INSULINOMA IN A PATIENT WITH TYPE

2 DIABETES

CASE REPORT
NAMA : IQBAL PUTRA AMIRULLAH
NIM : 030.14.098
ABSTRACT
Objective: To describe a case of insulinoma in a patient with pre-existing type 2 diabetes
mellitus.
Methods: We report a case, with clinical, biochemical, and imaging ndings, and give a literature
review.
Results: The most common causes of recurrent hypo- glycemia in a patient with diabetes mellitus
are insu- lin excess and use of insulin secretagogues. If these are completely ruled out, other
causes must be considered. The co-existence of diabetes mellitus and insulinoma is very rare,
with less than 40 cases reported in the litera- ture. We report the case of a 66-year-old woman
with obesity, hypertension, and type 2 diabetes mellitus treated with premixed insulin, who was
diagnosed with an insuli- noma in the setting of a 6-month history of severe recur- rent
hypoglycemia that persisted despite discontinuation of insulin therapy. A computed tomography
of the abdo- men revealed a 14-mm tumor in the pancreatic tail that was removed through
laparoscopic distal pancreatectomy
INTRODUCTION

• The most common causes of recurrent hypoglycemia in a patient with diabetes

mellitus (DM) are insulin excess and use of insulin secretagogues.
• Ifthese are completely ruled out, rare causes must be considered. The co-
existence of DM and insulinoma is very rare and can be a diagnostic
challenge.
• To our knowledge, less than 40 cases have been reported, mostly in patients
with type 2 DM.
CASE PRESENTASION

• A 66-year-old Caucasian woman, with a history of obesity (body mass index,

30 kg/m2), hypertension, and type 2 DM was referred to our outpatient clinic
for evalu- ation of severe recurrent episodes of hypoglycemia.
CASE PRESENTASION

• She was known to have type 2 DM diagnosed 14 years earlier and had been
managed with three times daily injections of premixed insulin since the diagnosis.
• She denied taking any further hypoglycemic drugs.
• She had no known long-term complications and her family history was unremarkable,
with no evidence of diabetes or other endocrine disorders.
• Approximately 6 months before referral to our department, the patient started
noticing recurrent episodes of weakness, blurred vision, and diaphoresis relieved by
eating,
• Due to these episodes, she progressively reduced the TDID until de nitive
suspension of insulin, which occurred approximately 5 weeks before referral.
Despite that, the episodes of hypoglycemia persisted, both fasting and
postprandial, so she was admitted for further investigation.
• During a hypoglycemic episode, assessment of serum insulin and C-peptide
revealed inappropriately high values,
• No other measurements were done, namely proinsulin, β-hydroxybutyrate,
screening of sulphonylurea and its metabolites, and insu- lin antibodies, and a
glucagon stimulation test was not performed.
• Results of liver and kidney tests were normal,
• A computed tomographic scan of the abdomen revealed a 14-mm hypervascular, rounded tumor
in the pancreatic tail (Fig. 1).
A, At low power, the tumor was well-circumscribed, abutting on the pancreatic parenchyma (arrow)
B, Architecturally, it had an organoid histologic pattern characterized by a nested and trabecular arrangement of the tumor cells.
C, The cells were relatively uniform, with ne granular eosinophilic cytoplasm and a centrally located round nucleus with a coarsely
clumped chromatin pattern (“salt and pepper” chromatin).
D, Tumor cells displayed strong and diffuse expression of synaptophysin
• Hypoglycemia is a feared complication of glucose- lowering therapy in patients with
DM, as it can cause considerable morbidity and even mortality. If hypogly- cemia,
diagnosed by Whipple’s triad, persists after the adjustment of antidiabetic
medications, other causes must be considered and investigated. The possibility of
surrepti- tious intake of drugs should also be considered.
• nsulinomas are extremely rare, with an estimated inci- dence of 4 cases per million
persons per year (9). They are insulin-secreting tumors that are mainly benign (90%)
and solitary (90%) and are usually small (90% are less than 2 cm).
• Insulinomas present with the neuroglycopenic and sympathoadrenal symptoms
induced by hypoglycemia. The diagnosis implies biochemical con rmation, by the
nding of high insulin and C-peptide during hypoglycemia. Imaging studies such as
computed tomography (CT) or magnetic resonance imaging are helpful when trying
to determine its location. After locating the tumor, surgery is generally cura- tive
• To our knowledge, less than 40 cases have been reported. The small
probability of these two disorders occurring together and the existence of
several other factors that may induce hypoglycemia in patients with DM poses
a diagnostic chal- lenge.
• Existing reports mostly describe patients with type 2 DM who developed
hypoglycemic episodes unexplained otherwise
• After distal pancreatectomy, the hypoglycemic episodes ceased and the
patient had to resume insulin treatment due to sustained hyperglycemia.
CONCLUSION

• Hypoglycemia may have severe compli- cations, and its cause must be intensively
sought.
• Finding the cause of hypoglycemia in diabetic patients is usually straightforward, but
we have to keep in mind other rare causes in order to avoid a diagnosis delay.
• The co-existence of DM and insulinoma is very rare. With this case report, we intend
to increase awareness of this unusual association that can be especially challenging
to diagnose. This entity must always be considered in the presence of recurrent
hypoglycemic episodes, especially after antidiabetic treatment discontinuation.