Endocrine Abstracts

Case history: 49 year old female with learning disabilities who was being treated as epilepsy for 2 years and attended the GP surgery for routine bloods. Patient had a seizure like activity and fell onto both knees. X ray which showed a distal femur fracture which was undisplaced and was extra-articular and patellar fracture. Patient was found to be hypoglycaemic on the ward and she was treated with 10% dextrose infusions. She underwent Left knee exploration and repair of medial retinaculum of quadriceps tendon and excision of patellar fragment. Post operatively, she was again found to be hypoglycaemic and had treatment with dextrose infusion.Due to persistent hypoglycaemic episodes, she was transferred to the endocrinology ward. She was found to have a C peptide of greater than 1100. Insulin antibodies were negative, cortisol >350, TSH=1.8. Her sulfonylurea screen was negative. Patient was started on diazoxide to help control blood sugar and this was found to be effective eventually.

Investigations: Patient underwent a CT AP which didn't showed any pancreatic lesion, she had endoscopic ultrasound which found a small lesion on the tail of the pancreas measuring 13×9 mm hypoechoic well defined lesion, which has good Doppler signals indicating high vascularity, suggesting a possibility of a NET. Biopsies were taken. Histopathology showed clusters of ovoid epithelial cells having bland nuclei resembling those of neuroendocrine cells that stain with synaptophysin and chromogranin in addition to Ber EP4, consistent with well-differentiated neuroendocrine tumour, Immunohistochemistry findings were positive for BerEP4 and Synaptophysin, chromogranin – smaller cells, it was negative for CA19.9, CD56.

Results and treatment: The morphology and IHC findings are consistent with a neuroendocrine tumour, case was discussed with regional tertiary care centre in NET MDT and the lesion was surgically excised with enucleation of the mass resulting in complete resolution of symptoms and came off anti-epiletic medications.

Conclusions and points for discussion: Insulinoma is a rare neuroendocrine tumour and can occur at any age with nonspecific sign and symptoms. While evaluating a patient with presentation of seizure, toxic and metabolic causes should always be considered as they are potentially curable, and may be fatal if left untreated. This case report highlights the need for careful assessment of all seizures and monitoring of blood sugars as this was a challenging case due to learning disabilities. A multidisciplinary approach and timely and effective collaboration of medical, surgical, radiological and histopathology teams for best patient outcome.