Case Presentation:
A 36 years old South Asian gentleman was brought by the ambulance to the emergency department with an episode of a generalized tonic-clonic seizure. As per the witness, the patient was sitting when he suddenly collapsed and had jerky movements of his arms and legs. The episode lasted for about 5 minutes. There was no bowel or bladder incontinence. After the episode, the patient remained confused for 15-20 minutes. At the time of the seizure, the patient’s blood glucose checked via point of care testing was 1.6mmol. He was given IV dextrose after the patient regained consciousness, he reported feeling sweaty and palpitations before the seizure episode. He denied any headache, neck pain, fever, dizziness, weakness, cough, rhinorrhea, sore throat, dysuria, nausea, vomiting or diarrhea.
The patient reported an off-and-on feeling of light-headedness in the last 2-3 months that improved after drinking juice. He did not have any chronic illnesses or previous surgeries. He denied taking any medications, including multivitamins or herbal remedies. The patient was a non-smoker and did not drink alcohol. There was no family history of malignancies. After the patient regained consciousness, physical examination revealed a temperature of 36.8 °C, respiratory rate of 20/minute, blood pressure of 135/80, heart rate of 76/minute, and oxygen saturation of 99% in room air. Cardiac, respiratory, abdominal and neurological examination was normal.
A basic laboratory workup revealed a normal complete blood count and metabolic and coagulation profile. Serum ethanol level was normal (table1). An MRI showed multiple calcified lesions in the brain concerning neuro-cysticercosis, which did not require any treatment. During the hospital stay, the patient had multiple episodes of hypoglycemia.
Hypoglycemia workup revealed a normal cortisol level, elevated insulin and c-peptide level consistent with hyperinsulinemia. (table 2). An MRCP, NM 18F-DOPA whole-body PET CT and Ga-68 DOTATATE scan were normal and did not reveal any pancreatic lesion consistent with insulinoma. Due to high suspicion of insulinoma and negative non-invasive imaging, an EUS was performed, showing hypoechoic homogenous mass lesion sized 13x9 mm in the proximal body/neck of the pancreas (Figure 1). A FNA via EUS was performed. Histopathology showed a well-differentiated neuroendocrine tumor, consistent with Grade 1 insulinoma (T1N0M0). Patient underwent distal pancreatectomy and splenectomy. Upon follow up 2 months after the surgery, the patient reports no further episodes of hypoglycemia and is doing all his activities of daily living without any difficulty.