Non- pancreatic neuroendocrine tumour presenting with hypoglycemia in an elderly patient

Abstract

Background: Hypoglycemia is a common, symptom seen in individuals. Hypoglycemia in the elderly is both under-recog- nized and misdiagnosed due to nonspesific hypoglycemic symptoms and accompanying comorbidities in this population. In diabetic individuals, hypoglycemia is most commonly caused by administering insulin or sulphonylureas and insulin secretagogues. Other drugs, such as antibiotics or beta-blockers, have been reported to reduce blood glucose to abnormally low levels. Hypoglycemia in non-diabetic patients is considered a rare event, and the possible reasons may be reactive hypo- glycemia, insulin-secreting tumours and other malignancies, hypopituitarism, hypocortisolism, alcohol abuse, inappropriate insulin self-administration, malnutrition, renal failure and sepsis.
 Case: An 86- year- old male was admitted to the emergency department with hypoglycemia diagnosed with non-pancreatic neuroendocrine tumour (NET) on lung secreting insulin. No surgical intervention or chemotherapy was planned due to patients age and comorbidities so best supportive care was planned. We used prednisone for symptomatic treatment of hy- poglycemia and the patient has been followed up periodically. In this period he had no hypoglycemic attack.
 Conclusion: For patients with hypoglycemia who are unable/decline to receive any further treatment, low dose glucocorti- coid is a good choice to achieve normoglycemia. It seems to be more cost effective compared to other treatment options. Furthermore hospitalisation rates may decrease due to decreased hypogylcemic attacks.
 Keywords: Neuroendocrine tumour; hypoglycaemia; prednisone; non-islet cell tumour.

Non-diabetic hypoglycemia

“…49 Ectopic insulin secretion has been reported in a few cases, but most have not been convincingly proven. 50 Nevertheless, extrapancreatic insulin-secreting neuroendocrine tumors with hyperinsulinemic hypoglycemia have been reported very rarely. 51 Non-islet cell tumor hypoglycemia (NICTH) is most commonly seen in tumors of mesenchymal or hepatic origin, but a wide variety of tumor types can cause large IGF-2 production.…”

Editor’s choice: this December 2020

“…Even during this Covid-19 pandemic, NCDs are forever with thus: cardio-vascular disease nursing care, 21 hypertention, 22 HIV-exposed infants 23 , ECG abnormalities in HIV, 24 left ventricular hypertrophy, 25 epicardial fat, 26 aerobic exercise, 27 insulin resistance, 28 asthma, 29 COPD and sleep, 30 e cigarettes, 31 non- alcoholic liver disease, 32 home care, 33 Bilateral paediatric surgery, 34 self-harm, 35 MRI, 36 osteosarcoma risk, 37 thyroid 38 and gastric esophageal cancer; 39 fibromatosis, 40 prostate cancer, 41 neuro-endocrine tumour, 42 polycystic ovary and vitamin D deficiency, 43 micro RNAs and disease: 44 all will hopefully make us appreciate the burden and effect of this scourge on our people.…”

Hypoglycemia in a Non-diabetic Patient and the Side Effects of Diazoxide Use

“…A low blood glucose level (less than 55 mg/dL) associated with autonomic (tremors, sweating, and palpitations) and neuroglycopenic (confusion, dysarthria, visual impairment, or even coma) signs and/or symptoms that resolve after glucose administration establishes the Whipple's triad, indicating the presence of a hypoglycemic disorder [1][2][3][4]. Hypoglycemia in non-diabetic patients is rare [5] and the diagnostic cascade can be challenging.…”

“…Furthermore, it is important to exclude acute alcoholism, critical illness, liver/kidney failure, cortisol deficiency, gastric/bariatric surgery, insulinoma, and islet cell hyperplasia (including nesidioblastosis). Other causes, even more rare, include genetic (monogenic congenital hyperinsulinism, insulin receptor mutations, and inborn errors of metabolism), paraneoplastic (non-islet-cell tumors), and autoimmune (Hirata's disease and Flier's syndrome) [1][2][3][4][5][6]. Therefore, an exhaustive clinical history, including the time of onset of symptoms and its correlation with meals, and examination are essential.…”

“…Therefore, an exhaustive clinical history, including the time of onset of symptoms and its correlation with meals, and examination are essential. Insulinoma is the most common cause of endogenous hyperinsulinism, although it has an annual incidence of only four in one to three million people [1,3,5,7,8]. It is generally associated with fasting hypoglycemia, and the diagnosis is established when there is biochemical evidence of hypoglycemia with an inappropriately normal/high level of insulin (equal to or greater than 3 μU/mL) and C-peptide (equal to or greater than 0.6 ng/mL) occurring spontaneously or during a 72-h fasting test.…”