Poster presentedat:
BES2
017
2’MuchofaProblemwithHypoglycaemiaNSukumar1,HVenkataraman1,JAyuk1,2
1DepartmentofEndocrinology,UniversityHospitalBirmingham, 2UniversityofBirmingham
• Endocrinereferral:2xhypoglycaemicepisodesinnon-diabeGc
paGent• 88yearoldman• AdmiIedunderoncology4weekspreviouslywithpulmonary
oedemaandblockeduretericstent11daysaLerpalliaGvetrabeciGdine
• Nocturnalhypo–CBG1.2whenfoundunrousablefromsleep,IVglucosegiven• PaGentdeniedanysymptomswhenquesGoned
CaseOverview
• MetastaGcmalignantfibromaofpelvis• CT(10/16):16cmpelvicmasswithsmallvolumelungnodules• Histology(12/16):solitaryfibroustumour,STAT6posiGve,Ki6730• ForpalliaGvechemotherapyonly
• Bilateralhydronephrosis,uretericstents:01/17• Bilateralnephrostomies:03/17(forblockedstentandworseningAKI)• Decompensatedheartfailure,NYHAClass3• DrughistoryèBisoprolol2.5mgOD,ForGsipliquidTDS,HyoscinebutylbromidePRN,MidazolamS/CPRN,OxynormIVPRN,Paracetamol1gQDS• Socialhistoryèlivesalone,independentADLsunGldiagnosis
- ReGredmachinist- Nonsmoker,occasionalwhiskey
Pastmedicalhistory
• IniGalinvesGgaGons:-
• AddiGonalbloodtestsrequestedduringnexthypopriortotreatment ênextnight
• CBG2.7mmol/l–bloodssentoff
Test(units) Result NormalrangeUrea(mmol/L) 22.5 3.4–8.0Crea6nine(umol/L) 352 60-126eGFR(ml/min) 13Cor6sol(nmol/L) 412 >350TSH(mIU/L) 1.85 0.3–4.5
Inves?ga?ons
Test(units) Result NormalrangeGlucose(mmol/L) 2.2 3.5–11Insulin(pmol/L) <10 >20C-pep<de(nmol/L) 380IGF-I(nmol/L) 7.1 4.6–23.4IGF-II(nmol/L) 137.2IGF-II:IGF-Ira<o 19.3 <10
• StartedPrednisolone10mgBDè5mgBDondischargeIni$albloodglucosechart Post-steroidbloodglucosechart
Management
Causesofhypoglycaemia Insulinmediated Non-insulinmediatedDrugsv Exogenousinsulinv Insulinsecretagogues
Drugsv Alcoholv Pentamidine,quinine,indomethacine
Insulinoma CriGcalillnessv HepaGc/renal/cardiacfailurev Sepsis
FuncGonalbeta-celldisorders(nesidoblastosis)v NoninsulinomapancreaGchypoglycaemiav Postgastricbypass‘dumpingsyndrome’
Hormonedeficiencyv CorGsolv Glucagon/adrenaline
Insulinautoimmunehypoglycaemia Non-isletcelltumourAccidental/surrepGGoushypoglycaemia
Discussion
Non-isletcelltumourhypoglycaemia• ComplicaGonofcertainmalignanciesresulGnginsymptomaGcseverehypoglycaemia
(usuallyinfasGngstate)• ~130casereports/smallseriesinEnglishlanguagemedicalliteratureinlast30years 1
• Occurwith<5%ofsolitaryfibroustumoursPathophysiology• Tumoursofmesenchymalorepithelialorigin1
• Solitaryfibroma/fibrosarcomaormesothelioma(22%)• Hepatocellularcarcinoma(17%)• Hermangiopericytoma(7%)• Adrenalcarcinoma,phaeochromocytoma
• 2/3retroperitoneal,1/3thoracic• 70%oftumours>10cmindiameter2• ‘Big’IGF-IIformedfromabnormalprocessingofproIGF-IIin tumourswithaberrant
genetranscripGon/expressionMechanismofhypoglycaemiaDiagnosis• Keyfeatureisêêglucose/insulin/C-pepGde/-hydroxybutaratePLUSéfreeIGF-II,IGF-
II:IGF-IraGo,proIGF-IIlevelsManagement
• GlucocorGcoids• SuppressesproducGon+increaseclearanceof
IGF-II• Usedin~25%ofcases• Typically30–60mg/dayneeded
• RecombinantGH• CauGonre:possibleeffectontumourgrowth
• IGF-IIproducGonbytumour• ActsoninsulinreceptortoéglucoseuGlisaGonin
muscle+êgluconeogenesis• Suppressesinsulin,glucagonandGHrelease
• InfiltraGonofhepaGcGssuebytumour• DestrucGonofadrenalglandsbytumour/haemorrhage
References1. BodnerTWetal.(2014)Managementofnon-isletcelltumorhypoglycemia:a
clinicalreview.JCEM;99(3):713-222. FukudaIetal.(2006)Clinicalfeaturesofinsulin-likegrowthfactor-IIproducing
non-islet-celltumourhypoglycemia.GrowthHormIGFRes;16(4):211-6
EP-049Nithya Sukumar
Clinical biochemistry
