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Recurrent hypoglycaemia in a frail elderly patient was caused by a rare proinsulin-secreting neuroendocrine tumour, not pancreatic cancer. Measuring proinsulin levels during hypoglycaemic episodes is crucial for accurate diagnosis.

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Area of Science:

  • Endocrinology
  • Oncology
  • Pathology

Background:

  • Spontaneous hypoglycaemia can present with non-specific symptoms like falls in the elderly.
  • Recurrent hypoglycaemic episodes in a frail 79-year-old woman were initially managed with continuous glucose infusion.
  • Hypoadrenalism and hypothyroidism were ruled out as causes of hypoglycaemia.

Purpose of the Study:

  • To investigate the cause of recurrent, unexplained hypoglycaemic episodes in an elderly patient.
  • To determine the origin of elevated C-peptide and proinsulin levels during hypoglycaemia.
  • To differentiate between insulinoma, proinsulinoma, and other causes of hypoglycaemia.

Main Methods:

  • Biochemical analysis of plasma glucose, C-peptide, proinsulin, and insulin during hypoglycaemic episodes.
  • Radiological investigations including contrast CT scan of the abdomen.
  • Post-mortem examination to confirm tissue diagnoses.

Main Results:

  • Inappropriately elevated plasma proinsulin (>200 pmol/L) and C-peptide (4210 pmol/L) with suppressed insulin (12 pmol/L) during hypoglycaemia (1.6 mmol/L).
  • CT scan revealed a renal cell carcinoma and extensive liver lesions.
  • Post-mortem confirmed liver lesions as proinsulin-secreting neuroendocrine tumours, while the kidney mass was clear cell renal carcinoma.

Conclusions:

  • Proinsulinoma diagnosis can be missed without measuring plasma proinsulin during hypoglycaemia.
  • Elevated C-peptide levels can be due to proinsulin cross-reactivity in the assay.
  • Non-pancreatic neuroendocrine tumours can cause proinsulinoma, and renal masses may represent a diagnostic red herring.