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Teng JH, Hu JP, Wang X, Zhang C, Chen J. A rare case report of reversible glucose counterregulation in an insulinoma patient with type 2 diabetes. Endocrine 2024:10.1007/s12020-024-03703-9. [PMID: 38334891 DOI: 10.1007/s12020-024-03703-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
CONTEXT Insulinoma is a neuroendocrine tumor derived from pancreatic β -cells whose clinical manifestation is recurrent hypoglycemia. Insulinoma in a patient with preexisting diabetes is extraordinarily rare, and the unmasking of type 2 diabetes (T2DM) after insulinoma surgery is even rarer. CASE REPORT This article reports a 49-year-old male patient with insulinoma that masked the diagnosis of T2DM. The patient was admitted to the hospital with symptoms of hypoglycemia, such as repeated sweating, palpitations, and asthenia for over 4 years. The patient was diagnosed with insulinoma after completing relevant examinations. The emergence of hyperglycemia after the removal of insulinoma is attributable to the coexistence of T2DM. Surprisingly, a reversible decrease in cortisol levels was observed during the diagnostic process. We searched the previously published reports of this type of case from PubMed to determine why type 2 diabetes was covered by insulinoma and why glucocorticoids decreased. CONCLUSIONS The diagnosis of T2DM in the patient after surgery may be related to increased food intake and insulin resistance induced by hyperinsulinemia caused by long-term hypoglycemia. The reversible decrease in cortisol levels, not adrenocortical insufficiency during the diagnostic process, may be caused by a transient abnormality in glucose counterregulation.
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Affiliation(s)
- Jian-Hui Teng
- Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 41005, Hunan Province, China
| | - Jun-Pei Hu
- Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 41005, Hunan Province, China
| | - Xia Wang
- Department of Endocrinology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 41005, Hunan Province, China
| | - Chi Zhang
- Department of Endocrinology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 41005, Hunan Province, China
| | - Jing Chen
- Department of Endocrinology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 41005, Hunan Province, China.
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2
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Singbo J, Locketz M, Ross IL. Challenge of coexisting type 2 diabetes mellitus and insulinoma: a case report. J Med Case Rep 2021; 15:479. [PMID: 34583764 PMCID: PMC8479877 DOI: 10.1186/s13256-021-03047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Insulinomas are rare clinical entities, but concurrent diabetes mellitus is even more uncommon, and the combination is easily missed. Recurrent hypoglycemia could be misconstrued as improved glycemic control. We present an unusual patient with type 2 diabetes and neuroglycopenia, with apparent improved glycemic control due to an insulinoma. Case presentation A 54-year-old mixed ancestry man with a positive family history of type 2 diabetes mellitus was diagnosed with type 2 diabetes mellitus and hypertension 8 years prior to admission. He presented with episodes of abnormal behavior and hypoglycemia. Inappropriately high insulin and C-peptide concentrations were identified at the time of hypoglycemia. Despite poor adherence to his diabetic treatment, he had no target organ damage relating to diabetes, and his hemoglobin A1c (HbA1c) was 5.3%. A diagnosis of insulinoma was made, and he was started on diazoxide, with endoscopic ultrasound revealing a possible lesion in the pancreatic tail measuring 12 mm × 12 mm. A fine-needle aspiration biopsy could not be performed due to overlying splenic arteries and the risk of vascular perforation. An intraoperative ultrasound confirmed a 15 mm × 10 mm tumor in the pancreatic tail, necessitating a partial pancreatectomy and splenectomy, which were curative. A well-differentiated intermediate grade 2 pancreatic neuroendocrine tumor producing insulin was confirmed on histopathology. Conclusions Recurrent, progressive hypoglycemia and improved glycemic control in a diabetic, without an alternative explanation, may suggest an insulinoma. Insulinomas that exist with type 1 diabetes mellitus, particularly malignant insulinomas, must have escaped autoimmune attack through lack of autoantigen expression. Computed tomography on its own may be insufficiently sensitive for diagnosis of insulinomas, whereas endoscopic and intraoperative ultrasonography may improve the identification of the culprit lesion.
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Affiliation(s)
- Joseph Singbo
- Department of Medicine J47 Old Main Building Division of Endocrinology and Diabetes, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7945, South Africa
| | - Michael Locketz
- Department of Histopathology, Groote Schuur Hospital, University of Cape Town, Anzio Road, Observatory, Cape Town, South Africa
| | - Ian Louis Ross
- Department of Medicine J47 Old Main Building Division of Endocrinology and Diabetes, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town, 7945, South Africa.
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Subramani S, Bellizzi AM, Borcherding N, Kao SC, Dillon J, Howe J, Norris AW, Tansey MJ, Pinnaro CT. Hypoglycemia secondary to insulinoma masking the onset of type 1 diabetes in an adolescent. Clin Case Rep 2021; 9:e04868. [PMID: 34594558 PMCID: PMC8462061 DOI: 10.1002/ccr3.4868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/16/2021] [Accepted: 09/09/2021] [Indexed: 11/13/2022] Open
Abstract
Type 1 diabetes and insulinoma can co-occur in pediatric patients and may present with episodes of hypo- and hyperglycemia, significant glycemic variability, and weight gain. Surgical resection leads to development of fulminant diabetes.
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Affiliation(s)
- Sriya Subramani
- Stead Family Department of PediatricsUniversity of IowaIowa CityIAUSA
| | | | - Nicholas Borcherding
- Department of Pathology & ImmunologyWashington University School of Medicine in St. LouisSt. LouisMOUSA
| | - Simon C. Kao
- Department of RadiologyDivision of Pediatric RadiologyUniversity of IowaIowa CityIAUSA
| | - Joseph Dillon
- Department of Internal MedicineDivision of EndocrinologyUniversity of IowaIowa CityIAUSA
| | - James Howe
- Department of SurgeryDivision of Surgical Oncology and Endocrine SurgeryUniversity of IowaIowa CityIAUSA
| | - Andrew W. Norris
- Stead Family Department of PediatricsUniversity of IowaIowa CityIAUSA
- Fraternal Order of Eagles Diabetes Research CenterUniversity of IowaIowa CityIAUSA
| | - Michael J. Tansey
- Stead Family Department of PediatricsUniversity of IowaIowa CityIAUSA
- Fraternal Order of Eagles Diabetes Research CenterUniversity of IowaIowa CityIAUSA
| | - Catherina T. Pinnaro
- Stead Family Department of PediatricsUniversity of IowaIowa CityIAUSA
- Fraternal Order of Eagles Diabetes Research CenterUniversity of IowaIowa CityIAUSA
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Nastos C, Giannoulopoulos D, Dellaportas D, Mizamtsidi M, Dafnios N, Klonaris N, Kalogeris N, Vryonidou A. Sudden 'cure' of type two diabetes due to pancreatic insulinoma: A case report. Mol Clin Oncol 2020; 12:174-178. [PMID: 31929890 DOI: 10.3892/mco.2019.1957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/05/2019] [Indexed: 01/16/2023] Open
Abstract
Insulinomas are rare tumors of the islet cells of the pancreas and are the most common cause of endogenous hyperinsulinism. Although they usually present with symptoms of hypoglycemia, sometimes they can have vague symptoms. We present the case of a 62-year-old diabetic female who was diagnosed with a large insulinoma after being investigated for the 'cure' of her diabetes. We also review the literature regarding insulinomas in patients with diabetic. A 62-year-old, obese woman with type 2 diabetes mellitus was initially investigated for an unexplained normalization of her blood glucose levels after the cessation of antidiabetic medication due to an episode of severe hypoglycemia. She remained without antidiabetics for three months maintaining normoglycemia, and thereafter, she started experiencing frequent but less severe hypoglycemic episodes. She did not change her diet habits or level of activity and did not lose any weight. The patient underwent further investigation with a supervised 72 h fasting test, which resulted in the biochemical diagnosis of endogenous hyperinsulinism. Imaging studies revealed the presence of a large insulinoma in the head of the pancreas. Finally, the patient underwent a pylorus preserving Whipple procedure, which reversed the aforementioned 'normalization' of glucose levels and the underlying diabetes mellitus reappeared. Insulinomas are rare tumors causing hypoglycemia. Even more rarely are found in diabetic patients, making the diagnosis more challenging and probably delayed, as the symptoms are masked by the presence of diabetes, thereby leading to a more advanced disease diagnosis.
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Affiliation(s)
- Constantinos Nastos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dimitrios Giannoulopoulos
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Dionysios Dellaportas
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Maria Mizamtsidi
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Dafnios
- Second Department of Surgery, Endocrine Surgery Unit, National and Kapodistrian University of Athens, School of Medicine, Aretaieion University Hospital, 11528 Athens, Greece
| | - Nikolaos Klonaris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Nikolaos Kalogeris
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, 11526 Athens, Greece
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Duvillié B, Kourdoughli R, Druillennec S, Eychène A, Pouponnot C. Interplay Between Diabetes and Pancreatic Ductal Adenocarcinoma and Insulinoma: The Role of Aging, Genetic Factors, and Obesity. Front Endocrinol (Lausanne) 2020; 11:563267. [PMID: 33101198 PMCID: PMC7556217 DOI: 10.3389/fendo.2020.563267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022] Open
Abstract
Epidemiologic analyses have shed light on an association between type 2 diabetes (T2D) and pancreatic ductal adenocarcinoma (PDAC). Recent data also suggest a potential relationship between T2D and insulinoma. Under rare circumstances, type 1 diabetes (T1D) can also be implicated in tumorigenesis. The biological mechanisms underlying such relationships are extremely complex. Some genetic factors contributing to the development of T2D are shared with pancreatic exocrine and endocrine tumors. Obesity and overweight can also contribute to the initiation and severity of T2D, while aging may influence both endocrine and exocrine tumors. Finally, pharmacological treatments of T2D may have an impact on PDAC. On the other hand, some treatments for insulinoma can trigger diabetes. In the present minireview, we discuss the cellular and molecular mechanisms that could explain these interactions. This analysis may help to define new potential therapeutic strategies.
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Affiliation(s)
- Bertrand Duvillié
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
- *Correspondence: Bertrand Duvillié,
| | - Rayane Kourdoughli
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Sabine Druillennec
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Alain Eychène
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
| | - Celio Pouponnot
- Department of Signaling, Radiobiology and Cancer, Institut Curie, Orsay, France
- INSERM U1021, Centre Universitaire, Orsay, France
- CNRS UMR 3347, Centre Universitaire, Orsay, France
- Université Paris-Saclay, Orsay, France
- PSL Research University, Paris, France
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Gjelberg HK, Hoem D, Verbeke CS, Eide J, Cooper JG, Molven A. Hypoglycemia and decreased insulin requirement caused by malignant insulinoma in a type 1 diabetic patient: when the hoof beats are from a zebra, not a horse. Clin Case Rep 2017; 5:761-768. [PMID: 28588806 PMCID: PMC5457997 DOI: 10.1002/ccr3.927] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/05/2017] [Indexed: 12/30/2022] Open
Abstract
Insulinomas are uncommon tumors, and in patients with diabetes mellitus they are extremely rare. We describe a patient with type 1 diabetes who developed malignant insulinoma. When hypoglycemic episodes persist in a patient with diabetes and treatment‐induced and other causes of hypoglycemia have been ruled out, an insulin‐producing tumor should be considered.
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Affiliation(s)
- Hilde K Gjelberg
- Department of Pathology Haukeland University Hospital Bergen Norway
| | - Dag Hoem
- Department of Gastrointestinal Surgery Haukeland University Hospital Bergen Norway
| | - Caroline S Verbeke
- Institute of Clinical Medicine University of Oslo Oslo Norway.,Department of Pathology Oslo University Hospital, Rikshospitalet Oslo Norway
| | - Johan Eide
- Department of Pathology Haukeland University Hospital Bergen Norway
| | - John G Cooper
- Department of Medicine Stavanger University Hospital Stavanger Norway
| | - Anders Molven
- Department of Pathology Haukeland University Hospital Bergen Norway.,Gade Laboratory for Pathology Department of Clinical Medicine University of Bergen Bergen Norway.,KG Jebsen Center for Diabetes Research Faculty of Medicine and Dentistry University of Bergen Bergen Norway
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Abstract
BACKGROUND Insulin assays are designed to detect endogenous insulin, however, insulin assays produced by different manufacturers may detect exogenous recombinant insulin, with varying degrees of cross-reactivity between different assays. We report a fascinating and difficult case of recurrent hypoglycaemia, where the final diagnosis was established with the help of insulin assays using different platforms. CASE REPORT A 24-year-old female presented with recurrent hypoglycaemic episodes on a background of Type 1 diabetes mellitus and a completely resected synovial sarcoma of the right hip several years previously. She reported significant physical, sexual and emotional abuse leading to reduced appetite and weight loss. Despite withdrawing insulin therapy, she experienced profound hypoglycaemic episodes with detectable C-peptide and inappropriately elevated insulin levels, suggesting endogenous hyperinsulinaemic hypoglycaemia; however, localization studies were negative and finally she was found to have exogenous hyperinsulinaemia after discordant insulin levels were detected using two different insulin assays. The C-peptide level was elevated as a result of stimulation by parenteral dextrose and was suppressed after dextrose was ceased. Her Type 1 diabetes mellitus was fabricated and she had factitious hypoglycaemia. CONCLUSIONS Factitious hypoglycemia is difficult to diagnose and treat. A low blood glucose level, suppressed C-peptide level and an inappropriately elevated insulin level is the classic finding. We were able to make a diagnosis in the present case after discordant insulin levels were detected on the two different insulin assays, signifying cross-reactivities of the recombinant insulin with the assays. A multidisciplinary team approach with psychiatric input is needed to treat such cases.
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Affiliation(s)
- T Joshi
- Department of Endocrinology, John Hunter Hospital, Newcastle, NSW, Australia
| | - A Caswell
- Department of Biochemistry, John Hunter Hospital, Newcastle, NSW, Australia
| | - S Acharya
- Department of Endocrinology, John Hunter Hospital, Newcastle, NSW, Australia
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Kracht MJL, Zaldumbide A, Roep BO. Neoantigens and Microenvironment in Type 1 Diabetes: Lessons from Antitumor Immunity. Trends Endocrinol Metab 2016; 27:353-362. [PMID: 27094501 DOI: 10.1016/j.tem.2016.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/15/2016] [Accepted: 03/20/2016] [Indexed: 12/24/2022]
Abstract
Type 1 diabetes (T1D) is characterized by the selective and progressive destruction of insulin-producing beta cells by the immune system. An incomplete thymic selection against self-reactive islet antigens partly explains how these T cells reach the periphery and become diabetogenic. Increasing evidence suggest that beta cells themselves also participate to their own demise by generating neoepitopes that could be recognized by the immune surveillance machinery. In this regard, these T cells eradicate self-tissue by mechanisms analogous to a classical antitumor response. Cancer immunotherapy has exploited mutations and transcriptional and translational errors to trigger a specific antitumor response. In this opinion article, we aim at merging insight in antitumor immunology and autoimmunity to reveal processes that had previously been ignored to create beta cell-specific neoantigens.
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Affiliation(s)
- Maria J L Kracht
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands; Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnaud Zaldumbide
- Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart O Roep
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands; Department of Diabetes Immunology, Diabetes and Metabolism Research Institute at the Beckman Research Institute of the City of Hope, Duarte, CA 91010, USA.
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Garrido S, Amado A, Costa F, Soares P, Bacelar C, Amaral C. Insulinoma in a Patient with Type 2 Diabetes: A Case Report. AACE Clin Case Rep 2016. [DOI: 10.4158/ep151129.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lablanche S, Chobert-Bakouline M, Risse O, Laverrière MH, Chabre O, Benhamou PY. Malignant insulinoma may arise during the course of type 1 diabetes mellitus: A case report. Diabetes & Metabolism 2015; 41:258-61. [DOI: 10.1016/j.diabet.2014.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/12/2014] [Accepted: 08/26/2014] [Indexed: 11/24/2022]
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