To present a case of hypoglycemia secondary to an insulinoma in a patient with HAART.
Methods : The clinical and paraclinical characteristics of the patient are described
Results : Woman, 43 yo. In 2013, HIV Dx in HAART (Lamivudine, Tenofovir, Atazanavir). For the past 4 years she has had palpitations, sweating and drowsiness, predominantly when she awoke, symptoms improved after eating food. Three years ago, she presented an episode of convulsion while she slept, of two minutes duration, which gave up spontaneously and in the postictal she received sweet foods, referring improvement; These episodes are recurrently presented with the same characteristics described, so the neurologist indicates treatment with phenytoin and phenobarbital, with no improvement and therefore suspends medication. 2 years ago, she presented G: 46mg%, which is why she is referred to our service. Weight: 65.5kg, BMI: 27.36. During hospitalization she had fasting capillary glycemia of 22 - 43mg% in 2 successive days with autonomic symptoms. Analytical: TSH: 2.9uU/ml, T4L: 0.952ng/dl; Cortisol 8am: 14.7ug/dl, Cr: 0.62mg/dl, Normal liver function tests and viral load: undetectable. The fasting test was suspended when a critical glycemia value was reached at 38mg/dl, insulin: 25.2uUI/ml, C peptide: 4.2ng/ ml; anti-insulin antibodies (-). CT: 13x8mm nodule in the anterior border of the body segment of the pancreas, suggestive of net. Echo-endoscopy: hypoechogenic lesion of 13.4x15mm with well-defined edges in the proximal and anterior bodies of the pancreas. She underwent distal pancreatectomy with 2cm tumor findings at the level of the body and proximal tail of the pancreas, indurated, delimited edges, whose pathology reported a type I neuroendocrine tumor, a trabecular pattern with a low mitotic index, and both surgical margins free. Ki67 1%. Patient has not presented episodes of hypoglycemia or seizures from the first intervention to the present.
Discussion : Insulinoma has an incidence of 1 - 4 cases / million persons / year; it is the most frequent functioning pancreatic islet tumor. His clinical presentation is with Whipple's triad, during fasting or exercise. It has been described that protease inhibitors reduce insulin-stimulated phosphorylation, causing a deficit in their secretion and peripheral resistance, which may explain a delay in diagnosis. More than 90% are benign and lonely. The surgical intervention of choice is the enucleation of the tumor. The prognosis depends on the degree of differentiation, ki-67 <2%, limitation to the pancreas and size <2cm. With a survival between 30 to 100% at 10 years.
Conclusion : The presence of seizures preceded by adrenergic symptoms should make us suspect in hypoglycemia.
Jose PAZ-IBARRA– ENDOCRINOLOGIST, HOSPITAL NACIONAL EDGARDO REBAGLIATI - UNIVERSIDAD NACIONAL MAYOR DE SAN MARCOS. LIMA - PERU, Lima, Lima, Peru
Victor Garcia– ENDOCRINOLOGY RESIDENT, HOSPITAL REBAGLIATI - LIMA - PERU, Lima, Peru
Karla Salas– ENDOCRINOLOGY RESIDENT, HOSPITAL REBAGLIATI - LIMA - PERU, Peru
HOSPITAL NACIONAL EDGARDO REBAGLIATI - UNIVERSIDAD NACIONAL MAYOR DE SAN MARCOS. LIMA - PERU
Lima, Lima, Peru
PERUVIAN ENDOCRINOLOGIST, UNIVERSITY TEACHER, ACTIVE MEMBER OF AACE, AREAS OF INTEREST NEUROENDOCRINOLOGY, THYROID, ENDOCRINOLOGY OF REPRODUCTION AND BONE MINERAL METABOLISM
HOSPITAL REBAGLIATI - LIMA - PERU, Lima, Peru