Hypoglycemic Encephalopathy as the Initial Presentation of Hepatic Tumor

Lau, Chi-Ieong; Wang, Han-Cheng; Hsu, Wei-Chih

doi:10.1097/nrl.0b013e3181a6ec56

Cited by 11 publications

(4 citation statements)

References 14 publications

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“…Interestingly, acute hypoglycemic encephalopathy occurred as the sole initial clinical symptom prior to the diagnosis of HCC. Different from a few previously reported cases[ 5 - 9 ], our patient had a very poor hepatic function and nutritional status which could both contribute to his hypoglycemia to some extent. He might have developed chronic hypoglycemia with diminished awareness during the past year since there were no signs of sympathetic activation.…”

Section: Discussioncontrasting

confidence: 81%

Non-islet cell tumor hypoglycemia as an initial presentation of hepatocellular carcinoma coupled with end-stage liver cirrhosis: A case report and review of literature

Douli

Suarez

et al. 2020

WJH

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BACKGROUND Non-islet cell tumor hypoglycemia (NICTH) is a rare cause of persistent hypoglycemia seen in patients with hepatocellular carcinoma (HCC). It is likely to be underdiagnosed especially in the patients with poor hepatic function and malnutrition. Herein, we report a rare case of NICTH as the initial presentation of HCC in a patient with chronic hypoglycemia due to end-stage liver cirrhosis. CASE SUMMARY A 62-year-old male with chronic fasting hypoglycemia secondary to end-stage hepatitis C-related cirrhosis, presented with altered mental status and dizziness. He was found to have severe hypoglycemia refractory to glucose supplements. Imaging studies and biopsy discovered well differentiated HCC without metastasis. Further evaluation showed low insulin, C-peptide and beta-hydroxybutyrate along with a high insulin-like growth factor-2/insulin-like growth factor ratio, consistent with the diagnosis of NICTH. As patient was not a candidate for surgical resection or chemotherapy, he was started on prednisolone with some improvements in the glucose homeostasis, but soon decompensated after a superimposed hospital acquired pneumonia. CONCLUSION NICTH can occur as the sole initial presentation of HCC and is often difficult to correct without tumor removal. Clinicians should maintain high clinical suspicion for early recognition of paraneoplastic NICTH in patients at risk for HCC, even those with chronic fasting hypoglycemia in the setting of severe hepatic failure and malnutrition.

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Section: Discussioncontrasting

confidence: 81%

Non-islet cell tumor hypoglycemia as an initial presentation of hepatocellular carcinoma coupled with end-stage liver cirrhosis: A case report and review of literature

Douli

Suarez

et al. 2020

WJH

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“…Tumor hypoglycemia may be due exclusively to increased glucose consumption by the tumor mass and/or its metastases, as well as in those with massive liver tumor infiltration (93,94,95,96,97). Among these tumors are hepatocellular carcinoma (95,96), meningioma (93,94), non-Hodgkin's lymphoma (98,99), and pheochromocytoma (97).…”

Section: Other Tumor-related Factorsmentioning

confidence: 99%

“…Among these tumors are hepatocellular carcinoma (95,96), meningioma (93,94), non-Hodgkin's lymphoma (98,99), and pheochromocytoma (97). Excessive tumor glucose consumption can become manifested through functional tests such as 18 F-2-fluoro-2-deoxy-D-glucose positron emission tomography/CT ( 18 F-FDG-PET/CT), showing remarkable glucose uptake in the tumor with reduced physiologic uptake in other organs (97).…”

Section: Other Tumor-related Factorsmentioning

confidence: 99%

MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

Iglesias

Díez

2014

European Journal of Endocrinology

139

144

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Tumor-induced hypoglycemia (TIH) is a rare clinical entity that may occur in patients with diverse kinds of tumor lineages and that may be caused by different mechanisms. These pathogenic mechanisms include the eutopic insulin secretion by a pancreatic islet b-cell tumor, and also the ectopic tumor insulin secretion by non-islet-cell tumor, such as bronchial carcinoids and gastrointestinal stromal tumors. Insulinoma is, by far, the most common tumor associated with clinical and biochemical hypoglycemia. Insulinomas are usually single, small, sporadic, and intrapancreatic benign tumors. Only 5-10% of insulinomas are malignant. Insulinoma may be associated with the multiple endocrine neoplasia type 1 in 4-6% of patients. Medical therapy with diazoxide or somatostatin analogs has been used to control hypoglycemic symptoms in patients with insulinoma, but only surgical excision by enucleation or partial pancreatectomy is curative. Other mechanisms that may, more uncommonly, account for tumor-associated hypoglycemia without excess insulin secretion are the tumor secretion of peptides capable of causing glucose consumption by different mechanisms. These are the cases of tumors producing IGF2 precursors, IGF1, somatostatin, and glucagon-like peptide 1. Tumor autoimmune hypoglycemia occurs due to the production of insulin by tumor cells or insulin receptor autoantibodies. Lastly, massive tumor burden with glucose consumption, massive tumor liver infiltration, and pituitary or adrenal glands destruction by tumor are other mechanisms for TIH in cases of large and aggressive neoplasias.

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“…Non-islet cell tumor hypoglycemia is a rare but well-recognized phenomenon. Hepatocellular carcinoma can present with SH 41,42. Hematological malignancies can present as a combination of lactic acidosis and hypoglycemia 43,44.…”

Section: Overviewmentioning

confidence: 99%

Hypoglycemia Revisited in the Acute Care Setting

et al. 2011

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Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

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Hypoglycemic Encephalopathy as the Initial Presentation of Hepatic Tumor

Abstract: This case highlights the importance of a hepatic evaluation in, otherwise, unexplained hypoglycemic coma in high prevalence areas of hepatocellular carcinoma such as the Asian-Pacific region.

Cited by 11 publications

References 14 publications

Non-islet cell tumor hypoglycemia as an initial presentation of hepatocellular carcinoma coupled with end-stage liver cirrhosis: A case report and review of literature

Non-islet cell tumor hypoglycemia as an initial presentation of hepatocellular carcinoma coupled with end-stage liver cirrhosis: A case report and review of literature

MANAGEMENT OF ENDOCRINE DISEASE: A clinical update on tumor-induced hypoglycemia

Hypoglycemia Revisited in the Acute Care Setting

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