglycemia: should we mind the gap? Long-term follow-up of healthy people who met Whipple's triad criteria. Hormones (Athens) 2024; 23:447-455. [PMID: 38457064 PMCID: PMC11436464 DOI: 10.1007/s42000-024-00542-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
CONTEXT Patients discharged as "healthy" with the symptoms of spontaneous hypoglycemia, commonly known as Whipple's triad, need more attention. OBJECTIVE Characterization and long-term follow-up of symptom development in patients with spontaneous hypoglycemia discharged as "healthy". The objective was to ascertain whether any conditions related to the symptoms were diagnosed during the follow-up period. METHODS Retrospective analysis of patient data and evaluation of a specific questionnaire on the development of symptoms of spontaneous hypoglycemia. In addition, patient questionnaires were evaluated and primary care physicians were asked about possible diseases not recorded at baseline that occurred during the follow-up period. SETTING Center for Endocrinology, Diabetology, and Osteology at the University Hospital Marburg, Inpatient Department, Germany. PATIENTS All patients who presented to our center for the 72-hour fast between 2005 and 2018 and were discharged without an internal medicine diagnosis were included. INTERVENTIONS Survey by questionnaire, via telephone interview. MAIN OUTCOME MEASURES Patient-reported information on current symptoms compared to original symptoms, diagnosis of insulinoma or diabetes mellitus during follow-up, matched with primary care physician data, and metabolic and biometric data such as body mass index (BMI), homeostasis model assessment for insulin resistance (HOMA IR), insulin sensitivity Matsuda Index (ISI-M), and area under the curve. RESULTS A total of 41 datasets were evaluated at baseline and 38 patients were followed for an average of approximately 10 years. In total, 61% of respondents still reported the same symptoms as at baseline. No insulinoma was missed in these patients. Only two of the 38 patients developed diabetes mellitus. CONCLUSION The high percentage of patients who are discharged as "healthy" and still have symptoms after many years is disturbing. It is possible that the symptoms are not due to low blood glucose. We urge caution with use of the term "healthy". We advocate a multidisciplinary therapeutic approach after an organic cause of hypoglycemia has been ruled out. Psychosomatic treatment seems to be useful. In addition, more research should be conducted on this topic.
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Affiliation(s)
- Jan Adelmeyer
- Center for Endocrinology, Diabetology & Osteology of Philipps, University Marburg, 35037, Marburg, Germany.
| | - Christian Marcel Schauer
- Center for Endocrinology, Diabetology & Osteology of Philipps, University Marburg, 35037, Marburg, Germany
| | - Peter Herbert Kann
- Center for Endocrinology, Diabetology & Osteology of Philipps, University Marburg, 35037, Marburg, Germany
- German Center for Endocrine Care (DEVZ), Düsseldorfer Str. 1-7, 60329, Frankfurt am Main, Germany
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6
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Son H, Lee BH, Cho YM. Theragnostic utility of continuous glucose monitoring in post-gastrectomy hypoglycemia. J Diabetes Investig 2024. [PMID: 39196672 DOI: 10.1111/jdi.14299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/02/2024] [Accepted: 08/12/2024] [Indexed: 08/30/2024] Open
Abstract
Diagnosing post-gastrectomy hypoglycemia is challenging, often relying on medical history with documented low plasma glucose levels. Here, we present three cases of patients who presented a high probability of post-gastrectomy hypoglycemia diagnosed and managed successfully using "theragnostic" continuous glucose monitoring and alpha-glucosidase inhibitors. In the first week, patients maintained their current lifestyle without medical intervention; in the second week, voglibose 0.2 mg before meals was prescribed. Continuous glucose monitoring data from the first week confirmed the diagnosis with multiple hypoglycemic events after postprandial peaks, whereas data from the second week showed reduced hypoglycemic events and lower glycemic variability, demonstrating voglibose's therapeutic effect. This report highlights the effective management of post-gastrectomy hypoglycemia using voglibose and theragnostic continuous glucose monitoring, showing its potential benefits and safety for similar cases.
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Affiliation(s)
- Heejun Son
- Division of Endocrinology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Bon Hyang Lee
- Division of Endocrinology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Min Cho
- Division of Endocrinology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Momenzadeh A, Cranney C, Choi SY, Bresee C, Tighiouart M, Gianchandani R, Pevnick J, Moore JH, Meyer JG. Medications that Regulate Gastrointestinal Transit Influence Inpatient Blood Glucose. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.31.24311287. [PMID: 39132476 PMCID: PMC11312652 DOI: 10.1101/2024.07.31.24311287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Objective A multitude of factors affect a hospitalized individual's blood glucose (BG), making BG difficult to predict and manage. Beyond medications well established to alter BG, such as beta-blockers, there are likely many medications with undiscovered effects on BG variability. Identification of these medications and the strength and timing of these relationships has potential to improve glycemic management and patient safety. Materials and Methods EHR data from 103,871 inpatient encounters over 8 years within a large, urban health system was used to extract over 500 medications, laboratory measurements, and clinical predictors of BG. Feature selection was performed using an optimized Lasso model with repeated 5-fold cross-validation on the 80% training set, followed by a linear mixed regression model to evaluate statistical significance. Significant medication predictors were then evaluated for novelty against a comprehensive adverse drug event database. Results We found 29 statistically significant features associated with BG; 24 were medications including 10 medications not previously documented to alter BG. The remaining five factors were Black/African American race, history of type 2 diabetes mellitus, prior BG (mean and last) and creatinine. Discussion The unexpected medications, including several agents involved in gastrointestinal motility, found to affect BG were supported by available studies. This study may bring to light medications to use with caution in individuals with hyper- or hypoglycemia. Further investigation of these potential candidates is needed to enhance clinical utility of these findings. Conclusion This study uniquely identifies medications involved in gastrointestinal transit to be predictors of BG that may not well established and recognized in clinical practice.
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Affiliation(s)
- Amanda Momenzadeh
- Department of Computational Biomedicine; Cedars-Sinai; Los Angeles, CA USA
| | - Caleb Cranney
- Department of Computational Biomedicine; Cedars-Sinai; Los Angeles, CA
| | - So Yung Choi
- Biostatistics Shared Resource; Cedars-Sinai; Los Angeles, CA
| | | | | | - Roma Gianchandani
- Division of Endocrinology, Diabetes & Metabolism; Cedars-Sinai; Los Angeles, CA
| | - Joshua Pevnick
- Division of General Internal Medicine; Cedars-Sinai; Los Angeles, CA
| | - Jason H Moore
- Department of Computational Biomedicine; Cedars-Sinai; Los Angeles, CA
| | - Jesse G Meyer
- Department of Computational Biomedicine; Cedars-Sinai; Los Angeles, CA
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8
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Stanley CA, De Leon DD. Etiology of the Neonatal Hypoglycemias. Adv Pediatr 2024; 71:119-134. [PMID: 38944478 DOI: 10.1016/j.yapd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
To provide a more appropriate foundation for dealing with the problem of hypoglycemia in newborn infants, this article focuses on the mechanisms which underlie the various forms of neonatal hypoglycemia and discusses their implications for newborn care. Evidence indicates that all of the major forms of neonatal hypoglycemia are the result of hyperinsulinism due to dysregulation of pancreatic islet insulin secretion. Based on these observations, the authors propose that routine measurement of B-hydroxybutyrate should be considered an essential part of glucose monitoring in newborn infants.
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Affiliation(s)
- Charles A Stanley
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diva D De Leon
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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9
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Taweerutchana V, Choksakunwong S, Lerwattrakarn A, Chalermwai WV, Intralawan T, Lertwattanarak R. Pioneering robotic-assisted surgery for insulinoma during pregnancy: The first case report and literature review. Heliyon 2024; 10:e34239. [PMID: 39100462 PMCID: PMC11296031 DOI: 10.1016/j.heliyon.2024.e34239] [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: 04/10/2024] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Insulinoma during pregnancy is a rare condition with vague clinical symptoms, making diagnosis challenging. The standard treatment for insulinoma is surgical tumor removal, preferably using a minimally invasive method. However, there have been no recorded examples of employing a robotic platform in pregnant women with insulinoma. In this report, we present the first successful case of robotic enucleation for insulinoma during pregnancy. Case presentation A 30-year-old pregnant woman presented with recurrent hypoglycemic symptoms throughout her first trimester that were relieved by food intake. After confirming endogenous hyperinsulinemia, an abdominal magnetic resonance imaging scan was performed to locate the tumor. A well-defined 2-cm mass was found in the pancreatic body. Robotic enucleation was performed at week 18 of gestation, and the patient experienced relief from hypoglycemic episodes postoperatively. Her blood glucose levels returned to normal, and she had an uneventful pregnancy. The patient eventually delivered a healthy baby via cesarean section without any complications. Conclusions For a subset of pregnant individuals with insulinoma, a minimally invasive approach as robotic-assisted surgery is safe and feasible. This innovative technique has the potential to both mothers and fetuses.
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Affiliation(s)
- Voraboot Taweerutchana
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sawaraj Choksakunwong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Diabetes, Thyroid, and Endocrine Clinic, Siriraj Piyamaharajkarun Hospital, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Amornrat Lerwattrakarn
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wipapat Vicki Chalermwai
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thita Intralawan
- Minimally Invasive Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Raweewan Lertwattanarak
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Nouira S, Bayar I, Hajji E, Hela M, Khochteli I. Neoadjuvant Imatinib Therapy for Gastrointestinal Stromal Tumors Associated With Non-islet Cell Tumor Hypoglycemia (NICTH): A Case Report. Cureus 2024; 16:e65903. [PMID: 39219869 PMCID: PMC11364915 DOI: 10.7759/cureus.65903] [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] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome characterized by insulin-like growth factor-2 (IGF-2) release, often associated with diverse tumor types. Gastrointestinal stromal tumors (GISTs), sarcomatous lesions of the gastrointestinal tract, are rarely associated with NICTH. We present a unique case of a 58-year-old patient diagnosed with a GIST exhibiting recurrent hypoglycemia suggestive of NICTH. Despite normal IGF-2 levels, the IGF-2/IGF-1 ratio supported the NICTH diagnosis, which was confirmed histologically. Imaging revealed a large intraperitoneal mass. Hypoglycemia was managed with high-dose dextrose and hydrocortisone. Treatment with the tyrosine kinase inhibitor, imatinib, was initiated. Surprisingly, imatinib not only reduced the tumor size but also improved hypoglycemia. The study highlights the complexities in managing NICTH and its underlying causes. Current diagnostic limitations, treatment modalities, and unexpected therapeutic responses challenge standard approaches. This emphasizes the need for personalized oncological strategies.
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Affiliation(s)
- Sawsen Nouira
- Endocrinology and Diabetes, Farhat Hached Hospital, Sousse, TUN
| | - Ines Bayar
- Endocrinology, Faculty of Medicine, Fattouma Bourguiba University Hospital of Monastir, Monastir, TUN
| | - Ekram Hajji
- Endocrinology, Faculty of Medicine, Fattouma Bourguiba University Hospital of Monastir, Monastir, TUN
| | - Marmouch Hela
- Endocrinology, Faculty of Medicine, Fattouma Bourguiba University Hospital of Monastir, Monastir, TUN
| | - Ines Khochteli
- Endocrinology, Faculty of Medicine, Fattouma Bourguiba University Hospital of Monastir, Monastir, TUN
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11
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Nakamura T, Asanuma K, Hagi T, Sudo A. Artifactual hypoglycaemia may be common in patients with soft tissue sarcoma who received pegfilgrastim-supported chemotherapy. J Orthop Sci 2024; 29:1108-1111. [PMID: 37271674 DOI: 10.1016/j.jos.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Recently, we identified artifactual hypoglycemia in patients with soft tissue sarcoma (STS) who received pegfilgrastim-supported chemotherapy. In the present study, we measured white blood cell count and fasting blood glucose levels after the administration of pegfilgrastim in patients with STS and showed the relationship between artifactual hypoglycemia and white blood cell count. PATIENTS A total of 19 patients were included in this study. The mean age of the patients was 54 years. They received chemotherapy and administration of pegfilgrastim. Pegfilgrastim was injected subcutaneously 48 h after chemotherapy. No patient had a history of diabetes mellitus. RESULTS Fifty-nine cycles were administered to 19 patients. One hundred and twenty-eight samples were obtained within one week after the of pegfilgrastim administration. Hypoglycemia was observed in 38 of the 13 patients. There were no symptoms of hypoglycemia in any patient. The white blood cell count in samples from patients with hypoglycemia was significantly higher than that in samples without hypoglycemia (p < 0.001). The median white blood cell count in samples with hypoglycemia was 29,415 and 3420 in samples without hypoglycemia. Age, sex, body mass index, performance status, and red blood cell count were not associated with hypoglycemia. White blood cell count was strongly negatively correlated with fasting blood glucose levels (Pearson's r: 0.786, 95% confidence interval: 0.844-0.709, p < 0.001). Of the 38 samples with hypoglycemia, 32 were measured within 2 days after pegfilgrastim administration. CONCLUSION If a lack of symptoms due to hypoglycemia and leukocytes is confirmed, physicians should wait and identify the normalization of the level of glucose according to the neutrophil nadir following temporal leukocytes, which prevents further invasive examination for hypoglycemia.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan.
| | - Kunihiro Asanuma
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan
| | - Tomohito Hagi
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan
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12
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Mikovic N, Mazzilli R, Zamponi V, Russo F, Mancini C, Mori F, Bollanti L, Conti F, Motta C, Monti S, Pugliese G, Faggiano A. Short fasting test as a reliable and effective tool to diagnose insulinoma. Endocrine 2024; 84:1258-1263. [PMID: 38451386 PMCID: PMC11208248 DOI: 10.1007/s12020-024-03759-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE The diagnosis of insulinoma can be challenging, requiring documentation of hypoglycaemia associated with non-suppressed insulin and C-peptide, often achieved during a prolonged 72 h fast performed in inpatient setting. Our goal is to predict weather a shorter outpatient fasting test initiated overnight and prolonged up until 24 h could be a sensitive method for diagnosing insulinoma. METHODS We conducted a retrospective monocentric study on subjects admitted to our Unit of Endocrinology from 2019 to 2022 for clinical suspicion of insulinoma and underwent the short fasting test. A comparison between the short test group and the group of subjects who underwent the standard prolonged fasting test (from 2003 to 2018) has also been performed. The short fasting test was initiated by the patient overnight at home and proceeded the following day in outpatient setting (Day Hospital). As in the standard protocol, symptoms and capillary blood glucose (CBG) were strictly monitored. Venous blood was drawn for glycaemia, insulin and C-peptide at admission and at established intervals, in case of symptoms of hypoglycaemia or if CBG ≤ 45 mg/dl, when the fast would be suspended. RESULTS The final sample consisted of 37 patients, with mean age of 44.5 ± 12.6 years (17-74). Short and standard tests were performed in 15 and 22 subjects, respectively. Diagnostic values for insulinoma were observed in 12 patients: in 5/15 who underwent the short fasting test, in 6/22 who underwent the prolonged test and in 1 patient who was initially negative on the short test and subsequently showed diagnostic values during the prolonged test. The diagnosis of insulinoma was achieved in 11/12 cases within 24 h of the beginning of the fast (91.7%). CONCLUSIONS A short fasting test could be a valid, sensitive and reliable first-line workup in diagnosing insulinoma.
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Affiliation(s)
- Nevena Mikovic
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy.
| | - Rossella Mazzilli
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Virginia Zamponi
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Flaminia Russo
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Camilla Mancini
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Fedra Mori
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Lucilla Bollanti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Francesco Conti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Cecilia Motta
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Salvatore Monti
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Giuseppe Pugliese
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
| | - Antongiulio Faggiano
- Unit of Endocrinology, Department of Clinical and Molecular Medicine, ENETS Excellence Center, Sant'Andrea Hospital, "Sapienza" University, Rome, Italy
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13
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Ziamanesh F, Rashidian H, Mohseni S, Behzad G, Ebrahimpur M, Pejman Sani M, Payab M, Fooladgar M, Mohajeri-Tehrani MR, Larijani B. Hypoglycemia in non-diabetic in-patients at a teaching referral hospital in Iran. J Diabetes Metab Disord 2024; 23:759-763. [PMID: 38932802 PMCID: PMC11196425 DOI: 10.1007/s40200-023-01346-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/08/2023] [Indexed: 06/28/2024]
Abstract
Purpose This study aims to investigate comorbidities, clinical features, laboratory values, and diagnoses in non-diabetic patients experiencing hypoglycemic episodes. Methods A retrospective observational study was conducted at Shariati Hospital in Iran from 2016 to 2023. Seventy-four non-diabetic patients admitted with a diagnosis of hypoglycemia were included, while patients with diabetes were excluded. Demographic data, symptoms, and biochemical assessments were obtained from the hospital information system. Hypoglycemic episodes were identified based on low measured blood glucose, recorded medications for hypoglycemia treatment, or recorded codes indicating hypoglycemia. Hypoglycemia was defined as blood glucose below 70 mg/dL (3.9 mmol/L) along with two other criteria of the Whipple triad. Statistical analysis was performed using SPSS software (version 26). Results Among the enrolled patients, 63.5% were female, and 13.5% were elderly (≥ 65 years). The most common comorbidities observed were cardiovascular disease (20.3%), psychological disorders (20.3%), hypothyroidism (14.9%), and hypertension (8.1%). The prevalent symptoms included weakness, loss of consciousness, sweating, palpitations, dizziness, and tremors. Non-diabetic hypoglycemia was caused by factitious disorders, insulinoma, organ failure, and infection, respectively. Conclusion Due to the diverse range of clinical symptoms, hypoglycemia in non-diabetic patients may be diagnosed late, leading to misdiagnoses such as psychological disorders or seizures. It is crucial to consider the possibility of hypoglycemia in non-diabetic patients and determine its underlying cause. Given the poor prognosis associated with hypoglycemia, timely interventions are essential.
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Affiliation(s)
- Fateme Ziamanesh
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Rashidian
- British Columbia Institute of Technology Vancouver, Vancouver, BC Canada
| | - Shahrzad Mohseni
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghazal Behzad
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahbube Ebrahimpur
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Pejman Sani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Moloud Payab
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Milad Fooladgar
- Fellowship, Department of Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Mohajeri-Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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14
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Metwalley KA, Farghaly HS. Idiopathic ketotic hypoglycemia in children: an update. Ann Pediatr Endocrinol Metab 2024; 29:152-155. [PMID: 38291759 PMCID: PMC11220389 DOI: 10.6065/apem.2346156.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/06/2023] [Accepted: 10/04/2023] [Indexed: 02/01/2024] Open
Abstract
Idiopathic ketotic hypoglycemia (IKH) is defined as bouts of hypoglycemia with increased blood or urine ketones in certain children after prolonged fasting or during illness. IKH is divided into physiological IKH, which is most frequently observed in normal children with intercurrent acute illness, and pathological IKH, which occurs in children who lack counter-regulatory hormones, have a metabolic disease, or have Silver-Russell syndrome. The typical patient is a young child between the ages of 10 months and 6 years. Episodes nearly always occur in the morning after overnight fasting. Symptoms include those of neuroglycopenia, ketosis, or both. IKH may be diagnosed after ruling out various metabolic and hormonal conditions associated with ketotic hypoglycemia. Sufficient amounts of carbohydrates and protein, avoidance of prolonged fasting, and increased frequency of food ingestion are the main modes of treating IKH. It is crucial to understand the pathogenesis of IKH and to distinguish physiological IKH from pathological IKH. In this mini-review, we present a brief summary of IKH in terms of its definition, types, clinical presentation, diagnosis, and therapeutic approach in children.
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Affiliation(s)
| | - Hekma Saad Farghaly
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
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15
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Mohammed SR, Mack N, Ramoutar V, Rampersad J. Recurrent Hypoglycemia in a Non-diabetic Female: A Case Study on Doege-Potter Syndrome. Cureus 2024; 16:e63329. [PMID: 39077286 PMCID: PMC11283929 DOI: 10.7759/cureus.63329] [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] [Accepted: 06/27/2024] [Indexed: 07/31/2024] Open
Abstract
Solitary fibrous tumors (SFT) are mesenchymal cell tumors that may arise from any site throughout the body. A small percentage of patients with SFT develop non-islet cell tumor-induced hypoglycemia (NICTH), eponymously termed Doege-Potter Syndrome (DPS). DPS is characterized by severe, refractory hypoinsulinemic hypoglycemia. Diagnosis of SFT is dependent on histologic findings and immunohistochemistry (IHC). NAB2-STAT6 gene fusions are pathognomonic for SFT but may be difficult to identify in routine cytogenetic studies. STAT6 IHC is a highly sensitive and specific surrogate for the NAB2-STAT6 gene fusion. Total resection of the tumor remains the gold-standard definitive treatment of SFT of the pleura. Palliative tumor debulking is recommended if total resection is not feasible. We here report a case of DPS in a 73-year-old female, managed with palliative care.
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Affiliation(s)
- Saeed R Mohammed
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine Campus, Champs Fleurs, TTO
| | - Narine Mack
- Department of Medicine, San Fernando General Hospital, San Fernando, TTO
| | - Valmikie Ramoutar
- Department of Medicine, San Fernando General Hospital, San Fernando, TTO
| | - Jessica Rampersad
- Department of Medicine, San Fernando General Hospital, San Fernando, TTO
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16
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Doğruel H, Aydemir M, Yılmaz N, Sarı R. An extremely rare case of hypoglycemia with a novel mutation and review of the literature: fructose-1,6 bisphosphatase deficiency in an adult man. Ir J Med Sci 2024; 193:1267-1273. [PMID: 38273074 DOI: 10.1007/s11845-024-03614-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/16/2024] [Indexed: 01/27/2024]
Abstract
Hypoglycemia is an uncommon clinical problem among non-diabetic patients. It requires systematic evaluation to determine the etiology. It may be related to critical illness, hepatic insufficiency, renal insufficiency, cardiac insufficiency, drugs, alcohol, cortisol insufficiency, growth hormone insufficiency, insulinoma, gastric bypass surgery, and paraneoplastic (insulin-like growth factor-2-related) immune-mediated or inherited metabolic disorders. We aimed to summarize the literature and present a case who suffered from hypoglycemia throughout his life and was diagnosed with fructose-1, 6 bisphosphatase deficiency in adulthood to attract attention to the rare causes of hypoglycemia in adulthood.
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Affiliation(s)
- Hakan Doğruel
- Endocrinology and Metabolism, Antalya City Hospital, Antalya, 07080, Turkey
| | - Mustafa Aydemir
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Nusret Yılmaz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey.
| | - Ramazan Sarı
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
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Kaketaka T, Mineo I, Kimura Y, Ito N, Okauchi Y, Tamura H, Adachi S, Iwahashi H. Insulinoma with Hyperprocalcitoninemia and Hypercalcitoninemia Showing Coexpression of Insulin and Calcitonin in Its Tumor Cells. Intern Med 2024; 63:1415-1420. [PMID: 37839887 PMCID: PMC11157324 DOI: 10.2169/internalmedicine.1565-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 08/28/2023] [Indexed: 10/17/2023] Open
Abstract
Neuroendocrine neoplasms can produce multiple hormones that are released into the bloodstream, causing symptoms that vary depending on the type and quantity of hormones involved. We herein report a 63-year-old asymptomatic patient with pancreatic insulinoma who showed marked elevations in circulating calcitonin and procalcitonin levels that returned to normal following surgery. Immunohistochemical analyses confirmed the co-staining of calcitonin and insulin immunoreactivity in the tumor cells, suggesting a calcitonin-producing insulinoma. This insulinoma released calcitonin and a considerable amount of its precursor peptide, procalcitonin, resulting in both hyperprocalcitoninemia and hypercalcitoninemia.
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Affiliation(s)
| | - Ikuo Mineo
- Diabetes Center, Toyonaka Municipal Hospital, Japan
| | - Yu Kimura
- Diabetes Center, Toyonaka Municipal Hospital, Japan
| | - Naohiko Ito
- Diabetes Center, Toyonaka Municipal Hospital, Japan
| | | | - Hiromi Tamura
- Department of Pathology, Toyonaka Municipal Hospital, Japan
| | - Shiro Adachi
- Department of Pathology, Toyonaka Municipal Hospital, Japan
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18
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Batra CM, Jain S, Kumar KP, Goyal M, Kachroo V, Takkar S, Yadav R. Spontaneous Hypoglycaemia due to Insulin Autoimmune Syndrome in Six Cases, Response to Steroid Therapy and Rituximab. Indian J Endocrinol Metab 2024; 28:295-301. [PMID: 39086578 PMCID: PMC11288520 DOI: 10.4103/ijem.ijem_378_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Dr. Hirata of Japan first described insulin autoimmune syndrome (IAS) in 1970. Seven hundred ninety-five cases of this rare syndrome have been reported from Japan and China and 29 from India. IAS has the following characteristic features 1) severe spontaneous attacks of hyperinsulinemic hypoglycaemia, 2) high total immunoreactive insulin levels, 3) elevated insulin autoantibody (IAA) titres, 4) no prior exposure to exogenous insulin, and 5) no pathological abnormalities of the pancreatic islet cells. Methods We treated six cases of IAS with high doses of prednisolone for 4-6 weeks and then gradually reduced the doses. Diagnosis of IAS was established by documenting Whipple's triad of symptoms and signs of hypoglycaemia, blood sugar <55 mg/dl, improvement of symptoms with dextrose infusion, inappropriately increased insulin levels >3 uU/ml, C-peptide levels >0.6 ng/ml, and increased titres of anti-insulin autoantibodies. Insulinoma and non-pancreatic tumours were ruled out by CECT (contrast-enhanced computerised tomography) or MRI (magnetic resonance imaging) of the abdomen and if necessary endoscopic ultrasonography and gallium 68 Dotanoc PET (positron enhanced tomography). Autoimmune screening and serum electrophoresis were done to rule out multiple myeloma. Monitoring of the patient's blood sugars was done by the laboratory, glucometer readings, and a freestyle libre glucose monitoring system. Results Remission of hypoglycaemic episodes, hyperglycaemic episodes, and marked reduction of serum insulin and insulin autoantibodies in four out of six patients with diet therapy and steroids. Two patients resistant to steroids were treated with rituximab successfully. Patient 6 developed serious complications of cytomegalovirus and Pneumocystis carnii after rituximab, which were treated successfully. Conclusion A careful history including recent infections, medications, and vaccinations provides vital clues in the evaluation. An increased awareness of IAS will prevent unnecessary and costly investigations and surgery. Although it is often self-remitting, steroids are contributory in severe cases. Immunosuppressives are used successfully in cases refractory to steroids. Continuous glucose monitoring system (CGMS), by freestyle libre glucose monitoring system, provided real-time blood sugar values, total time in hypoglycaemia, and total time in the range (TIR), which proved very valuable in managing IAS patients. Low CGMS values should be corroborated clinically and with laboratory or glucometer values.
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Affiliation(s)
- Chandar M. Batra
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Savita Jain
- Endocrinology Deep Hospital, Ludhiana, Punjab, India
| | - Kiran P. Kumar
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Monika Goyal
- Department of Endocrinology, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Varsha Kachroo
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Simran Takkar
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
| | - Rini Yadav
- Department of Endocrinology, Indraprastha Apollo Hospital, New Delhi, India
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19
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Shetty AJ, Das L, Jayant SS, Bhadada SK, Kumar R, Gulati A, Rana SS, Singh H, Saikia UN, Behera A, Mittal BR, Walia R, Dutta P. Diagnostic Modalities, Management Considerations, and Outcomes of Insulinoma: A Case Series from a Tertiary Care Centre. Indian J Endocrinol Metab 2024; 28:279-288. [PMID: 39086573 PMCID: PMC11288522 DOI: 10.4103/ijem.ijem_359_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/28/2024] [Accepted: 05/09/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Insulinomas are rare, usually sporadic, and typically benign pancreatic neuroendocrine tumours. Pre-operative localization is challenging and evidence on comparative analysis of anatomic and scintigraphic modalities for pre-operative tumour localization is limited, even in contemporary series. Methods The current study was designed to study the clinical features and management challenges of insulinomas managed at a tertiary care centre. Clinical features, diagnosis, imaging techniques, surgical procedures, and outcomes details were collated. Pre-operative imaging techniques (CT/MRI, nuclear scintigraphy) were compared with intraoperative and histopathological findings to assess their accuracy of localization. Results Thirty-seven patients (15 females [42%]; median age 36 years [IQR 28-49]) were included in the study. In four patients (10.8%), the tumour occurred in the setting of multiple endocrine neoplasia type 1 (MEN 1) while the remaining were sporadic. The sensitivity of pre-operative localization was 61.5% (multiphasic CT), 66.6% (multiphasic MRI), 100% (68Ga Exendin-4 PET-CT), and 91.6% (EUS). Three patients with normal multiphasic CT had localization on 68Ga Exendin-4 PET-CT. The positive predictive value (PPV) of both Exendin-PET-CT and EUS was similar at 91.6% and 91.6%, respectively. All patients (except one with nesidioblastosis), who underwent enucleation or partial pancreatic resection, were cured. Conclusion 68Ga Exendin-4 PET-CT based is a non-invasive imaging modality that has high sensitivity and PPV and can be used as a first-line imaging modality. The overall prognosis of these tumours is good with high cure rates attained following surgical resection.
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Affiliation(s)
- Anirudh J. Shetty
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Liza Das
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Satyam S. Jayant
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sanjay K. Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ajay Gulati
- Department of Radiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S. Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harmandeep Singh
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Uma N. Saikia
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunanshu Behera
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Bhagwant R. Mittal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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20
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Alshaakh Mohd Mari A, Sidhu A, Matos M, Kinaan M. A Rare Case of Insulin-Like Growth Factor (IGF-2) Induced Hypoglycemia Associated With Metastatic Colon Cancer. Cureus 2024; 16:e60211. [PMID: 38868260 PMCID: PMC11168588 DOI: 10.7759/cureus.60211] [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] [Accepted: 05/03/2024] [Indexed: 06/14/2024] Open
Abstract
The occurrence of hypoglycemia in patients without diabetes is rare, and non-islet cell tumor hypoglycemia (NICTH) accounts for a small portion of these instances. One of the infrequent causes is associated with tumor cell production of Insulin-like growth factor (IGF)-2. Here is a case of a 66-year-old man with stage IV colon cancer who presented to the emergency department with breathlessness during chemotherapy (Bevacizumab plus FOLFOX4 regimen). He had undergone partial colectomy and chemotherapy three years prior but was recently diagnosed with metastatic liver disease. A CT scan revealed a 15 cm hepatic mass occupying the entire right hepatic lobe. Despite receiving dextrose infusions, he experienced persistent hypoglycemia after meals and during fasting. Given that he had no history of diabetes and denied using any oral hypoglycemic agents, the Endocrinology service was consulted for further evaluation. Plasma blood glucose (BG) was measured at 74 mg/dL (reference range 74-106) during dextrose administration. An 8 AM cortisol test yielded a result of 8.08 mcg/dL (4.30-22.40), ruling out adrenal insufficiency. A 72-hour fast was initiated but terminated at eight hours due to symptomatic hypoglycemia with a plasma BG of 48 mg/dL. C-peptide and Insulin levels were both low, measuring <0.05 ng/mL (0.48-5.05) and <1.0 mU/L (3.0-25), respectively, while beta-hydroxybutyrate (BHB) levels were normal at 1.1 mg/dL (0.2-2.8). Administration of 1 mg glucagon during the fast increased BG to 112 mg/dL within 2 hours. IGF-1 levels were undetectable (<1.9 nmol/L), while IGF-2 levels were at 23 nmol/L (44-129 nmol/L), resulting in an IGF2:IGF1 ratio of 12 (>10), confirming IGF-2 mediated NICTH. Treatment with dexamethasone 10 mg daily was initiated, maintaining blood glucose levels above 70 mg/dL without dextrose infusion. In approximately 50% of cases of NICTH, the tumor is detected before the onset of hypoglycemia, yet up to half the patients may remain asymptomatic despite having very low BG. Despite having a known hepatic lesion, our patient exhibited minimal symptoms despite severely low BG levels. The mechanisms underlying NICTH may involve tumor secretion of insulin, replacement of hepatic tissue, increased glucose utilization by the tumor, or, most commonly, secretion of IGF-2. In cases of IGF-2-mediated hypoglycemia, insulin, proinsulin, C-peptide, and β-hydroxybutyrate levels are typically low. IGF-2 stimulates the insulin receptors resulting in increased glucose uptake by skeletal muscles and suppression of gluconeogenesis, glycogenolysis, and ketogenesis by the liver. Insulin secretion from pancreatic β-cells is suppressed. IGF-1 levels are usually low, while IGF-2 levels may be high or normal, as many IGF-2omas produce IGF-2 precursors (pro-IGF-2). An elevated IGF-2:IGF-1 ratio (>10) confirms the diagnosis which may be helpful when IGF-2 levels are normal. The primary treatment is through surgical removal or debulking of the tumor. Neoadjuvant therapies such as radiation and chemotherapy may reduce occurrences of hypoglycemia, but only temporarily. Glucocorticoids may be used when the underlying malignancy cannot be treated.
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Affiliation(s)
| | - Ashlee Sidhu
- Internal Medicine, HCA University of Central Florida (UCF), Florida, USA
| | - Moises Matos
- Endocrinology, Diabetes, and Metabolism, University of Central Florida/HCA Healthcare/Orlando VA Medical Center, Orlando, USA
| | - Mustafa Kinaan
- Endocrinology, HCA Florida Osceola Hospital, Kissimmee, USA
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21
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Goel Y, Kurlekar U, Chitharanjan A, Beke AN. Insulinoma Unmasked Post Sleeve Gastrectomy With Incidental Renal Cell Carcinoma: A Rare Case. Cureus 2024; 16:e60395. [PMID: 38883112 PMCID: PMC11179045 DOI: 10.7759/cureus.60395] [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] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Insulinoma is a functional pancreatic neuroendocrine tumor (pNET). Usually benign and solitary, these tumors present with recurrent episodes of hypoglycemia due to insulin hypersecretion. It's a rare cause of post bariatric surgery hypoglycemia and hence poses a diagnostic challenge. Here, we report the first case of a 53-year-old male with insulinoma unmasked post sleeve gastrectomy with incidental renal cell carcinoma (RCC). He presented with symptoms of Whipple's triad after two months of sleeve gastrectomy done for morbid obesity. On further inquiry, the patient gave a history of an asymptomatic peripancreatic neuroendocrine tumor (NET) for the past 11 years. With a suspicion of insulinoma, biochemical workup followed by non-invasive imaging like GA-68 DOTA and CT triphasic abdomen scan was done to guide the diagnosis of an insulinoma which also detected a second primary tumor in the right kidney, likely to be a malignant RCC. Following pancreatic mass excision with radical nephrectomy for right renal mass, histopathology (HPE) and immunohistochemistry (IHC) confirmed the diagnosis of an insulinoma and a right renal clear cell carcinoma. The patient was discharged with no further episodes of hypoglycemia. Hence, persistent hypoglycemia post bariatric surgery could be an indication of a hidden insulinoma and this possibility of synchronous tumors should be kept in mind when dealing with rare tumors like insulinoma.
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Affiliation(s)
- Yashika Goel
- Department of General Surgery, Deenanath Mangeshkar Hospital and Research Center, Pune, IND
| | - Utkrant Kurlekar
- Department of General Surgery, Bariatric Surgery, and Surgical Oncology, Deenanath Mangeshkar Hospital and Research Center, Pune, IND
| | - Ashish Chitharanjan
- Department of General Surgery, Deenanath Mangeshkar Hospital and Research Center, Pune, IND
| | - Amruta N Beke
- Department of Surgical Oncology, Deenanath Mangeshkar Hospital and Research Center, Pune, IND
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22
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Modestino MR, Iacono O, Ferrentino L, Lombardi A, De Fortuna U, Verdoliva R, De Luca M, Guardasole V. How should we differentiate hypoglycaemia in non-diabetic patients? J Basic Clin Physiol Pharmacol 2024; 35:111-119. [PMID: 38619602 DOI: 10.1515/jbcpp-2024-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/10/2024] [Indexed: 04/16/2024]
Abstract
Hypoglycaemic syndromes are rare in apparently healthy individuals and their diagnosis can be a difficult challenge for clinicians as there are no shared guidelines that suggest how to approach patients with a suspect hypoglycaemic disorder. Since hypoglycaemia symptoms are common and nonspecific, it's necessary to document the Whipple Triad (signs and/or symptoms compatible with hypoglycaemia; relief of symptoms following glucose administration; low plasma glucose levels) before starting any procedure. Once the triad is documented, a meticulous anamnesis and laboratory tests (blood glucose, insulin, proinsulin, C-peptide, β-hydroxybutyrate and anti-insulin antibodies) should be performed. Results can guide the physician towards further specific tests, concerning the suspected disease. In this review, we consider all current causes of hypoglycaemia, including rare diseases such as nesidioblastosis and Hirata's syndrome, describe appropriate tests for diagnosis and suggest strategies to differentiate hypoglycaemia aetiology.
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Affiliation(s)
- Michele R Modestino
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Olimpia Iacono
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Laura Ferrentino
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Anna Lombardi
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Umberto De Fortuna
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Rita Verdoliva
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Mariarosaria De Luca
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
| | - Vincenzo Guardasole
- Department of Translational Medical Sciences, 165474 Federico II University Hospital , Napoli, Italy
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23
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Kanazawa K, Hijikata M, Koga S, Kuwabara K. Impact of Glucocorticoid Replacement Therapy on Nocturnal Hypoglycemia in Adrenal Insufficiency: An Analysis of Multiple Case Studies. Cureus 2024; 16:e61456. [PMID: 38947638 PMCID: PMC11214865 DOI: 10.7759/cureus.61456] [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] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND AND AIM Adrenal insufficiency (AI) is a hormonal disorder characterized by insufficient glucocorticoid production. Nocturnal hypoglycemia (NH) occurs in patients with AI. However, the effect of glucocorticoid replacement therapy (GCRT) on AI and NH remains unclear. This study aimed to investigate the relationship between AI and NH by evaluating the impact of GCRT on NH in patients newly diagnosed with AI. METHODS The present study was conducted between October 2018 and December 2022 at the Department of Diabetes, Metabolism and Endocrinology of the Tokyo Rosai Hospital, Japan. In total, 15 patients aged ≥18 years with newly diagnosed AI or NH were included in this study. The NH frequency was measured using continuous glucose monitoring (CGM). The primary outcome was the change in NH frequency before and after the GCRT intervention. RESULTS GCRT significantly decreased NH frequency. Severe NH frequency and minimum nocturnal glucose levels changed significantly while fasting blood glucose and glycated hemoglobin levels did not change significantly. GCRT intervention improved CGM profiles' time below range, time in range, and average daily risk range. CONCLUSIONS The present study suggests that GCRT can help newly diagnosed patients with AI manage NH. These findings show that CGM can detect NH in patients with newly diagnosed AI, determine the optimal GCRT dosage, and hence prevent an impaired quality of life and even serious adverse effects in these patients. Further large multicenter studies should validate these findings and delve deeper into the mechanistic link between AI and NH.
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Affiliation(s)
- Ken Kanazawa
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Mai Hijikata
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Shinichiro Koga
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
| | - Koichiro Kuwabara
- Department of Diabetes, Metabolism, and Endocrinology, Japan Labor Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, JPN
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Kartik A, Armstrong VL, Stucky CC, Wasif N, Fong ZV. Contemporary Approaches to the Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2024; 16:1501. [PMID: 38672582 PMCID: PMC11048062 DOI: 10.3390/cancers16081501] [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: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The incidence of pancreatic neuroendocrine tumors (PNETs) is on the rise primarily due to the increasing use of cross-sectional imaging. Most of these incidentally detected lesions are non-functional PNETs with a small proportion of lesions being hormone-secreting, functional neoplasms. With recent advances in surgical approaches and systemic therapies, the management of PNETs have undergone a paradigm shift towards a more individualized approach. In this manuscript, we review the histologic classification and diagnostic approaches to both functional and non-functional PNETs. Additionally, we detail multidisciplinary approaches and surgical considerations tailored to the tumor's biology, location, and functionality based on recent evidence. We also discuss the complexities of metastatic disease, exploring liver-directed therapies and the evolving landscape of minimally invasive surgical techniques.
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Affiliation(s)
| | | | | | | | - Zhi Ven Fong
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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25
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Zacharia GS, Jacob A, Bose BM. Schmidt's Syndrome: An Uncommon Cause of Spontaneous Hypoglycemia. Avicenna J Med 2024; 14:130-133. [PMID: 38957156 PMCID: PMC11216804 DOI: 10.1055/s-0044-1779745] [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] [Indexed: 07/04/2024] Open
Abstract
Schmidt's syndrome, or autoimmune polyendocrine syndrome type 2 (APS-2), is an uncommon disorder characterized by the co-occurrence of autoimmune thyroiditis and adrenalitis. APS-2 is defined as a combination of Addison's disease, autoimmune thyroid disease, and/or type 1 diabetes mellitus. It is an autosomal dominantly inherited polygenic disorder with incomplete penetrance; the candidate genes include but are not limited to HLA-DR3, HLA-DR4, CTLA-4, PTPN22, and CD25-IL-2. Autoimmune thyroiditis, often Hashimoto's disease, results in hypothyroidism. Primary adrenal failure results in enhanced secretion of adrenocorticotrophic hormone melanocyte and co-secretion of melanocyte-stimulating hormone, contributing to hyperpigmentation. Mineralocorticoid deficiency results in salt wasting, fatigue and cramps, postural hypotension, and hyperkalemia. Cortisol, an insulin counter-regulatory hormone, plays a pivotal role in maintaining euglycemia; deficiency predisposes to the development of hypoglycemia. We here report a rare presentation of Schmidt's syndrome as hypoinsulinemic hypoglycemia in a middle-aged male patient. Management includes treatment of acute hypoglycemic episodes with glucose or glucagon, long-term glucocorticoids and mineralocorticoids for adrenal insufficiency, and thyroid hormone supplements for hypothyroidism. This case report and brief overview aim to contribute to the scientific understanding of Schmidt's syndrome/APS-2. Additionally, here we briefly outline the diagnostic challenges in hypoglycemia evaluation, including the utilization of Whipple's triad and the gold standard supervised 72-hour fast and evaluation for primary adrenal and thyroid insufficiencies.
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Affiliation(s)
- George Sarin Zacharia
- Department of Internal Medicine & Gastroenterology, Ahalia Hospital, Mussafah, Abu Dhabi, United Arab Emirates
| | - Anu Jacob
- Department of Anaesthesiology, Ahalia Hospital, Mussafah, Abu Dhabi, United Arab Emirates
| | - Binu Mary Bose
- Department of Pathology, Malankara Orthodox Syrian Church Medical College, Ernakulum, Kerala, India
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26
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Edem D, Maradana J, Majety P, Antony MA, Menon L. Persistent Insulin Autoimmune Syndrome in a Caucasian Male in the Absence of Triggers. Cureus 2024; 16:e58270. [PMID: 38623323 PMCID: PMC11016734 DOI: 10.7759/cureus.58270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 04/17/2024] Open
Abstract
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare condition presenting as recurrent hypoglycemia, and associated with elevated insulin levels in the presence of insulin autoantibodies (IAAs) in patients who were never exposed to exogenous insulin and with no evidence of pancreatic abnormalities. IAS is much more frequent in East Asians, especially the Japanese population, compared to the lower incidence in Caucasians. However, it can be associated with other autoimmune diseases or drug use like methimazole and alpha-lipoic acid (ALA). We report a case of a 47-year-old Caucasian male presenting with a 12-month history of worsening episodes of fasting and post-prandial hypoglycemia associated with symptoms of dizziness, tremors, palpitations, and unconsciousness associated with hypoglycemia. Symptoms resolved with the administration of carbohydrate-containing foods, establishing Whipple's triad. At an outside facility, he had initial labs that showed elevated insulin levels (141 µU/ml) with normal glucose, C-peptide, and proinsulin levels, but there was no availability of an IAA lab assay. Given his symptoms, severity, and frequency of hypoglycemia, he was admitted to the hospital for a 72-hour fast, which showed the lowest glucose level of 64 mg/dl with inappropriately high insulin of 22.2 µU/ml, low C-peptide of 0.57 ng/ml, and undetectable proinsulin of <1.6 pmol/L, but with IAA being >50 U/ml (0.0-0.4 U/ml). He was treated with intensive dietary counseling with a low-carbohydrate diet and prednisone 20 mg twice daily initially. Additionally, he could not tolerate octreotide, diazoxide, and acarbose due to side effects. He is currently on prednisone 10 mg daily and nifedipine with no further hypoglycemic episodes, but still has a high IAA of >50 U/ml and serum insulin levels of 70-112 µU/ml. Our case highlights the importance of recognizing hypoglycemia and checking for IAA levels as first-line diagnostic tests, in the absence of which there could be a delay in diagnosis and leading to unnecessary lab and imaging testing. Our case is unique since it happened in a Caucasian without any prior exposure to a triggering factor and has not undergone self-remission yet, which happens in most of IAS cases.
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Affiliation(s)
- Dinesh Edem
- Endocrinology, Diabetes and Metabolism, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Jhansi Maradana
- Endocrinology, Diabetes and Metabolism, Mass General Brigham Wentworth-Douglas Hospital, Dover, USA
| | - Priyanka Majety
- Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, USA
| | - Mc Anto Antony
- Endocrinology, Diabetes and Metabolism, Medical University of South Carolina, Anderson, USA
| | - Lakshmi Menon
- Endocrinology, Diabetes and Metabolism, University of Arkansas for Medical Sciences, Little Rock, USA
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27
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Kubo H, Sugimoto K, Wada R, Sekikawa N, Inoue M. A Case of Acromegaly With Progressed Diabetic Retinopathy and Sarcopenia Diagnosed Following the Onset of Severe Hypoglycemia. Cureus 2024; 16:e58461. [PMID: 38765413 PMCID: PMC11100447 DOI: 10.7759/cureus.58461] [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] [Accepted: 04/13/2024] [Indexed: 05/22/2024] Open
Abstract
Acromegaly is a rare disorder characterized by excessive production of growth hormone (GH) from a pituitary tumor, typically leading to elevated glucose levels due to increased insulin resistance; hypoglycemia is rare. However, the long-term effect of excess GH on the peripheral organs is still unclear. Here we present a 69-year-old man evaluated for the cause of a hypoglycemic episode. He was underweight (body mass index: 17.3 kg/m2) with sarcopenia, which potentially contributed to his hypoglycemia. Notably, he exhibited progressed proliferative diabetic retinopathy compared to other microvascular complications, leading to further endocrinological investigation. As a result, he was diagnosed with acromegaly showing elevated GH and insulin-like growth factor-1 (IGF-1) with a pituitary tumor. Opting against transsphenoidal surgery (TSS), the patient was treated with a somatostatin analog (SSA), achieving normalized IGF-1 levels with a monthly 120 mg lanreotide injection. In this case, acromegaly could lead to sarcopenia from GH-derived gluconeogenesis in the peripheral organs such as the reduction of muscle leading to reduced glucose reserves. Acromegaly in the elderly may present atypicality. Clinicians should be vigilant for unique manifestations such as advanced diabetic retinopathy, even in elderly patients with hypoglycemia.
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Affiliation(s)
- Haremaru Kubo
- Diabetes Center, Ohta Nishinouchi Hospital, Koriyama, JPN
- Diabetes, Endocrinology, and Metabolism, Kitasato University School of Medicine, Sagamihara, JPN
| | | | - Ryota Wada
- Diabetes Center, Ohta Nishinouchi Hospital, Koriyama, JPN
| | | | - Minoru Inoue
- Internal Medicine, Ohta Nishinouchi Hospital, Koriyama, JPN
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28
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Fujii Y, Harada T, Enomoto K, Nakai M. Hypoglycemia caused by pregabalin-induced insulin hypersecretion. Postgrad Med J 2024; 100:267-268. [PMID: 38160408 DOI: 10.1093/postmj/qgad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/22/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Yoichi Fujii
- Division of General Medicine, Nerima Hikarigaoka Hospital, Tokyo 179-0072, Japan
| | - Taku Harada
- Division of General Medicine, Nerima Hikarigaoka Hospital, Tokyo 179-0072, Japan
- Division of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi 321-0293, Japan
| | - Kiichi Enomoto
- Department of Pharmacy, Nerima Hikarigaoka Hospital, Tokyo 1790-0072, Japan
| | - Mori Nakai
- Division of General Medicine, Nerima Hikarigaoka Hospital, Tokyo 179-0072, Japan
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29
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Hofland J, Refardt JC, Feelders RA, Christ E, de Herder WW. Approach to the Patient: Insulinoma. J Clin Endocrinol Metab 2024; 109:1109-1118. [PMID: 37925662 PMCID: PMC10940262 DOI: 10.1210/clinem/dgad641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Insulinomas are hormone-producing pancreatic neuroendocrine neoplasms with an estimated incidence of 1 to 4 cases per million per year. Extrapancreatic insulinomas are extremely rare. Most insulinomas present with the Whipple triad: (1) symptoms, signs, or both consistent with hypoglycemia; (2) a low plasma glucose measured at the time of the symptoms and signs; and (3) relief of symptoms and signs when the glucose is raised to normal. Nonmetastatic insulinomas are nowadays referred to as "indolent" and metastatic insulinomas as "aggressive." The 5-year survival of patients with an indolent insulinoma has been reported to be 94% to 100%; for patients with an aggressive insulinoma, this amounts to 24% to 67%. Five percent to 10% of insulinomas are associated with the multiple endocrine neoplasia type 1 syndrome. Localization of the insulinoma and exclusion or confirmation of metastatic disease by computed tomography is followed by endoscopic ultrasound or magnetic resonance imaging for indolent, localized insulinomas. Glucagon-like peptide 1 receptor positron emission tomography/computed tomography or positron emission tomography/magnetic resonance imaging is a highly sensitive localization technique for seemingly occult, indolent, localized insulinomas. Supportive measures and somatostatin receptor ligands can be used for to control hypoglycemia. For single solitary insulinomas, curative surgical excision remains the treatment of choice. In aggressive malignant cases, debulking procedures, somatostatin receptor ligands, peptide receptor radionuclide therapy, everolimus, sunitinib, and cytotoxic chemotherapy can be valuable options.
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Affiliation(s)
- Johannes Hofland
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Julie C Refardt
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Richard A Feelders
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
| | - Emanuel Christ
- ENETS Center of Excellence, Division of Endocrinology, Diabetology and Metabolism, University Hospital Basel, CH-4031 Basel, Switzerland
| | - Wouter W de Herder
- ENETS Center of Excellence, Department of Internal Medicine, Section of Endocrinology, Erasmus MC and Erasmus MC Cancer Institute, 3015 GD Rotterdam, The Netherlands
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30
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Quiroz-Aldave JE, Gamarra-Osorio ER, Durand-Vásquez MDC, Rafael-Robles LDP, Gonzáles-Yovera JG, Quispe-Flores MA, Concepción-Urteaga LA, Román-González A, Paz-Ibarra J, Concepción-Zavaleta MJ. From liver to hormones: The endocrine consequences of cirrhosis. World J Gastroenterol 2024; 30:1073-1095. [PMID: 38577191 PMCID: PMC10989500 DOI: 10.3748/wjg.v30.i9.1073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
Hepatocrinology explores the intricate relationship between liver function and the endocrine system. Chronic liver diseases such as liver cirrhosis can cause endocrine disorders due to toxin accumulation and protein synthesis disruption. Despite its importance, assessing endocrine issues in cirrhotic patients is frequently neglected. This article provides a comprehensive review of the epidemiology, pathophysiology, diagnosis, and treatment of endocrine disturbances in liver cirrhosis. The review was conducted using the PubMed/Medline, EMBASE, and Scielo databases, encompassing 172 articles. Liver cirrhosis is associated with endocrine disturbances, including diabetes, hypoglycemia, sarcopenia, thyroid dysfunction, hypogonadotropic hypogonadism, bone disease, adrenal insufficiency, growth hormone dysfunction, and secondary hyperaldosteronism. The optimal tools for diagnosing diabetes and detecting hypoglycemia are the oral glucose tolerance test and continuous glucose monitoring system, respectively. Sarcopenia can be assessed through imaging and functional tests, while other endocrine disorders are evaluated using hormonal assays and imaging studies. Treatment options include metformin, glucagon-like peptide-1 analogs, sodium-glucose co-transporter-2 inhibitors, and insulin, which are effective and safe for diabetes control. Established standards are followed for managing hypoglycemia, and hormone replacement therapy is often necessary for other endocrine dysfunctions. Liver transplantation can address some of these problems.
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Affiliation(s)
| | | | | | | | | | | | | | - Alejandro Román-González
- Department of Endocrinology, Hospital Universitario de San Vicente Fundación, Medellin 050010, Colombia
- Internal Medicine, Universidad de Antioquia, Medellín 050010, Colombia
| | - José Paz-Ibarra
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
- Department of Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Lima 15072, Peru
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31
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Stanley CA, Weston PJ, Harris DL, De León DD, Harding JE. Role of beta-hydroxybutyrate measurement in the evaluation of plasma glucose concentrations in newborn infants. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326865. [PMID: 38429075 PMCID: PMC11366039 DOI: 10.1136/archdischild-2024-326865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/23/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE The Glucose in Well Babies (GLOW) Study showed that there are two phases of low glucose concentrations in healthy newborn infants: an initial phase in which plasma concentrations of ketones are low; and a second phase in which low glucose concentrations are accompanied by elevated concentrations of ketones. The implications of these two phases for the brain differ depending on whether ketones are available as alternative substrate for brain metabolism. The purpose of this study was to estimate the duration of these two phases of neonatal low glucose concentrations in 66 healthy breastfed newborns from the GLOW Study during the first 5 days of life. METHODS The sum of glucose and beta-hydroxybutyrate (BOHB) was used as a proxy for the total concentrations of insulin-dependent fuels for the brain; a threshold value below 4 mmol/L was taken to indicate the presence of relative hyperinsulinism and a BOHB concentration above 0.5 mmol/L to indicate ketonaemia. RESULTS The first phase of low glucose concentrations lasted a median of 40 hours and in 15% of infants, this persisted beyond 60 hours. Fifty (76%) of the 66 infants subsequently had ketonaemia, which resolved at a median age of 76 hours (range 41->120 hours). CONCLUSIONS These data suggest that monitoring BOHB concentrations may be useful for interpreting glucose concentrations in newborns and screening for persistent hyperinsulinism.
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Affiliation(s)
- Charles A Stanley
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip J Weston
- Newborn Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand
| | - Deborah L Harris
- School of Nursing, Midwifery and Health Practice, Faculty of Health, Te Herenga Waka, Victoria University of Wellington, Wellington, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Diva D De León
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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32
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Padarabinda Tripathy K, Pathi D, Kumar Behera P, Das S, Tarun Venkat Mahesh S. An Unusual Case of Hypoglycemia in a Non-diabetic Individual due to Hirata Disease. Cureus 2024; 16:e56297. [PMID: 38629013 PMCID: PMC11018556 DOI: 10.7759/cureus.56297] [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] [Accepted: 03/16/2024] [Indexed: 04/19/2024] Open
Abstract
Hypoglycemia is common in diabetic populations using insulin or insulin secretagogues, but rare in non-diabetics. A 60-year-old non-diabetic male presented with repeated episodes of abnormal behavior persisting for 10-15 minutes for seven days, associated with sweating, intense hunger, and relief on food intake, with no history of insulin or secretagogue intake, with stable vitals and normal systemic examination. Laboratory tests during attacks revealed low blood sugar, high serum insulin, and normal C-peptide levels, with no evidence of pancreatic or extrapancreatic hyperinsulinism, and serum anti-insulin antibody levels >100 U/ml. Based on these results, he was diagnosed with autoimmune insulin syndrome (AIS). Treatment with low-carb meals, oral prednisolone, and acarbose led to the resolution of symptoms. Hirata syndrome, though rare in India, requires consideration as a differential diagnosis to avoid unnecessary invasive procedures.
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Affiliation(s)
| | - Debasis Pathi
- General Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Sambit Das
- Endocrinology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Chen L, Wang N, Xie G, Wang M, Yu Y, Wang H, Fang X. The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial. BMC Anesthesiol 2024; 24:78. [PMID: 38408918 PMCID: PMC10895784 DOI: 10.1186/s12871-024-02457-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/12/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Modern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography. METHODS We conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings. RESULTS The CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients' feelings (P < 0.001). CONCLUSION Preoperative consumption of carbohydrate drinks 2 h before surgery is safe in "healthy" extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice. TRIAL REGISTRATION Chinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.
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Affiliation(s)
- Lingyang Chen
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Nana Wang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Guohao Xie
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Mingcang Wang
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Yulong Yu
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Huiqin Wang
- Department of Anesthesiology, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Xiangming Fang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
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Bódis K, Schön M, Dauben L, Wilker M, Strassburger K, Burkart V, Roden M, Müssig K. Homeostasis Model Assessment of β-Cell Function for Diagnosis of Insulinoma. J Clin Endocrinol Metab 2024; 109:e1125-e1132. [PMID: 37888878 DOI: 10.1210/clinem/dgad618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Indexed: 10/28/2023]
Abstract
CONTEXT Diagnosis of insulinoma is based on different criteria from the 72-hour fasting test according to current guidelines (Endocrine Society [ES], European [ENETS], and North American [NANETS] Neuroendocrine Tumor Societies), including assessment of β-cell function by glucagon stimulation test. OBJECTIVE This study tested whether the homeostasis model assessment of insulin secretion, including assessment of β-cell function, (HOMA-B) at the end of the fasting test provides comparable efficacy for insulinoma diagnosis. METHODS In 104 patients with suspected insulinoma, 72-hour fasting tests were performed with frequent assessment of glucose, insulin, and C-peptide in venous blood. HOMA-B values using insulin and C-peptide were calculated at the end of the fasting test, as defined by the lowest glucose concentration from each participant. RESULTS HOMA-B was more than 6.5-fold higher in patients with (n = 23) than in those without (n = 81) insulinoma (insulin and C-peptide; both P < .001). HOMA-B (cutoff using insulin >253 a.u. and C-peptide >270 a.u.) had a sensitivity of 0.96, 0.78 to 1.00, and a specificity of 0.96 or greater (≥0.89-0.99) for insulinoma diagnosis. ES and ENETS/NANETS criteria reached a diagnostic sensitivity of less than or equal to 0.96 (≤0.78-1.00) and ≤0.83 (≤0.61-0.95) as well as specificity of ≤0.85 (≤0.76-0.92) and less than or equal to 1.00 (≤0.96-1.00) for insulin, and C-peptide, respectively. Using insulin for HOMA-B, sensitivity tended to be higher compared to ENETS/NANETS criteria (P = .063) and specificity was higher compared to ES criteria using insulin and C-peptide (both P < .005). CONCLUSION HOMA-B, as calculated at the end of the fasting test employing defined cutoffs for insulin and C-peptide, provides excellent diagnostic efficacy, suggesting that it might represent an alternative and precise tool to diagnose insulinoma.
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Affiliation(s)
- Kálmán Bódis
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Martin Schön
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Laura Dauben
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Miriam Wilker
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Klaus Strassburger
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Volker Burkart
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Karsten Müssig
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, 85764 München-Neuherberg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- Department of Internal Medicine, Gastroenterology and Diabetology, Niels Stensen Hospitals, Franziskus Hospital Harderberg, 49124 Georgsmarienhütte, Germany
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Cristina García-Ulloa A, Jaime-Casas S, Rosado-Lozoya J, Serrano-Pérez NH, Hernández-Juárez D, Luis Cárdenas-Fragoso J, Eduardo Briones-García L, Jiménez-Soto R, García-Padilla C, García-Lara J, Aguilar-Salinas CA, Hernández-Jiménez S. De-escalating treatment indications for patients who achieve metabolic goals. Diabetes Res Clin Pract 2024; 208:111096. [PMID: 38244782 DOI: 10.1016/j.diabres.2024.111096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects. OBJECTIVE To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals. METHODS We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs). RESULTS Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term. CONCLUSION Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.
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Affiliation(s)
- Ana Cristina García-Ulloa
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Nancy H Serrano-Pérez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Hernández-Juárez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Luis Cárdenas-Fragoso
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis Eduardo Briones-García
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rodolfo Jiménez-Soto
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos García-Padilla
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan García-Lara
- Departamento de Geriatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A Aguilar-Salinas
- Dirección de Investigación, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sergio Hernández-Jiménez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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36
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Suman S, Kumar A, Kumar M, Saxena I. Reactive Hypoglycemia in Patients Prior to Cataract Surgery: A Case Series. Cureus 2024; 16:e55126. [PMID: 38420291 PMCID: PMC10900283 DOI: 10.7759/cureus.55126] [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] [Accepted: 02/28/2024] [Indexed: 03/02/2024] Open
Abstract
Cataract surgery is one of the most frequently performed surgical procedures and is often performed under topical anesthesia in conscious patients. Sweating, palpitations, and anxiety may be seen in patients about to undergo surgery. However, these are typical adrenergic symptoms of hypoglycemia and should be further investigated if occurring before surgery. Here, we report five cases of postprandial or reactive hypoglycemia observed in hospital settings just before conducting cataract surgeries in non-diabetic 52-78-year-old patients from 2019 to 2023.
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Affiliation(s)
- Suwarna Suman
- Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Arushi Kumar
- Otolaryngology, Nalanda Medical College Patna, Patna, IND
| | - Manoj Kumar
- Physiology, Maharshi Vashishtha Autonomous State Medical College, Basti, Rampur, IND
| | - Indu Saxena
- Biochemistry, All India Institute of Medical Sciences, Gorakhpur, Gorakhpur, IND
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37
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Dirim AB, Seker A. A Rare Cause of Hypoglycemia in Elderly Patients: Insulinoma. Cureus 2024; 16:e54002. [PMID: 38476778 PMCID: PMC10928961 DOI: 10.7759/cureus.54002] [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] [Accepted: 02/10/2024] [Indexed: 03/14/2024] Open
Abstract
Insulinoma is the most common pancreatic neuroendocrine tumor and is often solitary and benign. To make a diagnosis, high insulin levels must be demonstrated, and proinsulin and C-peptide measurements must be done. The presence of hypoglycemic measurements and symptoms in the 72-hour fasting test is diagnostic. We present a case of a 91-year-old patient with no known diagnosis of diabetes mellitus who was admitted to the emergency department due to confusion. As a result of the clinical evaluation and differential diagnosis, it was determined that her complaint was due to hypoglycemia, and she was admitted to the internal medicine service for further examination, diagnosis, and treatment.
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Affiliation(s)
- Ahmet Baris Dirim
- Gastroenterological Surgery, University of Health Sciences, Adana City Training and Research Hospital, Adana, TUR
| | - Ahmet Seker
- Gastroenterological Surgery, University of Health Sciences, Adana City Training and Research Hospital, Adana, TUR
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38
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Mohamed F, Raal FJ. Unraveling the Whipple Triad: Non-Islet Cell Tumor-Induced Hypoglycemia. JCEM CASE REPORTS 2024; 2:luae006. [PMID: 38283730 PMCID: PMC10821760 DOI: 10.1210/jcemcr/luae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Indexed: 01/30/2024]
Abstract
Tumor-induced hypoglycemia (TIH) is a rare paraneoplastic phenomenon resulting from several tumor types and mechanisms. Insulinomas are the most common cause of TIH. However, non-islet cell tumors can also trigger hypoglycemia by releasing insulin-like growth factor 2 (IGF-II) or its precursor. We present a case of a 56-year-old woman experiencing spontaneous hypoglycemia due to a pleural-based solitary fibrous tumor. Diagnostic evaluations revealed diminished C-peptide levels, increased IGF-II, and a 4-fold increase in the IGF-II: IGF-I ratio, indicative of non-islet cell tumor hypoglycemia. Localization imaging identified a left pleural mass, confirming the diagnosis. Preoperatively, the patient received intravenous dextrose and corticosteroids, but surgical resection was essential for the resolution of symptoms. The identified tumor, a benign solitary fibrous tumor, was successfully removed, leading to an immediate postoperative cessation of hypoglycemia. Six years post resection, the patient remains symptom free. Managing TIH necessitates an early diagnosis aiming for complete tumor resection, with alternative approaches considered when complete resection is not possible. This case highlights the importance of a systematic diagnostic and management approach for TIH, emphasizing the need to identify the underlying cause, particularly in people without diabetes.
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Affiliation(s)
- Farzahna Mohamed
- Division of Endocrinology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Frederick J Raal
- Division of Endocrinology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, 2193, South Africa
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39
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Goudet P, Cadiot G, Barlier A, Baudin E, Borson-Chazot F, Brunaud L, Caiazzo R, Cardot-Bauters C, Castinetti F, Chanson P, Cuny T, Dansin E, Gaujoux S, Giraud S, Groussin L, Le Bras M, Lifante JC, Mathonnet M, de Mestier L, Mirallié E, Pattou F, Romanet P, Sebag F, Tresallet C, Vezzosi D, Walter T, Tabarin A. French guidelines from the GTE, AFCE and ENDOCAN-RENATEN (Groupe d'étude des Tumeurs Endocrines/Association Francophone de Chirurgie Endocrinienne/Reseau national de prise en charge des tumeurs endocrines) for the screening, diagnosis and management of Multiple Endocrine Neoplasia Type 1. ANNALES D'ENDOCRINOLOGIE 2024; 85:2-19. [PMID: 37739121 DOI: 10.1016/j.ando.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Affiliation(s)
- Pierre Goudet
- Department of Digestive and Endocrine Surgery, Dijon University Hospital, Dijon, France; INSERM, U1231, EPICAD Team UMR "Lipids, Nutrition, Cancer", Dijon, France; INSERM, CIC1432, Clinical epidemiology Dijon, Dijon, France.
| | - Guillaume Cadiot
- Department of Hepato-Gastro-Enterology and Digestive Oncology, Robert Debré Hospital, Reims, France.
| | - Anne Barlier
- Aix Marseille Univ, APHM, INSERM, MMG, Laboratory of Molecular Biology Hospital La Conception, Marseille, France.
| | - Eric Baudin
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Cancer Campus, Villejuif, France.
| | - Françoise Borson-Chazot
- Federation of Endocrinology, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon1 University and INSERM U1290, Lyon, France.
| | - Laurent Brunaud
- Department of Gastrointestinal, Visceral, Metabolic, and Cancer Surgery (CVMC), University Hospital of Nancy (CHRU Nancy), University of Lorraine, 54511 Vandoeuvre-les-Nancy, France; INSERM U1256 NGERE, Lorraine University, 11, allée du Morvan, 54511 Vandoeuvre-les-Nancy, France.
| | - Robert Caiazzo
- General and Endocrine Surgery Department, University Hospital Center of Lille, Lille, France.
| | | | - Frédéric Castinetti
- Aix Marseille University, Marseille Medical Genetics, INSERM U1251 and Assistance Publique Hopitaux de Marseille, La Conception Hospital, Department of Endocrinology, Marseille, France.
| | - Philippe Chanson
- University Paris-Saclay, INSERM, Endocrine Physiology and Pathophysiology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Service of Endocrinology and Reproductive Diseases, National Reference Center for Rare Pituitary Diseases, 94275 Le Kremlin-Bicêtre, France.
| | - Thomas Cuny
- APHM, Marseille Medical Genetics, INSERM U1251, Conception Hospital, Endocrinology Department, Aix Marseille University, Marseille, France.
| | - Eric Dansin
- Department of Medical Oncology, Oscar Lambret Center, 59000 Lille, France.
| | - Sébastien Gaujoux
- Department of Endocrine and Pancreatic Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
| | - Sophie Giraud
- Cancer Genetics Unit, Institut Bergonié, Bordeaux, France.
| | - Lionel Groussin
- Department of Endocrinology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Institut Cochin, INSERM U1016, CNRS UMR8104, Université Paris Cité, 75014 Paris, France.
| | - Maëlle Le Bras
- Department of Endocrinology, Nantes University Hospital, Nantes, France.
| | - Jean-Christophe Lifante
- Department of Digestive and Endocrine Surgery, University Hospital of Lyon Sud, Lyon, France; EA 7425 HESPER, Health Services and Performance Research, University Claude Bernard Lyon 1, Lyon, France.
| | - Muriel Mathonnet
- Department of Surgery, Dupuytren University Hospital of Limoges, Limoges, France.
| | - Louis de Mestier
- Paris-Cité University, Department of Pancreatology and Digestive Oncology, Beaujon Hospital (AP-HP-Nord), Clichy, France.
| | - Eric Mirallié
- Department of Oncological, Digestive and Endocrine Surgery (CCDE) Hôtel Dieu, CIC-IMAD, Nantes, France.
| | - François Pattou
- Department of General and Endocrine Surgery, University Hospital. Lille, INSERM U1190, Lille, France.
| | - Pauline Romanet
- Aix Marseille University, APHM, INSERM, MMG, Laboratory of Molecular Biology, La Conception Hospital, Marseille, France.
| | - Frédéric Sebag
- Department of General Endocrine and Metabolic Surgery, Conception University Hospital, APHM, Aix Marseille University, Marseille, France.
| | - Christophe Tresallet
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne University Hospital, Sorbonne Paris Nord Universty, Assistance Pubique des Hôpitaux de Paris (APHP), Paris, France.
| | - Delphine Vezzosi
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059 Toulouse Cedex, France.
| | - Thomas Walter
- Medical Oncology Department, Edouard-Herriot Hospital, Hospices Civils de Lyon, Lyon, France.
| | - Antoine Tabarin
- Endocrinology Department, INSERM Unit 1215, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France.
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40
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Hoffman EG, D’Souza NC, Liggins RT, Riddell MC. Pharmacologic inhibition of somatostatin receptor 2 to restore glucagon counterregulation in diabetes. Front Pharmacol 2024; 14:1295639. [PMID: 38298268 PMCID: PMC10829877 DOI: 10.3389/fphar.2023.1295639] [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: 09/16/2023] [Accepted: 12/13/2023] [Indexed: 02/02/2024] Open
Abstract
Glucose homeostasis is primarily maintained by pancreatic hormones, insulin and glucagon, with an emerging role for a third islet hormone, somatostatin, in regulating insulin and glucagon responses. Under healthy conditions, somatostatin secreted from pancreatic islet δ-cells inhibits both insulin and glucagon release through somatostatin receptor- induced cAMP-mediated downregulation and paracrine inhibition of β- and α-cells, respectively. Since glucagon is the body's most important anti-hypoglycemic hormone, and because glucagon counterregulation to hypoglycemia is lost in diabetes, the study of somatostatin biology has led to new investigational medications now in development that may help to restore glucagon counterregulation in type 1 diabetes. This review highlights the normal regulatory role of pancreatic somatostatin signaling in healthy islet function and how the inhibition of somatostatin receptor signaling in pancreatic α-cells may restore normal glucagon counterregulation in diabetes mellitus.
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Affiliation(s)
- Emily G. Hoffman
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Ninoschka C. D’Souza
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | | | - Michael C. Riddell
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
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41
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Khanimov I, Zingerman B, Rozen-Zvi B, Shimonov M, Leibovitz E. Lower Incidence of Hypoglycemia With Angiotensin Receptor Blocker Versus ACE Inhibitor Therapy in People With or Without Diabetes. Clin Diabetes 2024; 42:300-307. [PMID: 38694239 PMCID: PMC11060618 DOI: 10.2337/cd23-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
This article describes a study examining the association between treatment with ACE inhibitors or angiotensin receptor blockers (ARBs) and incident hypoglycemia in patients with or without diabetes who were admitted to the internal medicine departments of a tertiary hospital in the Tel Aviv district of Israel. The authors found that treatment with ARBs, but not ACE inhibitors, compared with treatment with neither, was associated with a reduced risk of hypoglycemia regardless of diabetes status.
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Affiliation(s)
- Israel Khanimov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Zingerman
- Department of Nephrology at the Hasharon Campus, Rabin Medical Center, Petah Tikva, Israel
| | - Benaya Rozen-Zvi
- Department of Nephrology at the Hasharon Campus, Rabin Medical Center, Petah Tikva, Israel
| | | | - Eyal Leibovitz
- Department of Internal Medicine A, Yoseftal Medical Center, Eilat, Israel
- Research Unit of the Surgical Division, Edith Wolfson Medical Center, Holon, Israel
- The Adelson School of Medicine, Ariel University, Ariel, Israel
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42
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Lourenço DM, Corrêa-Giannella ML, Siqueira SAC, Nery M, Ribeiro FG, Quedas EPDS, Rocha MDS, do Nascimento RM, Pereira MAA. Case report: Insulinomatosis: description of four sporadic cases and review of the literature. Front Endocrinol (Lausanne) 2024; 14:1308662. [PMID: 38264280 PMCID: PMC10803616 DOI: 10.3389/fendo.2023.1308662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/23/2023] [Indexed: 01/25/2024] Open
Abstract
The best-known etiologies of hyperinsulinemic hypoglycemia are insulinoma, non-insulinoma pancreatogenous hypoglycemic syndrome, autoimmune processes, and factitious hypoglycemia. In 2009, a disease not associated with classic genetic syndromes and characterized by the presence of multiple pancreatic lesions was described and named insulinomatosis. We present the clinical and pathologic features of four patients with the diagnosis of insulinomatosis, aggregated new clinical data, reviewed extensively the literature, and illustrated the nature and evolution of this recently recognized disease. One of our patients had isolated (without fasting hypoglycemia) postprandial hypoglycemia, an occurrence not previously reported in the literature. Furthermore, we reported the second case presenting malignant disease. All of them had persistent/recurrent hypoglycemia after the first surgery even with pathology confirming the presence of a positive insulin neuroendocrine tumor. In the literature review, 27 sporadic insulinomatosis cases were compiled. All of them had episodes of fasting hypoglycemia except one of our patients. Only two patients had malignant disease, and one of them was from our series. The suspicion of insulinomatosis can be raised before surgery in patients without genetic syndromes, with multiple tumors in the topographic investigation and in those who had persistent or recurrent hypoglycemia after surgical removal of one or more tumors. The definitive diagnosis is established by histology and immunohistochemistry and requires examination of the "macroscopically normal pancreas." Our case series reinforces the marked predominance in women, the high frequency of recurrent hypoglycemia, and consequently, a definitive poor response to the usual surgical treatment.
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Affiliation(s)
- Delmar Muniz Lourenço
- Unidade de Endocrinologia Genética (LIM-25), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Lucia Corrêa-Giannella
- Laboratório de Carboidratos e Radioimunoensaio (LIM-18), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Marcia Nery
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Flavio Galvão Ribeiro
- Unidade de Endocrinologia Genética (LIM-25), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Elizangela Pereira de Souza Quedas
- Unidade de Endocrinologia Genética (LIM-25), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Manoel de Souza Rocha
- Departamento de Radiologia, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ramon Marcelino do Nascimento
- Unidade de Endocrinologia Genética (LIM-25), Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Adelaide Albergaria Pereira
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Yan D, Song Y, Zhang B, Cao G, Zhou H, Li H, Sun H, Deng M, Qiu Y, Yi W, Sun Y. Progress and application of adipose-derived stem cells in the treatment of diabetes and its complications. Stem Cell Res Ther 2024; 15:3. [PMID: 38167106 PMCID: PMC10763319 DOI: 10.1186/s13287-023-03620-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
Diabetes mellitus (DM) is a serious chronic metabolic disease that can lead to many serious complications, such as cardiovascular disease, retinopathy, neuropathy, and kidney disease. Once diagnosed with diabetes, patients need to take oral hypoglycemic drugs or use insulin to control blood sugar and slow down the progression of the disease. This has a significant impact on the daily life of patients, requiring constant monitoring of the side effects of medication. It also imposes a heavy financial burden on individuals, their families, and even society as a whole. Adipose-derived stem cells (ADSCs) have recently become an emerging therapeutic modality for DM and its complications. ADSCs can improve insulin sensitivity and enhance insulin secretion through various pathways, thereby alleviating diabetes and its complications. Additionally, ADSCs can promote tissue regeneration, inhibit inflammatory reactions, and reduce tissue damage and cell apoptosis. The potential mechanisms of ADSC therapy for DM and its complications are numerous, and its extensive regenerative and differentiation ability, as well as its role in regulating the immune system and metabolic function, make it a powerful tool in the treatment of DM. Although this technology is still in the early stages, many studies have already proven its safety and effectiveness, providing new treatment options for patients with DM or its complications. Although based on current research, ADSCs have achieved some results in animal experiments and clinical trials for the treatment of DM, further clinical trials are still needed before they can be applied in a clinical setting.
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Affiliation(s)
- Dongxu Yan
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Yujie Song
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Bing Zhang
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Guojie Cao
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Haitao Zhou
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Hong Li
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Hao Sun
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Meng Deng
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Yufeng Qiu
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China
| | - Wei Yi
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China.
| | - Yang Sun
- Department of General Medicine, Xijing Hospital, Fourth Military Medical University, 127# Changlexi Road, Xi'an, 710032, China.
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44
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Soyoye DO, Atolani SA, Adetunji TA, Alatise OI. Insulinoma Presenting as Seizures: Challenges of Managing a Rare Disease in a Resource-challenged Setting. JCEM CASE REPORTS 2024; 2:luad162. [PMID: 38116164 PMCID: PMC10729851 DOI: 10.1210/jcemcr/luad162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Indexed: 12/21/2023]
Abstract
Insulinomas are functioning pancreatic neuroendocrine tumors (NETs). They secrete insulin, and hence, present with hypoglycemia. We report a case of insulinoma in a 16-year-old girl presenting as seizures. She was initially managed at a private clinic and later commenced on carbamazepine when convulsion persisted. Convulsions were generalized, associated with dizziness and altered sensorium, often preceded by hunger and physical exertion, but relieved by the intake of carbonated drinks and fruit juice. She was referred to the neurology clinic when seizures persisted, despite the use of anticonvulsant. She was later referred to the endocrine clinic on suspicion of insulinoma when her random blood glucose (BG) was found to be low during an episode of convulsion. She was moderately obese but other examination findings were normal. She had a 72-hour prolonged fast, which was terminated when hypoglycemia (BG = 2.2 mmol/L) ensued after 12 hours, with elevated serum insulin and C-peptide. Abdominal magnetic resonance imaging scan showed a pancreatic tumor suggestive of insulinoma. She subsequently had distal pancreatectomy performed with complete resolution of symptoms. Unusual presentation of insulinoma may delay diagnosis, resulting in wastage of resources with increased morbidities and mortality.
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Affiliation(s)
- David O Soyoye
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun 220282, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220213, Nigeria
| | - Segun A Atolani
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220213, Nigeria
| | - Tajudin A Adetunji
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun 220282, Nigeria
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220213, Nigeria
| | - Olusegun I Alatise
- Department of Surgery, Obafemi Awolowo University, Ile-Ife, Osun 220282, Nigeria
- Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220213, Nigeria
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45
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Watson CJ, Edlow JA. Managing Adults With Hypoglycemia. Ann Emerg Med 2023; 82:705-712. [PMID: 37632497 DOI: 10.1016/j.annemergmed.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Christopher James Watson
- Tufts University School of Medicine, Boston, MA; Division of Medical Toxicology, Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - Jonathan A Edlow
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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46
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Gullace ME, Ortuño MV, Canteros TM, Bosco B, Rodriguez C, Giunta J, Costa L, Kozak A, de Miguel V, Grosembacher L. Evaluation of plasma cortisol during fasting test in patients with endogenous hyperinsulinemic hypoglycemia. Fifteen years experience. ENDOCRINOL DIAB NUTR 2023; 70:634-639. [PMID: 38016856 DOI: 10.1016/j.endien.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 09/24/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Endogenous hyperinsulinemic hypoglycemia (EHH) is a rare clinical condition. The aim of this study was to evaluate baseline plasma cortisol concentration and its concentration during hypoglycemic crisis in fasting tests (FT) performed in our center. Secondarily, the aim was to establish the relationship between baseline cortisol and the time of evolution of EHH. MATERIAL AND METHODS A retrospective, observational, descriptive study was carried out which included patients with hypoglycemic disorder with positive FT. RESULTS Of a total of 21 patients, 16 presented insulinoma, 1 nesidioblastosis, 2 malignant insulinoma and 2 EHH without pathological diagnosis. The time from the onset of symptoms to diagnosis was 2 years (Q1=1.5-Q2=5.5). The comparison between median baseline cortisol (BC)=11.8 mcg/dl (nmol/L 340.68) (Q1=9-Q3=14.1) and median cortisol during hypoglycemic episode (HC)=11.6 mcg/dl (nmol/L: 303.44) (Q1=7.8-Q3=16.1) showed no differences (Z=-0.08; P>.05). When correlating BC with HC, no significant relationship was observed (r=0.16; P>.05). When correlating the glycemic value in the crisis and the HC, a slight negative trend was found (r=-0.53; P=.01). In addition, we found that recurrent hypoglycemic disorder is associated with lower baseline cortisol values the longer the time of its evolution. CONCLUSION We confirmed that cortisol values remain low during hypoglycemic episodes, reinforcing the hypothesis of lack of response of this counterregulatory hormone in cases of recurrent hypoglycemia.
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Affiliation(s)
- María Eugenia Gullace
- Unidad de Endocrinología, Hospital Municipal de Agudos «Dr. Leónidas Lucero», Bahía Blanca, Argentina.
| | | | - Teresa Mabel Canteros
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Belén Bosco
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Cintia Rodriguez
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Javier Giunta
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Lucas Costa
- Unidad de Bioestadística, Facultad de Ciencias Médicas, Universidad Nacional del Litoral, Santa Fe, Argentina
| | - Andrea Kozak
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Valeria de Miguel
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Luis Grosembacher
- Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
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47
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Belay KE, Urge SB, Birhan YA, Efrem P, Alemneh TA. Clopidogrel-induced non-diabetic hypoglycemia reported from Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: a case report. J Med Case Rep 2023; 17:460. [PMID: 37925464 PMCID: PMC10625709 DOI: 10.1186/s13256-023-04166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/08/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Recurrent episodes of hypoglycemia may be caused by several factors, including drugs, critical illnesses, hormonal deficiency, non-islet cell tumor endogenous hyperinsulinism, and accidental, surreptitious, or malicious hypoglycemia. Multiple drugs have been previously reported as causes of hypoglycemia, with moderate and low-quality evidence. However, Clopidogrel as a cause of non-diabetic hypoglycemia is rarely reported. Here we describe a single non-diabetic patient who experienced recurrent episodes of hypoglycemia after initiation of clopidogrel for clinical suspicion of acute coronary syndrome. CASE PRESENTATION The patient, a 33-year-old Ethiopian male with documented hypertension on antihypertensive medication, has started receiving treatment for acute coronary syndrome after experiencing angina symptoms. He experienced hypoglycemia following the start of Clopidogrel, but it subsided once it was stopped. Currently, he has a follow-up at the cardiac clinic with a normal measurement of his serum blood glucose level. CONCLUSION Non-diabetic hypoglycemia is a rare illness characterized by low blood glucose levels in people who do not have diabetes. Patients with severe hypoglycemia may become unconscious or have seizures as a result of low blood sugar. Severe hypoglycemia is fatal and must be treated as soon as possible. Therefore, if non-diabetic hypoglycemia occurs, a thorough evaluation of the causes is essential, particularly any potential drug as a cause of hypoglycemia should be evaluated.
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Affiliation(s)
- Kibret Enyew Belay
- Department of Internal Medicine, Endocrinology and Metabolism Unit, Addis Ababa University, Addis Ababa, Ethiopia
| | - Saba Belay Urge
- Department of Internal Medicine, Endocrinology and Metabolism Unit, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Paulos Efrem
- Department of Internal Medicine, Endocrinology and Metabolism Unit, Addis Ababa University, Addis Ababa, Ethiopia
| | - Theodros Aberra Alemneh
- Department of Internal Medicine, Endocrinology and Metabolism Unit, Addis Ababa University, Addis Ababa, Ethiopia.
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48
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Chang M, Willis G. Approach to the Hypoglycemic Patient. Emerg Med Clin North Am 2023; 41:729-741. [PMID: 37758420 DOI: 10.1016/j.emc.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Hypoglycemia is commonly encountered in the emergency department. Patients can present with a myriad of symptoms and its presentation can mimic other more serious diagnoses. Despite the relative ease of its management, clinicians often miss the diagnosis or mismanage it even when discovered. Glucose is an important energy source for the brain and failing to recognize hypoglycemia or mismanaging it can lead to permanent neurologic disability or death. Although it is important to replenish glucose in a rapid fashion, it is equally important to discover and manage the underlying etiology to prevent further episodes of hypoglycemia.
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Affiliation(s)
- Molly Chang
- Baylor University Medical Center, 3500 Gaston Avenue, 1st floor, Roberts Building, Dallas, TX 75246, USA; Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA
| | - George Willis
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
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49
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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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50
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Jiao F, Cui J, Fu D, Li Q, Wu Z, Teng Z, Zhang H, Zhou J, Zhang Z, Chen X, Zhou Y, Li Y, Mou Y, Qin R, Sun Y, Jin G, Cheng Y, Wang J, Ren G, Yue J, Jin G, Xiao X, Wang L. Chinese Medical Association consensus for standardized diagnosis and treatment of pancreatic neuroendocrine neoplasms. Chin Med J (Engl) 2023; 136:2397-2411. [PMID: 37690992 PMCID: PMC10586833 DOI: 10.1097/cm9.0000000000002848] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Feng Jiao
- Department of Oncology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Jiujie Cui
- Department of Oncology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qi Li
- Department of Oncology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiao Tong University, Xi'an, Shaanxi 710061, China
| | - Zan Teng
- Department of Oncology, The First Hospital of China Medical University, Shenyang, Liaoning 110801, China
| | - Hongmei Zhang
- Department of Medical Oncology, The First Affiliated Hospital of Air Force Medical University, Xi'an, Shaanxi 710032, China
| | - Jun Zhou
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Zhihong Zhang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiaobing Chen
- Department of Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan 450003, China
| | - Yuhong Zhou
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yixiong Li
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yiping Mou
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yongwei Sun
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yuejuan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jian Wang
- Department of Radiology, Shanghai Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Gang Ren
- Department of Radiotherapy, Peking University Shougang Hospital, Beijing 100144, China
| | - Jiang Yue
- Department of Endocrinology and Metabolism, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Guangxin Jin
- Department of Interventional Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiuying Xiao
- Department of Oncology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Liwei Wang
- Department of Oncology, State Key Laboratory of Systems Medicine for Cancer, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
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