Hypo

1. A case of recurrent hypoglycemia
Dr sarathchandran k
M1 unit

2. • Afkar
• 19 year old male
• First year B TECH

3. Presenting complaints
 drowsiness and giddiness while waking up in morning * 6 months

4. History of present illness
C/o recurrent episodes of drowsiness and giddiness while waking up
from bed
Usually go to sleep at around 11 pm
According to mother it was difficult to waking him up from sleep in
morning
After waking up he experienced headache and drowsiness
It was relieved after taking breakfast

5. He usually wakes up at 10am
breakfast at 10.30 am
lunch at 3 pm
tea with snacks at 5 pm
dinner at 7 pm
usually take some snacks at 10 pm
sleep at 11 pm
no h/o any drowsiness and giddiness in day time or night

6. Last month he was send to a hostel
In hostel he takes dinner at 7 pm and went to sleep at 10pm
Next day morning he was drowsy in the morning
but managed to get up from bed had breakfast
3rd day morning he was lying in the bed not waking up at 9 am
Inmates tried to wake him up
He was drowsy – brought to near by hospital
GRBS –low (no records available)
given IV fluids, he improved and send home

7. next day his parents brought him to a physician
GRBS low-22mg/dl
refered to MCH KOTTAYAM

8. HISTORY CONTINUED
• no h/o any drowsiness and giddiness in day time or night
• no h/o diabetes
• no h/o any chronic drug intake, ethanol consumption
• no h/o weight loss ,chronic fatigue ,nausea, abdominal pain,
hyperpigmentation
• no h/o of exercise intolerance, muscle cramps
• no h/s/o any chronic liver or renal disease

9. Personal , developmental and family history
mixed diet
Bowel and bladder habits normal
Normal developmental history
No family history of hypoglycemic events

10. Differential diagnosis
 endogenous hyperinsulinism
insulinoma
functional beta cell disorders ( nesidioblastosis)
 insulin secretagogues intake
 inborn errors of metabolism ( glycogen storage disorders)

11. EXAMINATION
conscious and oriented
no pallor, icterus ,clubbing, cyanosis,lymphadenopathy,edema
PR:78 per min
BP:120/70 mmhg
RR:12 per min
Head to Toe normal

12. Systemic examination
• GIT
P/A –soft, No HSM
• Cvs: S1,S2 normal
• Resp: chest clear
• CNS: HMF normal, no FND

13. Investigations
• Hb-13.6 tb/db-0.5/0.1 USG abdomen-normal
• Mcv-80.7 tp/alb-8.4/4.5 pancreas normal
• Pcv-46.4 ot/pt_30/35 liver normal
• Tc-11200 alp-102
• Dc-P47L39M12 URE - normal
• Platelet-2.64L ECG- normal
• Rbs-164 CXR PA-wnl
• Ur/cr-19/0.9
• Na/k-135/4.5

14. IN HOSPITAL
FBS- <50 mg/dl
PPBS- 93 mg/dl
Day time - no symptoms of hypoglycaemia
Next day he was kept in fasting
After 8 hrs of fasting

15. After 8 hrs of fasting
he developed
 symptoms of hypoglycemia – sweating headache giddiness
GRBS -36mg/dl
Blood sample was taken for c peptide and insulin levels
Symptoms relieved after D25 infusion
Whipple triad positive
c peptide –1.64 ( 0.81-3.35)
s. insulin – 11.4 (2.6-24.9)
Endocrinology opnion
Endogenous hyperinsulinemia

16. MRI abdomen
Initial MRI report came as normal
due to strong suspicion case discussed
Report came as
A well defined T1 hypo , T2 hyperintense lesion in body of pancreas
predominantly exophytic . Measure 1.8*1.2cm.post contrast there is an
homogenous enhancement . Lesion show diffusion restriction with mild
low ADC.
Imaging finding s/o neuroendocrine tumor - insulinoma

20. bystander wanted discharge
he went to private hospital for EUS and guided Bx
EUS report
An isoechoic rounded lesion noted in the body of pancreas
(8.4*8.9cm) . Pancreatic duct not dilated. No nodes seen. Visualised
liver and spleen normal. GB normal. CBD normal. Aorta normal. Portal
vein normal

21. Final Diagnosis
ENDOGENOUS HYPERINSULINEMIA
INSULINOMA

22. Next step
Early age of presentation
so consider syndromic associations
MEN 1
plan is to evaluate further
once the biopsy result is
available

23. DISCUSSION
SYMPTOMS OF HYPOGLYCEMIA
NEUROLOGICAL AUTONOMIC
CONFUSION SWEATING
DROWSINESS POUNDING HEART
SPEECH DIFFICULTIES HUNGER
INABILITY TO CONCENTRATE ANXIETY
INCORDINATION

25. Physiology of glucose counterregulation

26. • Hepatic glycogen stores can only maintain sufficient glucose level to
8hrs
• Brain requires glucose but cant synthesis or utilize fatty acids
• Dynamic thresholds----higher than normal to be maintained in
diabetic population
• CNS glucose deprivation----sympathoadrenal discharge

27. Approch to hypoglycemia

29. 1- hypoglycemia in diabetics
• Drugs
• Ckd
• HAAF
recent antecedent hypoglycemia reduces glucose couter regulation and
hypoglycemic unawareness

31. er
2- hypoglycemia without diabetes
• Drugs – ethanol, ACEI, ARBS, beta blockers
• Critical illness –renal, hepatic , cardiac failure , sepsis
• Hormone deficiencies- addisons , hypopituitarism, GH deficiency
• Non beta cell tumors—
mesenchymal or epithelial tumors producing IGF
• Endogenous hyperinsulinism

32. Endogenous hyperinsulinism
1-primary beta cell disorder
insulinoma
functional beta cell disorder with beta cell hypertrophy or
hyperplasia
2-antibodies to insulin or insulin receptor
3-beta cell secretagogue
4-ectopic insulin secretion

33. • Critical diagnostic findings
plasma insulin concentration ≥3 μU/mL (≥18 pmol/L)
plasma C-peptide concentration ≥0.6 ng/mL (≥0.2 nmol/L)
plasma proinsulin concentration ≥5.0 pmol/L
when the plasma glucose concentration is <55mg/dl with symptoms
of hypoglycaemia or
an increment in plasma glucose level of >25 mg/dL (>1.4 mmol/L)
after IV administration of glucagon (1.0 mg)

34. Insulinoma
• uncommon 1 in 250000
• >90% bengin
• Median age 50 yrs , in MEN 1 presents in 3rd decade
• Equal incidence in body tail head
• neuroglycopenic symptoms > autonomic
• Diagnosis

35. Non invasive test
USG abdomen
Spiral CECT- 70 -80% detection rate
MRI -70 – 80% detection rate
Ga 68 DOTATATE PET CT

36. • Invasive tests
1- EUS – 90%
2- selective arterial calcium stimulation

37. • Treatment
resection
medical –diazoxide, octreotide, everolimus

38. Inborn errors of metabolism causing hypoglycaemia
1- fasting hypoglycemia
GSD 0 ,1, 3, 4 and fanconi bickel syndrome
defect in fatty acid oxidation
2-post prandial hypoglycemia
glucokinase, SURI and Kir6 potassium channel mutation
congenital disorders of glycosylation
inherited fructose intolerance
Exercise induced hypoglycemia
increase activity of monocarboxylase transporter 1 in beta cells

39. Hiratas disease
autoantibodies to insulin
>40 years
post prandial hypoglycemia
autoimmune association
severe neuroglycopenic symptoms
methimazole ppt
insulin molecule dissociate quickly causing marked hypoglycaemia
spontaneous recovery

40. • Thank you