Fellow Jersey Shore University Medical Center Freehold, New Jersey, United States
Introduction : Insulinomas are functional insulin-secreting tumors of pancreatic origins that cause hypoglycemia. Although rare, they represent a diagnostic challenge due to the multitude of conditions that can cause hypoglycemia. Even after the insulinoma is biochemically confirmed, localizing the source can be an additional hurdle. The difficulty of diagnosis and treatment of these tumors is amplified when patients are uninsured and unable to navigate a complex health system.
Case(s) Description : We present a 28 year old male, who initially presented to the emergency department after being found minimally responsive by his mother. The patient recently came to the United States and reported having multiple episodes where he would pass out during his travels. He had positive Whipple’s triad, and underwent 72-hour fast that showed a serum glucose of 39 mg/dL with hypoglycemic symptoms, inappropriately normal insulin levels, inappropriately high C-peptide levels, negative sulfonylurea screen, and low beta-hydroxybutyrate, indicating excess endogenous insulin production in the setting of negative insulin antibody levels, consistent with insulinoma. An abdominal computed tomography (CT) scan and a magnetic resonance imaging (MRI) scan were unable to localize a focal area, with no obvious lesion on the pancreas. An endoscopic ultrasound with fine needle aspiration was not diagnostic of insulinoma. The patient was unable to afford medications, such as octreotide and diazoxide, even with patient assistance. This made treatment challenging and to compensate, the patient ate every few hours to avoid hypoglycemia. A copper-64 (64Cu)-DOTATATE-positron emission/CT scan did not show any increased metabolic activity, but a selective arterial calcium stimulation test with hepatic venous sampling was able to confirm the presence of insulinoma to the head of the pancreas. The patient underwent a Whipple procedure, with pathology showing a 1.4 cm well differentiated pancreatic neuroendocrine tumor. His symptoms resolved after surgery and he is not on any medication.
Discussion : This case highlights the difficulties of managing a complex disease state when there is diagnostic uncertainty. For patients with insurance, the necessary diagnostic imaging and procedures can be costly and for those without any insurance and an inability to apply for government assistance due to immigration status, it can become a truly harrowing experience. Necessary studies took longer to be completed as an outpatient, and due to cost, treatment was limited. Fortunately, no serious adverse events occurred, and our patient was able to get appropriate care with complete resolution of his symptoms following surgery.
