Nesidioblastosis in an elderly patient

An Uncommon Cause of Recurrent Presyncope, Dizziness, and Tachycardia: A Case Report of Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS)

Neurovegetative and autonomic symptoms are common presentations of various diseases, ranging from psychosomatic to severe organic disorders. A 23-year-old man presented with a history of recurrent presyncope, dizziness, and tachycardia. Repeated diagnostic work-up in various clinical settings could not identify any definite cause for approximately eight years. However, the incidental detection of postprandial and exercise-induced hypoglycemia was suggestive of an insulin-related disorder. A 72 h plasma glucose fasting test revealed endogenous hyperinsulinism. Upon imaging studies, no tumor mass potentially indicating insulinoma could be detected. ⁶⁸Ga-DOTA-Exendin-4 PET/CT showed diffuse tracer enrichment throughout the whole pancreas. A subtotal pancreatectomy was performed, and the diagnosis of diffuse, adult-onset nesidioblastosis was established histopathologically. This corresponds to the clinical findings of a functional β-cell disorder, also known as non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). After nine months, the symptoms recurred, making complete pancreatectomy necessary. Postoperative laboratory evaluation exhibited no residual endogenous C-peptide production. This case illustrates the diagnostic challenges in patients presenting with unspecific, neurovegetative and autonomic symptoms with a severe and rare underlying cause.

Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia

Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.

Endogenous hyperinsulinism: diagnostic and therapeutic difficulties

Endogenous hyperinsulinism is an abnormal clinical condition that involves excessive insulin secretion, related in 55% of cases to insulinoma. Other causes are possible such as islet cell hyperplasia, nesidioblastosis or antibodies to insulin or to the insulin receptor. Differentiation between these diseases may be difficult despite the use of several morphological examinations. We report six patients operated on for endogenous hyperinsulinism from 1^st January 2000 to 31^st December 2015. Endogenous hyperinsulinism was caused by insulinoma in three cases, endocrine cells hyperplasia in two cases and no pathological lesions were found in the last case. All patients typically presented with adrenergic and neuroglycopenic symptoms with a low blood glucose level concomitant with high insulin and C-peptide levels. Computed tomography showed insulinoma in one case out of two. MRI was carried out four times and succeeded to locate the lesion in the two cases of insulinoma. Endoscopic ultrasound showed one insulinoma and provided false positive findings three times out of four. Intra operative ultrasound succeeded to localize the insulinoma in two cases but was false positive in two cases. Procedures were one duodenopancreatectomy, two left splenopancreatectomy and two enucleations. For the sixth case, no lesion was radiologically objectified. Hence, a left blind pancreatectomy was practised but the pathological examination showed normal pancreatic tissue. Our work showed that even if morphological examinations are suggestive of insulinoma, other causes of endogenous hyperinsulinism must be considered and therefore invasive explorations should be carried out.

Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia

PURPOSE

Indications for total pancreatectomy (TP) have increased, including for diffuse main duct intrapapillary mucinous neoplasms of the pancreas and malignancy; therefore, the need persists for surgeons to develop appropriate endocrine post-operative management strategies. The brittle diabetes after TP differs from type 1/2 diabetes in that patients have absolute deficiency of insulin and functional glucagon. This makes glucose management challenging, complicates recovery, and predisposes to hospital readmissions. This article aims to define the disease, describe the cause for its occurrence, review the anatomy of the endocrine pancreas, and explain how this condition differs from diabetes mellitus in the setting of post-operative management. The morbidity and mortality of post-TP endocrine insufficiency and practical treatment strategies are systematically reviewed from the literature. Finally, an evidence-based treatment algorithm is created for the practicing pancreatic surgeon and their care team of endocrinologists to aid in managing these complex patients.

METHODS

A PubMed, Science Citation Index/Social sciences Citation Index, and Cochrane Evidence-Based Medicine database search was undertaken along with extensive backward search of the references of published articles to identify studies evaluating endocrine morbidity and treatment after TP and to establish an evidence-based treatment strategy.

RESULTS

Indications for TP and the etiology of pancreatogenic diabetes are reviewed. After TP, ~80% patients develop hypoglycemic episodes and 40% experience severe hypoglycemia, resulting in 0-8% mortality and 25-45% morbidity. Referral to a nutritionist and endocrinologist for patient education before surgery followed by surgical reevaluation to determine if the patient has the appropriate understanding, support, and resources preoperatively has significantly reduced morbidity and mortality. The use of modern recombinant long-acting insulin analogues, continuous subcutaneous insulin infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed.

CONCLUSION

Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.

A rare case of noninsulinoma pancreatogenous hypoglycemia syndrome

As the obesity pandemic continues to worsen and medical interventions remain only moderately effective, bariatric surgery remains an important option for patients. In certain instances, patients who have undergone the procedure experience postprandial symptoms of neuroglycopenia caused by noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS). NIPHS is a recently described syndrome and is also very rare, and therapeutic approaches are still under debate. We report the case of a 51-year-old female who underwent Roux-en-Y gastric bypass and presented with episodic postprandial hypoglycemia 2 years after surgery. An insulinoma was absent from all abdominal imaging. Fasting C-peptide, insulin, and glucose were normal. Due to the possibility of NIPHS, clinical treatment was commenced with acarbose, leading to a significant reduction of hypoglycemic episodes. NIPHS occurs in approximately 0.5% to 7% of patients with hyperinsulinemic hypoglycemia. Sporadic hypoglycemia postgastric bypass is an important entity that should be understood by all surgeons and internists who are involved in postgastric bypass care.

[Hyperinsulinemic hypoglycemia in adults. Case reports and a short review]

Persistent hyperinsulinemic hypoglycemia (nesidioblastosis) not caused by an insulinoma is rare in adults. Morphologically no insulin secreting tumor is present. Keystones of diagnosis are not only low glucose levels but to maintain normoglycemia by use of intravenous glucose and the presence of high insulin and C-peptide levels. Noninvasive and invasive diagnostic techniques are required to rule out a hormone secreting tumor. Both conservative and/or surgical therapy are suggested to prevent damaging effects of repeated hypoglycemia.

CASE REPORT

Two patients with frequent and serious episodes of hypoglycemia are reported. In the 34-year-old female symptoms appeared with sweating, dizziness, trembling, nervousness and serious neuroglycopenic signs. In the 22-year-old male the main complaint was tympany, a rare and unusual sign of hypoglycemia, and intense feeling of esurience. The 24-hour fasting test was positive in both cases, i.e. it had to be stopped because of symptomatic hypoglycemia. No insulinoma could be localized, despite extensive search, therefore in both cases the diagnosis of adult-onset nesidioblastosis was set up, despite lack of histological confirmation. Diazoxide therapy resulted in symptom-free life for both patients.

CONCLUSION

Several diagnostic methods and treatment options are suggested for the rare disease nesidioblastosis to balance defective insulin secretion. However, once the decision is made in favour of surgical therapy, there is a thin line between successful treatment, persistence of the disease, and pancreatic insufficiency. Therefore it is worth considering to try conservative therapy especially when surgery is of high risk. Our cases suggest that diazoxide therapy is an effective and safe alternative in the treatment of adult-onset nesidioblastosis.

Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS)

OBJECTIVE

Noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS), characterized by postprandial neuroglycopaenia, negative prolonged fasts and negative perioperative localization studies for insulinoma, but positive selective arterial calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas, is a rare hypoglycaemic disorder of undetermined aetiology. We analysed the clinical, morphological and immunohistological features to further clarify the aetiology and pathogenesis of this rare disease.

PATIENTS

Ten consecutive patients with NIPHS (nine men and one woman, aged 29-78 years) were included in the study. Six of the 10 received a gradient-guided subtotal (70%) or distal (50%) pancreatectomy. In the remaining four patients, diazoxide treatment was initiated and the precise mechanism of its action was assessed by meal tests.

RESULTS

All of the patients showed a combination of postprandial neuroglycopaenia, negative prolonged fasts (except one patient) and negative localization studies for insulinoma, but positive calcium stimulation tests and nesidioblastosis in the gradient-guided resected pancreas. Immunohistological studies of the resected pancreatic tissues revealed neither an increased rate of proliferation of beta-cells nor an abnormal synthesis and/or processing of either proinsulin or amylin. Evidence of overexpression of the two pancreatic differentiation factors, PDX-1 and Nkx-6.1, as well as the calcium sensing receptor (CaSR) was absent. Nevertheless, abnormal expression of islet neogenesis-associated protein (INGAP), a human cytokine expressed only in the presence of islet neogenesis, in ducts and/or islets, was identified in three of the five patients studied. All of the six patients who received a surgical operation were relieved of further neuroglycopaenic attacks, but one patient who received a subtotal pancreatectomy developed diabetes. In the remaining four patients who received diazoxide treatment, hypoglycaemic episodes were satisfactorily controlled with an attenuated response of beta-cell peptides to meal stimulation.

CONCLUSIONS

Our results strengthen the existence of this unique clinical hypoglycaemic syndrome from beta-cell hyperfunction as well as the value of the selective arterial calcium stimulation test in its correct diagnosis and localization. The mechanisms underlying beta-cell hyperfunction and release of insulin to calcium, however, remain poorly characterized. Nevertheless, in a subset of patients with NIPHS, there exists some, as yet undefined, pancreatic humoral/paracrine factor(s) other than proinsulin, amylin, PDX-1, Nkx-6.1 and possibly glucagon-like peptide-1 (GLP-1) that are capable of inducing the INGAP gene and, if activated, will initiate ductal proliferation and islet neogenesis. As for the treatment, we recommend that diazoxide be tried first in each patient and, should it fail, a gradient-guided subtotal or distal pancreatectomy be attempted.

A rare case of adult-onset nesidioblastosis treated successfully with diazoxide

A 54-year-old man was admitted to our hospital for evaluation of hypoglycemia. He had frequent episodes of loss of concentration before dinner. The ratio of IRI to plasma glucose (PG) was 0.8-1.0. Abdominal CT revealed no pancreatic tumor, and angiography of splenic artery showed no definite tumor stain within the pancreas. Based on the results of selective arterial calcium stimulation and hepatic venous sampling (ASVS), the provisional diagnosis was a small insulinoma in the pancreatic body. The patient underwent subtotal distal pancreatectomy. However, histopathological and immunohistochemical examinations of the resected tissue showed hypertrophy of islets of Langerhans islands and beta cells around pancreatic ducts. The final diagnosis was adult-onset nesidioblastosis. Postoperatively, the patient continued to exhibit hyperinsulinemia and nighttime hypoglycemia. Octreotide, voglibose and diet therapies failed to improve the nocturnal hypoglycemia. However, treatment with diazoxide at a starting dose of 200 mg/day resulted in immediate amelioration of nocturnal hypoglycemia. This is the first Japanese adult case of nesidioblastosis treated successfully with diazoxide. This case report suggests that diazoxide may be effective for adult-onset nesidioblastosis in a manner similar to that described for pediatric cases.

Noninsulinoma pancreatogenous hypoglycemia syndrome: a rare case of adult-onset nesidioblastosis

The most common cause of hyperinsulinemic hypoglycemia in adults is insulinoma. Nesidioblastosis is a rare, but well-recognized disorder of persistent hyperinsulinemic hypoglycemia in infancy, but adult-onset nesidioblastosis associated with hyperinsulinemic hypoglycemia, termed noninsulinoma pancreatogenous hypoglycemic syndrome (NIPHS), has been reported. Here, we describe an extremely rare case of NIPHS in an elderly man. A 78-year-old man was admitted to our hospital due to hypoglycemic coma. During the previous 3 months, he noticed excessive sweating at midafternoon. His low fasting plasma glucose level (27 mg/dl) and high immunoreactive insulin level (11.1 muU/ml) were consistent with the possible presence of insulinoma. Localizing studies including computed tomography of the abdomen and celiac arteriography were negative, but selective arterial calcium infusion (SACI) test suggested the presence of insulinoma in the body and tail of the pancreas. Surgical exploration by palpation and intraoperative ultrasonography failed to detect any mass in the pancreas, and 60% distal pancreatectomy was performed. Postoperatively, his hypoglycemic episodes completely disappeared. Histological examination of the resected pancreas revealed diffuse islet cell hyperplasia consistent with a pathological diagnosis of nesidioblastosis. Thus, our case is a very rare case of NIPHS, or adult-onset nesidioblastosis, in which SACI test was proven to be a useful diagnostic tool for localization of the pancreatic lesion.

Nesidioblastosis: An Old Term and a New Understanding

Nesidioblastosis is a clinically, pathologically, and genetically heterogeneous disease. Differences between well described forms in neonates with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and rare forms in adults are described. Histopathologic criteria include hypertrophic islets occasionally showing beta cells with pleomorphic nuclei, ductuloinsular complexes, and neoformation of islets from ducts. These changes can be found as diffuse or focal forms of nesidioblastosis. Although most cases occur sporadically, several genetic defects ( SUR1, Kir6.2, GCK, and GLUD1 genes) have been described in neonates. In adults a higher rate of nesidioblastosis is observed in conjunction with multiple endocrine neoplasia type 1. The disease is diagnosed biochemically by a supervised fasting test in adults and in neonates by determining the glucose requirements to maintain normoglycemia, inappropriately high insulin and c-peptide levels, low free fatty acid and ketone body concentrations, glycemic response to glucagons, and the absence of ketonuria. If all highly selective noninvasive imaging techniques fail to identify a tumor, selective arterial calcium stimulation testing for gradient-guided surgery in adults and percutaneous transhepatic pancreatic venous sampling in neonates should be performed. a 95% pancreatectomy is necessary in neonates with a diffuse form of nesidioblastosis, whereas focal forms can be treated by partial pancreatectomy.

Nesidioblastosis associated with hyperinsulinemic hypoglycemia in adults: review of the literature

Nesidioblastosis is a term that was first introduced by Laidlaw in 1938 to define the diffuse proliferation of pancreatic islet cells budding from ductal epithelium. First described in neonates, it is widely recognized to be the primary cause of persistent hyperinsulinemic hypoglycemia in infants. In adults, insulinoma accounts for most cases of hyperinsulinemic hypoglycemia. Adult-onset nesidioblastosis associated with hyperinsulinemic hypoglycemia is a very rare entity, representing 0.5-5% of cases of organic hyperinsulinemia. Since 1981, when Harness et al. reported the first series of adult nesidioblastosis causing hypoglycemia, only 71 cases have been published. This article provides a guide for the diagnosis of organic hyperinsulinism and indicates when nesidioblastosis should be suspected. New diagnostic methods and treatment options for this rare disease are proposed. We also present a review of all reported cases of adult nesidioblastosis in the last 22 years.

Surgical treatment of insulinomas

Differential diagnosis of hypoglycemic patients should include insulinoma. Plasma insulin-to-glucose ratio greater than 0.3 or C-peptide levels of 2 nmol/L or greater suggest insulinoma. Abdominal CT scan can exclude metastatic disease and identify uncommonly large islet cell tumors, but has poor sensitivity for localizing insulinomas; transgastric endoscopic ultrasound is the most sensitive technique. Palpation combined with intraoperative ultrasound identifies most tumors at operation and gives vital information about surrounding structures. If no tumor is found, blind distal pancreatectomy should not be performed, and the patient should be referred to an endocrinologist or endocrine surgeon for diagnostic confirmation and further localization. Laparoscopy is a viable alternative to open tumor resection; laparoscopic ultrasound can facilitate localization and guide safe resection.

Noninsulinoma pancreatogenous hypoglycemia syndrome: an update in 10 surgically treated patients

BACKGROUND

Neuroglycopenia from endogenous hyperinsulinism usually is caused by insulinomas in adults. We recently reported a novel hypoglycemic disorder in 5 patients (patients 1 to 5) with postprandial neuroglycopenia, negative 72-hour fasts, negative perioperative imaging studies, but positive calcium stimulation tests and islet hypertrophy and nesidioblastosis in the gradient-guided resected pancreata.

METHODS

In this report we compare our experience with 5 additional patients (patients 6 to 10) with this syndrome to that in the original report.

RESULTS

The clinical features of patients 6 to 10 were similar to those of patients 1 to 5. Each had positive calcium stimulation testing that guided the extent of the distal pancreatectomy and histologic evidence of islet cell hypertrophy or nesidioblastosis. All 10 patients are alive from 9 to 50 months after operation, 1 of whom had no amelioration of neuroglycopenia. Minor perioperative complications occurred in 3 patients. One patient has experienced repeated bouts of acute pancreatitis, pseudocyst formation, and exocrine insufficiency.

CONCLUSIONS

We have identified adult patients with severe, postprandial hyperinsulinemic hypoglycemia from diffuse islet cell disease, 80% of whom have been well palliated with surgery. The results in 7 men have been better than those in the 3 women for reasons that are not obvious.

Nesidioblastosis, myelodysplastic syndrome and nodular diabetic glomerulosclerosis in an elderly nondiabetic woman: an autopsy report

Nesidioblastosis as the cause of hyperinsulinaemic hypoglycaemia in an adult is rare. We report here an additional case of nesidioblastosis, which resulted in fatal hyperinsulinaemic hypoglycaemia in a 72-year-old woman with an underlying myelodysplastic syndrome. The diagnosis of nesidioblastosis was established only after post-mortem examination with a careful exclusion of minute insulinoma. To our surprise, the renal pathology disclosed typical diabetic nodular glomerulosclerosis in the same patient who had no previous history of diabetes mellitus (DM). Nesidioblastosis has been reported to cause 'reversal' of Type 1 DM and insulinoma causing 'reversal' of Type 2 disease. We therefore hypothesize that our patient might have had an undiagnosed DM in the past, which resulted in the typical diabetic nodular glomerulosclerosis. The nesidioblastosis caused a 'reversal' of DM and even the ultimate development of hyperinsulinaemic hypoglycaemia.

Nesidioblastosis with hyperinsulinemic hypoglycemia in adults: report of two cases

We report herein the cases of two women, aged 34 years and 39 years, respectively, found to have hyperinsulinemic hypoglycemia after presenting with a history of episodes of temporary loss of consciousness, nausea, and fainting. Under the suspected diagnosis of insulinoma, localization procedures were carried out, but no tumor was found. In both patients, a definite gradient in insulin concentration was found in the pancreas by percutaneous transhepatic or intraoperative portal venous sampling, and a misdiagnosis of insulinoma of the pancreatic body was made. During exploratory laparotomy no tumor was palpable in the pancreas, and intraoperative ultrasonography showed no low echoic mass in the pancreas. A distal pancreatectomy was performed in both patients, and histopathological examination of the resected specimens revealed graded slight hyperplasia of the islet cells.