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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) 2024:10.1007/s42000-024-00542-1. [PMID: 38457064 DOI: 10.1007/s42000-024-00542-1] [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: 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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Nakajima R, Idesawa H, Sato D, Ito J, Ito K, Fujii M, Suzuki T, Furuta T, Kawai H, Takayashiki N, Kurata M, Yagyu H. Continuous glucose monitoring in a patient with insulinoma presenting with unawareness of postprandial hypoglycemia. Endocrinol Diabetes Metab Case Rep 2023; 2023:23-0056. [PMID: 37767703 PMCID: PMC10563612 DOI: 10.1530/edm-23-0056] [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: 05/09/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Summary Unawareness of postprandial hypoglycemia for 5 years was identified in a 66-year-old man at a local clinic. The patient was referred to our hospital because of this first awareness of hypoglycemia (i.e. lightheadedness and impaired consciousness) developing after lunch. In a 75 g oral glucose tolerance test, the plasma glucose concentration was decreased to 32 mg/dL (1.8 mmol/L) at 150 min with relatively high concentrations of insulin (8.1 μU/mL), proinsulin (70.3 pmol/L), and C-peptide (4.63 ng/mL). In a prolonged fasting test, the plasma glucose concentration was decreased to 43 mg/dL (2.4 mmol/L) at 66 h with an insulin concentration of 1.4 μU/mL and a C-peptide concentration of 0.49 ng/mL. Computed tomography showed an 18 mm hyperenhancing tumor in the uncinate process of the pancreas. A selective arterial calcium stimulation test showed an elevated serum insulin concentration in the superior mesenteric artery. The patient was then diagnosed with insulinoma and received pancreaticoduodenectomy. Continuous glucose monitoring (CGM) using the Dexcom G6 system showed unawareness of hypoglycemia mainly during the daytime before surgery. When the sensor glucose value was reduced to 55 mg/dL (3.1 mmol/L), the Dexcom G6 system emitted an urgent low glucose alarm to the patient four times for 10 days. Two months after surgery, an overall increase in daily blood glucose concentrations and resolution of hypoglycemia were shown by CGM. We report a case of insulinoma with unawareness of postprandial hypoglycemia in the patient. The Dexcom G6 system was helpful for assessing preoperative hypoglycemia and for evaluating outcomes of treatment by surgery. Learning points Insulinoma occasionally leads to postprandial hypoglycemia. The CGM system is useful for revealing the presence of unnoticed hypoglycemia and for evaluating treatment outcomes after surgical resection. The Dexcom G6 system has an urgent low glucose alarm, making it particularly suitable for patients who are unaware of hypoglycemia.
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Affiliation(s)
- Rikako Nakajima
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hiroto Idesawa
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Daisuke Sato
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Jun Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Kei Ito
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Masanao Fujii
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Takamichi Suzuki
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Tomoaki Furuta
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hitomi Kawai
- Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Norio Takayashiki
- Department of Pathology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Masanao Kurata
- Department of Gastrointestinal Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
| | - Hiroaki Yagyu
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi, Mito, Ibaraki, Japan
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Isaacs D, Clements J, Turco N, Hartman R. Glucagon: Its evolving role in the management of hypoglycemia. Pharmacotherapy 2021; 41:623-633. [PMID: 33963599 DOI: 10.1002/phar.2534] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/21/2022]
Abstract
More than 10% of the United States population has diabetes, characterized by hyperglycemia. Insulin and other agents used to treat diabetes predispose people to hypoglycemia, which can be life threatening. Glucagon is an emergency medication that can save lives by quickly raising glucose in people who are unconscious or unable to consume glucose due to severe hypoglycemia. Although glucagon has been commercially available since 1960, earlier formulations required reconstitution of a dry powder with diluent immediately prior to injection, due to lack of long-term stability once reconstituted. Glucagon has been underutilized due to the lack of confidence or ability to administer in emergency situations. More recently, new formulations including a nasal powder glucagon and liquid-stable glucagon have become available. This article discusses the evidence surrounding new glucagon formulations compared with the original glucagon emergency kit including ease of use, efficacy, and safety with a focus on important patient counseling points and relevant clinical information on hypoglycemia.
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Affiliation(s)
- Diana Isaacs
- Cleveland Clinic Diabetes Center, Cleveland, Ohio, USA
| | - Jennifer Clements
- Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
| | | | - Rachel Hartman
- University of Findlay College of Pharmacy, Findlay, Ohio, USA
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Yuan T, Liu S, Zhu C, Dong Y, Zhu H, Wu X, Tang Y, Zhao W. Continuous Glucose Monitoring in Patients With Insulinoma Treated by Endoscopic Ultrasound-Guided Ethanol Injection. Pancreas 2021; 50:183-188. [PMID: 33560091 DOI: 10.1097/mpa.0000000000001735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aims of this study were to analyze the continuous glucose monitoring (CGM) profiles of patients with insulinoma before and after treatment with endoscopic ultrasound-guided ethanol injection and assess the value of CGM in curative effect evaluating. METHODS We included 8 patients, and CGM was performed for 3 to 5 days before and after treatment. RESULTS The proportion of monitoring points at which the glucose level was lower than 3.9 mmol/L after treatment decreased in patient 5 (from 4% to 3%) and patient 8 (from 30% to 12%), whereas the proportion increased in patient 1 (from 1% to 16%), patient 3 (from 5% to 23%), and patient 7 (from 7% to 63%). There was no mean significant difference between CGM values (5.75 [standard deviation, 2.49] mmol/L) and self-monitoring of blood glucose values (5.76 [standard deviation, 2.32] mmol/L) (P > 0.05). Pearson correlation analysis showed positive correlation between CGM values and self-monitoring of blood glucose values (r = 0.88, P < 0.05). Clarke Error Grid Analysis showed that 91.5% of pairs were located in areas A and B. CONCLUSIONS Continuous glucose monitoring is useful for detecting hypoglycemia and evaluating curative effect, but the correction of fingertip blood glucose is necessary when the blood glucose is relatively low.
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Affiliation(s)
- Tao Yuan
- From the Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission
| | - Shixuan Liu
- From the Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission
| | | | - Yingyue Dong
- From the Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission
| | - Huijuan Zhu
- From the Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission
| | - Xi Wu
- Departments of Gastroenterology
| | - Yan Tang
- Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Weigang Zhao
- From the Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission
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Prídavková D, Samoš M, Kyčina R, Adamicová K, Kalman M, Belicová M, Mokáň M. Insulinoma presenting with postprandial hypoglycemia and a low body mass index: A case report. World J Clin Cases 2020; 8:4169-4176. [PMID: 33024775 PMCID: PMC7520770 DOI: 10.12998/wjcc.v8.i18.4169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/23/2020] [Accepted: 08/21/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Insulinomas are the most common type of functioning endocrine neoplasms of the pancreas presenting hypoglycemic symptoms. Patients characteristically develop symptoms while fasting, but some patients have reported symptoms only in the postprandial state. Repeated and prolonged hypoglycemic episodes can reduce the awareness of adrenergic symptoms, and patients may have amnesia, which delays diagnosis.
CASE SUMMARY We describe a case of a 24-year-old underweight patient who showed hypoglycemic symptoms for almost 6 years. Although patients with insulinoma characteristically develop symptoms while fasting, this young man had hypoglycemic symptoms up to one hour postprandially, especially after high-sugar meals and after physical activity. The fasting tests and imaging methods performed at local hospitals were evaluated as negative for abnormal results. However, brown adipose tissue exhibited increased metabolic activity, and some muscle groups had histological changes as indicated by positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography. Glycogen deficiency was also histologically confirmed. The patient’s symptoms progressed over the years and occurred more frequently, i.e., several times a month, and the patient had reduced awareness of adrenergic symptoms. The follow-up fasting test was positive, and the imaging results showed a tumor in the head of the pancreas. The patient underwent laparotomy with enucleation of the insulinoma.
CONCLUSION Weight gain and fasting hypoglycemia are not necessarily characteristics of insulinoma. In prolonged cases, adrenergic symptoms can be suppressed.
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Affiliation(s)
- Dana Prídavková
- Clinic of Internal Medicine I, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Matej Samoš
- Clinic of Internal Medicine I, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Roman Kyčina
- Clinic of Surgery and Transplant Center, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Katarína Adamicová
- Department of Pathological Anatomy, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Michal Kalman
- Department of Pathological Anatomy, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Margita Belicová
- Clinic of Internal Medicine I, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
| | - Marián Mokáň
- Clinic of Internal Medicine I, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin 03601, Slovakia
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Sada K, Hidaka S, Imaishi N, Shibata K, Katashima R, Noso S, Ikegami H, Kakuma T, Shibata H. Clinical and genetic analysis in a family with familial renal glucosuria: Identification of an N101K mutation in the sodium-glucose cotransporter 2 encoded by a solute carrier family 5 member 2 gene. J Diabetes Investig 2020; 11:573-577. [PMID: 31584752 PMCID: PMC7232273 DOI: 10.1111/jdi.13157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/19/2023] Open
Abstract
We report the identification of a mutation in the solute carrier family 5 member 2 (SLC5A2) gene, which encodes sodium-glucose cotransporter 2, in a family with familial renal glucosuria. The proband was a 26-year-old Japanese man referred to the diabetes division with repeated glucosuria without hyperglycemia. His mother, uncle and grandfather also had a history of glucosuria. A heterozygous missense mutation (c.303T>A:p.N101K) in SLC5A2 was identified in the patient and his mother, but not in 200 chromosomes from 100 healthy and unrelated individuals, or in 3,408 Japanese individuals in the Tohoku Medical Megabank. Furthermore, bioinformatics software predicted that this lesion would be pathogenic. We infer that the mutation led to clinically relevant sodium-glucose cotransporter 2 dysfunction. The patient showed no symptoms of hypoglycemia, but continuous glucose monitoring confirmed asymptomatic hypoglycemia.
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Affiliation(s)
- Kentaro Sada
- Department of Diabetes and MetabolismKoseiren Tsurumi HospitalOitaJapan
| | - Shuji Hidaka
- Department of Diabetes and MetabolismKoseiren Tsurumi HospitalOitaJapan
| | - Nao Imaishi
- Department of Diabetes and MetabolismKoseiren Tsurumi HospitalOitaJapan
| | - Kohei Shibata
- Department of Gastrointestinal SurgeryKoseiren Tsurumi HospitalOitaJapan
| | - Rumi Katashima
- Laboratory for Pediatric Genome MedicineDepartment of Clinical ResearchNational Hospital Organization Shikoku Medical Center for Children and AdultsKagawaJapan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and DiabetesFaculty of MedicineKindai UniversityOsakaJapan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and DiabetesFaculty of MedicineKindai UniversityOsakaJapan
| | - Tetsuya Kakuma
- Department of Health Support CenterOita UniversityOitaJapan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and NephrologyFaculty of MedicineOita UniversityOitaJapan
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Suminaga K, Murakami T, Yabe D, Sone M, Sugawa T, Masui T, Uza N, Yoshizawa A, Ogura M, Yasoda A, Inagaki N. Factory-calibrated continuous glucose monitoring and capillary blood glucose monitoring in a case with insulinoma: usefulness and possible pitfall under chronic hyperinsulinemic hypoglycemia. Endocr J 2020; 67:361-366. [PMID: 31761874 DOI: 10.1507/endocrj.ej19-0339] [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] [Indexed: 11/23/2022] Open
Abstract
The accuracy of factory-calibrated continuous glucose monitoring (fCGM) within hypoglycemic ranges, especially under the status of chronic hyperinsulinemic hypoglycemia like insulinomas, remains an issue. Even so, fCGM is known to be useful for detecting hypoglycemia unawareness in insulinoma cases. A 25-year-old woman presenting with sudden unconsciousness was diagnosed with insulinoma; fCGM facilitated diagnosis by continuous monitoring for hypoglycemia. Before surgery, she was treated with continuous and frequent bolus infusions of 50% glucose via central venous catheter. To evaluate the accuracy of fCGM values in this case, a comparison between fCGM and capillary blood glucose (CBG) values was also performed. According to the simultaneously measured values, those of fCGM were largely in accordance with those of CBG. Moreover, compared with the previously reported case not having glucose infusions via central venous catheter, both the mean absolute relative differences (MARDs) and the absolute differences (Δ glucose) between fCGM and CBG values were larger in the present case, although no significant differences of MARDs and Δ glucose between the two cases were observed in several different conditions including fasting, post-meal, hypoglycemia, and others. Therefore, we should note possible increased differences between fCGM and CBG values in cases using frequent intravenous glucose infusions as well as case-dependent differing levels of consistency between them.
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Affiliation(s)
- Keiichiro Suminaga
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takaaki Murakami
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Diabetes and Endocrinology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Taku Sugawa
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Toshihiko Masui
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiko Yoshizawa
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Koca N, Cander S, Gul OO, Uğraş N. Insulinoma Case Admitted with Reactive Hypoglycemia Symptoms. Curr Diabetes Rev 2020; 16:790-796. [PMID: 31544700 DOI: 10.2174/1573399815666190712200716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 11/22/2022]
Abstract
AIM To present an insulinoma case with post-prandial hypoglycemic symptoms associated with glucose inducible endogenous hyperinsulinemia. CASE A 52-year-old female patient was evaluated for hypoglycemic symptoms especially those occuring within 3 hours after consuming sugary foods. These symptoms were persistent for a year and a half. She was diagnosed with reactive (post-prandial) syndrome and followed a recommended diet and was given acarbose but there was no improvement. The results suggested post-prandial endogenous hyperinsulinemia related hypoglycemia. Multiphasic computerized tomography revealed an 11x15x12 mm size mass lesion, anteriorly in the head and uncinate process of the pancreas and then the patients were treated surgically with pancreatic enucleation and cured. CONCLUSION Distinguishing post-prandial syndrome by careful history and clinical evaluation in patients with postprandial symptoms is of great importance in terms of cost-effectivity. However, it should not be forgotten that although organic pathologies are mostly presented with fasting hypoglycemia, they may also cause post-prandial symptoms. Severity and progression of the symptoms that point to neuroglycopenia is important, and in this condition the most convenient clinical approach to the patient should be performed with careful and appropriate assessment steps.
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Affiliation(s)
- Nizameddin Koca
- Department of Internal Medicine, University of Health Sciences, Bursa Yüksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Soner Cander
- Department of Internal Medicine, Division of Endocrinology & Metabolism, Uludağ University Medical School, Bursa, Turkey
| | - Ozen Oz Gul
- Department of Internal Medicine, Division of Endocrinology & Metabolism, Uludağ University Medical School, Bursa, Turkey
| | - Nesrin Uğraş
- Department of Pathology, Uludağ University Medical School, Bursa, Turkey
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