MON-139 Hyperinsulinemic Hypoglycemia In A Patient Of Chronic Calcific Pancreatitis : A Medical Oxymoron

Abstract

Introduction Hypoglycemia is rare in persons without diabetes due to normal physiological defences and thus a thorough evaluation is warranted in such cases. Neurogenic symptoms occur initially followed by neuroglycopenic symptoms like cognitive impairment, behavioural changes, psychomotor abnormalities and rarely seizures and coma. Causes of hypoglycemia in non diabetic patients include hepatogenous hypoglycemia, critical illness, alcohol and multiple drugs. Major causes of hypoglycemia in a seemingly healthy individual, after excluding drug intake, include hyperinsulinemic hypoglycemia caused by Insulinomas, Nesidioblastosis, Insulin autoimmune syndrome; and IGF2 secreting tumors. Management includes removal of the tumor, if found, or medical management with Diazoxide and frequent feeds. Octreotide can be used in patients with suspected Insulinoma. Medical management is difficult and frequent feeds can lead to obesity. Chronic calcific pancreatitis, on the other hand, usually leads to hyperglycemia due to pancreatic diabetes which is generally brittle. Hypoglycemia can occur in such patients but is generally a result of antidiabetic therapy. However, it is rare to have hyperinsulinemic hypoglycemia in patients who are not on antidiabetic medication and diagnosis can be delayed. Here we present a case of hyperinsulinemic hypoglycemia in a patient of chronic calcific pancreatitis. Case A 47 year old female with history of repeated episodes of slurred speech, confusion, disorientation and abnormal limb movements for last 3 years. She had been treated as seizure disorder with antiepileptics and was incidentally found to be hypoglycemic during one of these episodes. She was subsequently referred to us for further evaluation. At presentation she was conscious, oriented and had no history suggestive of any chronic illness or drug intake other than antiepileptics. Investigations showed RBS of 85 mg/dl and HbA1c of 3.2%. During prolonged fasting test, she developed hypoglycemia within 10 hours with RBS of 26 mg/dl with concomitant serum Insulin level of 15.47 µU/ml (cutoff < 3 µU/ml with hypoglycemia) and C-peptide level of 2.07 ng/ml (cutoff < 0.2 ng/ml with hypoglycemia). These were consistent with hyperinsulinemic hypoglycemia. CT abdomen showed features of chronic calcific pancreatitis, no focal pancreatic lesion was found. 68Ga DOTATATE PET/CT scan was negative for any functional lesion. She was started on Diazoxide and advised frequent feeds. She improved symptomatically with diazoxide with recurrence of symptoms off it. She was given a trial of octreotide due to non-availability of diazoxide. She improved with octreotide and was started on long acting octreotide. Conclusion Hyperinsulinemic hypoglycemia should be excluded in all patients with unexplained seizure disorder, even if the clinical probability for the same is low, as in our patient.