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I Am Always Hungry. Is It Just Because I Am A Food Lover?
A 71-year-old Indonesian gentleman with past medical history of hyperlipidemia presented to our hospital with drowsiness. He was found drowsy by his family members at 4pm and capillary sugar reading at the same time was 2.3 mmol/L. After consuming the glucose drink, he became alert within 5 minutes. He denied taking complementary medicine, diabetes medication or illicit drugs. Further inquiry revealed that he just had a heavy lunch at 12pm followed by dessert at 2pm on the day he had hypoglycaemia. He has been having frequent hunger and giddiness for the past 1 year. He adopted the habit of frequent eating at 2-3 hourly frequency to minimize the hypoglycaemia symptoms. His body mass index was 31.4 kg/m2. He underwent a 72-hour-fasting test. The investigation result was consistent with endogenous hyperinsulinaemia related hypoglycaemia (table 1). The sulfonylureas and anti-diabetic medications screen was negative. Insulin antibodies were negative. Computed tomography of pancreas showed a heterogeneously enhancing exophytic mass lesion in the uncinate process of the pancreas. Diazoxide 100mg twice daily was started. He was discharged with follow up with our endocrinologist and hepatobiliary surgeon to plan for a surgical resection of the pancreatic mass.
Hypoglycaemia that fulfils Whipple’s triad warrants further evaluation. Hypoglycaemia in patients with diabetes is usually the result of anti-diabetic treatment whereas diagnosing the aetiology of hypoglycaemia in patients without diabetes mellitus is challenging. In patients who are ill, drugs, critical illnessess like renal failure, sepsis and hypocortisolism are the possible causes. In seemingly well patients, causes of hypoglycaemia include insulinoma, nesidioblastosis and insulin autoimmune hypoglycaemia.
Our case illustrated the classical symptoms and 72-hour-fasting test result that was consistent with insulinoma. We would like to use this case to review the Endocrine Society guideline on evaluation and management of adult hypoglycaemic disorders.