Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 17

17 - A RARE CASE OF DIABETES MELLITUS FOLLOWING INSULINOMA REMOVAL

Friday, Apr 26
11:00 AM – 11:30 AM

Objective : Insulinoma is a common pancreatic islet cell tumor and post-operative hyperglycemia is usually transient. We report a rare case of a patient who developed diabetes mellitus following surgical removal of an insulinoma.


Methods : N/A


Results :

A 46 years old woman presented with repeated episodes of hypoglycemia over 2 years characterized by tremor, tingling, palpitation, and lightheadedness, requiring food ingestion at 2 hours interval to prevent symptoms, leading to a weight gain of 90 lbs (BMI 44.2 kg/m2). Evaluation during an episode showed blood glucose 48 mg/dl, insulin 264.8 mU/L, C-peptide 10.6 ng/ml and negative beta- hydroxybutyrate. Drug screen for sulfonylureas and insulin antibodies were negative.  HbA1C was 5.4 %. Abdominal CT scan showed a 3.6 X 2.5 cm solid enhancing mass adjacent and superior to the body of the pancreas. MRI was unable to discriminate between an exophytic pancreatic tumor or a peri-gastric lymph node. Fine needle aspiration biopsy via endoscopic ultrasonography confirmed the mass to be an insulinoma.

Under intraoperative ultrasound guidance a 4 x 4 cm mass was enucleated from above and within the body of the pancreas. Markedly increased intraabdominal fat and fatty liver were seen at surgery. Immediately following surgery, glucose rose to 258 mg/dl requiring insulin treatment. Post-operative day 7, fasting glucose was 226 mg/dl, insulin and C-peptide fell to 52.8 mU/L and 3.9 ng/ml, respectively. Patient was discharged on detemir insulin due to persistent hyperglycemia. Three weeks later, a 75 gram OGTT revealed baseline values for glucose, insulin, and C-peptide of 154 mg/dl, 27.2 mU/L, and 2.7 ng/ml, respectively, and post-glucose increased to 264 mg/dl, 42 mU/L, and 3.07 ng/ml, respectively, demonstrating a relatively deficient response of insulin to hyperglycemia.


Discussion : The patient has multiple metabolic abnormalities including diabetes based on the OGTT, beta cell deficiency evidenced by low insulin/glucose ratio 0.18, and insulin resistant at the level of the liver (increased fasting insulin) with marked fatty liver and peripheral tissue (HOMA-IR 10.3). Whether her beta cell function will improve over time and “wake up” following several years of suppression from high level of endogenous insulin can only be determined over time. Weight loss and reduction of liver fat may also improve her overall insulin resistance.


Conclusion : In rare cases, hyperglycemia after insulinoma resection may be persistent and require long term treatment with anti-hyperglycemic agents. The advent of diabetes mellitus following the excision of an insulinoma may result from both suppression of normal beta cell function by the tumor and peripheral insulin resistance.

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Fan Zhang

Fellow
Endocrinology Department, SUNY Downstate Medical Center
Woodhaven, New York

Born in a physician’s family, I was naturally drawn to medicine. After graduating Peking University Health Science Center, I had three years of ophthalmology residency training in Peking Union Medical College Hospital, the most prestigious hospital in China. To join my husband, I came to USA. I pursued a research track by obtaining a Ph.D. in vision science at the State University of New York (SUNY), and continued research as a post-doctoral fellow and later as a PI.

My passion for direct patient care driven me to return to working as a physician. I finished my residency training in the Brookdale University Hospital and Medical Center (BUHMC) where I published three case reports and conducted a clinical study which was accepted as a late-breaking abstract in AACE. I was honored with a Research Reward of Endocrinology in BUMHC. Being attracted by endocrinology, I enrolled in the fellowship of Endocrinology in SUNY Downstate Medical Center. My research of thyroid nodule location and malignancy was accepted for publication by Endocrine Practice in Nov 2018.

Milay Luis Lam

Clinical assistant professor
Endocrinology Department, SUNY Downstate Medical Center
REGO PARK, New York

Endocrinologist at SUNY downstate

Vladimir Lokshin

Fellow
Endocrinology Department, SUNY Downstate Medical Center

A current fellow of Endocrinology Department in SUNY Downstate Medical Center

Lucas Policastro

Resident
Internal Medicine Department, SUNY Downstate Medical Center

Currently a resident of Internal Medicine Department, State University of New York, Downstate Medical Center

Shalini Arora

Assistant professor of surgery
SUNY Downstate Medical center
Brooklyn, New York

Dr. Arora is an endocrine surgeon who completed her training at Rush University in 2009. Her focus is mainly on Thyroid and parathyroid disease at Kings County hospital.

Jean Pujals-Kury

Fellow
Endocrinology Department, SUNY Downstate Medical Center

Currently a Fellow of Endocrinology Department, State University of New York, Downstate Medical Center

Qiang Xie

Attending
Pathology Department, Kings County Hospital Center
Brooklyn, New York

Currently an attending physician in the Pathology Department, Kings County Hospital Center

Justin Loona

Attending
Radiology Department, Kings County Hospital Center

Currently an attending in the Radiology Department, Kings County Hospital Center

Maryann Banerji

Professor, Chief
Endocrinology Department, SUNY Downstate Medical Center

Chief of Endocrinology Department, SUNY Downstate Medical Center

Nathaniel Winer

Professor, Chief
Endocrinology Department, Kings County Hospital Center
brooklyn, New York

Chief of Endocrinology Division, Kings County Hospital Center