Insulinoma and Prolactinoma in A Young Female - Philippine ...

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138 Cardino MJ T and Lantion-Ang FLdisorder and was started with Carbamazepine withescalating doses. Brain computed tomography scanand electroencephalogram were normal. Topiramatewas added to the anti-seizure regimen howeverpatient still had 4-6 seizure episodes per year. Therewere episodes of true hypoglycemia precipitatingthe seizure attacks thus a computed tomographyscan of the abdomen was done and showed a 2 x1.8cm pancreatic mass thus she was referred toEndocrinology for evaluation.Fig 1.MRI of the Abdomen Showing A 2 x 1.8cmPancreatic Nodule Enhanced By ContrastOn review, our patient started to have symptomsof generalized weakness associated with palpitations,hunger pangs and dizziness resolved with food intakefor 5 years. These symptoms usually occurredon waking up. Because of this pattern, she begangaining weight until 6 months later, she had onsetof generalized tonic seizures. Everytime she wasbrought to the emergency room, her blood sugarwas low. After giving intravenous glucose, patientregained consciousness. She gained 18 kg in 4months prior to referral to our service.Menarche was at 11 years old. Menstrual flowwas regular until a year prior to consult she hadamenorrhea. She had no dysmenorrheal, abnormaldischarges and history of contraceptive intake.Developmental history was at par with age. Shehad good school performance and even graduatedcollege. She had no history of blurring of vision, andchronic headaches. She had no family history oftumors, diabetes and hypertension.On examination, she had normal vital signs.She was obese with a BMI of 32 kg/m, 2 waistcircumference of 95 cm, hip circumference of 99cm, and waist to hip ratio was 0.95. There was noacanthosis nigricans, thyromegaly, and xanthomas.Silver striae were noted in the inner thighs. She hadno visual field cuts on confrontation test.Fig 2.Photograph of the Patient During Her Admission atPGHIn the approach to hypoglycemic patients, wehave to classify the etiology of the hypoglycemia.Our patient had fasting hypoglycemia. Differentialdiagnoses for fasting hypoglycemia includeddrugs e.g. sulfonylurea, critical illness, adrenaland pituitary insufficiency and insulinoma. Shewas not hypotensive, lethargic and weak makingthe consideration of adrenal insufficiency unlikely.Patient had no intake of sulfonylurea.The signs and symptoms of patients weresuggestive of insulinoma, thus serum insulin, C-peptide and random blood sugar were taken aftera 72-hour fast test. Baseline counter-regulatoryhormone levels were taken and then blood sugarwas monitored every 2 hours while patient fasted.Baseline 8 oÊclock morning serum cortisol (880nmol/L) was normal. A 72 hour fast test was done. Onthe 18th hour, she manifested with neuroglycopenicsymptoms. Capillary blood sugar was 38 mg/dl.A low random blood sugar at 18mg/dl with aninappropriately high serum insulin levels at 41.08uU/ml (normal: 2.6-24 uU/ml) were documented.C peptide was elevated at 25.6 ng/ml (normal: 1-5ng.ml) indicative of endogenous hyperinsulinemia.Serum insulin and C-peptide are secreted inequimolar amounts. In our patient, the serum insulinto C-peptide was 1.6 reflective of degradation of theC-peptide. The cathepsin B degrades the C terminalamino acids of C-peptide which is being determinedin the assay, resulting to higher insulin to C-peptideratio. 4
Insulinoma and Prolactinoma in A Young Female 139Table I. Review of Cases with Insulin to C-peptide Ratio inInsulinoma Patients 4AuthorLevels in InsulinomaKatabami 7.2Gin 6.3Sakai 6.1Scarlet 5.9Saudek 5Lebowitz 4.9Kondo 4.2Service 3.6Ciavarella 2.9Turner 2Fujikura 2Our Case 1.6Intraoperative ultrasound showed a 2 x 1.8 cmsolid nodule at the antero-inferior portion of the bodyof the pancreas and subsequently an enucleation ofthe nodule was done. Post-operatively, blood sugarrose to 208 mg/dl within 30 minutes from enucleationof the tumor. No symptoms of acute pancreatitis weredocumented and serum amylase was slightly elevatedonly at 178 U/ml (normal 83-110 U/ml). There wereno calcifications noted. Post-operative biopsy revealedan insulinoma. Cells were arranged in anastomosingcords separated by a vascular stroma, interspersedwith sparse collagenous stroma. Chromogranin-Aand synaptophysin staining of the tumor were positive(see figure 3). These staining results confirmed thatthe tumor was an insulinoma.Fig 3.A) 2x2 cm Pancreatic Nodule Post-Pancreatic Enucleation. B) Hematoxylin and Eosin Staining Showing Uniform Cellsin Anastomosing Cords. C) Panoramic View of the Tumor Cells in Clumps with Sparse Collagenous Stroma. D) PositiveSynaptophysin Staining of the Pancreatic Nodule. E) Positive Chromogranin Staining of the Pancreatic Nodule.
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