Background : Insulinoma is the most common functioning pancreatic neuroendocrine tumor. It’s an important endocrine etiology of obesity, which is characterized by a hyperinsulinemic hypoglycemia (HH). Case reports: Case 1: A 23 years old woman developed hypoglycemia symptoms and weight gain (13kg in 6 months). The prolonged fasting test (PFT) was performed: plasma glucose 29 mg/dL, C-peptide 2,6ng/mL (< 0,6 ng/mL), plasma insulin 29,9 μU/mL (< 3,0 μU/mL), showing a HH. Abdominal CT showed a 1.3 cm hypervascularity nodule, next to the distal portion of the pancreatic tail close to the vein and splenic artery. A successful partial pancreatectomy and splenectomy were performed and she remains asymptomatic. Case 2: A 41 years old man, with severe obesity Body Mass Index (BMI) 65 kg/m 2 and impaired fasting glucose presented HH (glucose 41 mg/dL, C-peptide 27,3 ng/mL, insulin 637 μU/mL) and weight gain. MRI showed a 3,0 cm hypervascularity nodule between the body and pancreas tail. Octreotide, diazoxide, dextrose continuous infusion pump and hydrochlorothiazide were prescribed to control hypoglycemia. Partial pancreatectomy and splenectomy were performed but in the postoperative period, patient developed renal failure, sepsis, acute respiratory distress syndrome and death. Case 3: A 21 years old woman with severe obesity (BMI 60 kg/m 2 ), after using intragastric balloon for 6 months, developed hypoglycemic symptoms, including seizures. The PFT showed plasma glucose 44 mg/dl, plasma insulin 47 μU/mL, C-peptide 3,2 ng/mL. MRI showed a 1.9 cm hypervascularity nodule in the cephalic portion of the pancreas, very close to cava vein. Diazoxide was prescribed with improvement of hypoglycemia. Due to the high surgical risk given the location of the tumor and obesity, an endoscopic ultrasound (EUS) guided ethanol ablation was performed. After the procedure, diazoxide was discontinued and two months later she had no hypoglycemia and is still loosing weight. Antiinsulin antibodies were negative and all biopsies confirmed insulinoma. Conclusion: Insulinomas can be a challenging diagnose and management. Once, most of the patients are overweight, the surgical treatment became a threat , therefore advanced techniques are an important advance for reducing mortality.
Background: The thyroid storm is a rare disorder characterized by multisystem involvement and high mortality rates. A high index of suspicion should be maintained in patients with thyrotoxicosis associated with evidence of systemic decompensation. Case Presentation: A 25 year old male was referred to an endocrine clinic with the diagnose of Graves disease, complained about 34kg weight loss, goiter, diarrhea, palpitation and exophthalmia, his hormonal profile showed TSH <0.05 uUI/mL (0.4-5.8), T4l >7.77 ng/dl (0.7-1.8), TRAb 25.2 UI/L, T3>651,0 ng/dl; Methimazole 20mg/day, and Propanolol 120mg/day were introduced at that appointment. After a month the patient was admitted at Santa Casa de São Paulo hospital as a result of orquiepididymitis and jaundice. He evolved 48hs after the admission with respiratory insufficiency, fever and tachycardia. Propylthiouracil 200mg 4/4hs, Lugol 8/8hs, dexamethasone, Tazocin, Meropenem, Vancomicine were introduced by the internal medicine team. The laboratory profile showed: total bilirubin 11.4, direct 10.4, RNI 2.06, AST 40, ALT 46, hemoglobin 10.7, hematocrit 33.4, leucocytes 7800 (86,7% neutrophils), plaques 128.000. Transthoracic echocardiogram revealed diffuse hypokinemia, mainly antero-septal, FE=38%, moderated left ventricle eccentric hypertrophy. After 48hs the endocrine team discontinued thionamide drugs, lithium and plasmapheresis was indicated. The patient did 3 session of plasmapheresis, the day after the first section he was extubated, and his hormonal scan revealed TSH 0.01 (0.4-5.8), T4l 1.04 (0.7-1.8), at that day. After recovering from the infection a total thyroidectomy was performed, and levothyroxine 1.0mcg/kg/day was introduced. The patient had post-operative hypoparathyroidism and is takin calcitriol, calcium carbonate and cholecalciferol. Conclusion: A multimodality treatment approach should be used. Therapeutic plasma exchange (TPE) is a potential therapeutic option for thyroid storm, but its indication is not well established. The literature contains few reported cases and no clear guidelines about indication criteria and best time to start. When there are threatening symptoms, TPE should be done early, without waiting for the efficiency of conventional treatment. It’s effect can be explained by the rapid decline of plasma hormones and antibodies responsible for Graves’ disease. It is a relatively safe therapy, although it has a high cost. Monitoring the thyroid hormones is interesting, but clinical improvements are often dissociated from the hormonal levels and must be mainly judged on the patient’s condition.
and tail. 74% of sensory fibres were localized in the pancreatic head, 19% in the corpus and 7% in the tail. Conclusions: Murine pancreatic head has the highest density of pancreatic nerves. Overall, due to its intraperitoneal and perilymphoid localization, the mouse pancreas bears a substantially different structural innervation pattern when compared to the human pancreas.
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