In the name of GOD Problem list - PowerPoint Presentation

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In the name of GOD

Problem list

Episodic sever Hypoglycemia

High level of insulin in hypoglycemic episode

High level of c-peptide

in hypoglycemic

episode

long periods without

hypoglycemia

relapse

after event-free periods of

3 month

after

pancreatic lesion enucleation

High serum

glibenclamide

level

Evaluation and Management of Adult

Hypoglycemic Disorders

: An Endocrine Society Clinical

Practice Guideline

J

Clin

Endocrinol

Metab

, March 2009, 94(3):709–728

The

noninsulinoma

pancreatogenous

hypoglycemia syndrome (NIPHS)

The frequency of NIPHS is

much less

than that of

insulinoma

.

endogenous

hyperinsulinemic

hypoglycemia typically, but

not invariably

,

after a meal

.

There

is a predominance

in

men

.

The pancreatic abnormality is

diffuse

islet

involvement with

nesidioblastosis

Radiological

localization procedures are invariably

negative

.

Confirmation

of islet

hyperfunction

depends on a

positive

selective arterial

calcium stimulation test.

Amelioration

of

symptoms can

be expected with

partial pancreatectomy

guided by the

results of

the calcium stimulation test.

Hypoglycemia due to the development of antibodies to native insulin

is

a

rare

disorder

reported

to occur primarily among

persons of

Japanese

or

Korean

ethnicity

often have

a history of

autoimmune disease

Symptoms

occur in the

late postprandial

period

Clues to the diagnosis include

very

high measured

insulin

levels during hypoglycemia.

Factitious hypoglycemia

Sulfonylurea

consumption produces a

biochemical pattern

,

mimicking

insulinoma

(inappropriately

high plasma

levels of insulin and C-peptide

)

Diagnosis is usually established via

exclusion

it can be diagnosed with

positive drug

screening

clinical

suspicion

is the best strategy for

diagnosis,

due to the lack of any definitive

laboratory findings

,

Surreptitious hypoglycemia

is more common in people

with

knowledge

of

, and

access

to, glucose-lowering medications

Methods: In this systematic review, 114 articles with 6222 cases

of insulinoma

were reviewed with emphasis on localization

techniques and

surgical treatment

A total of

17 patients

were referred to the NIH after

a failed

blind distal pancreatectomy. Of these,

five

were

diagnosed as having factitious hypoglycemia, and in

the remaining

patients a tumor was localized in the head.

Hypoglycemia after

factitiously self-administered

sulfonylurea

overdosages

has been previously described in

23 cases

.

Surreptitious sulfonylurea

overdosages

have led to

reports

of

eight unnecessary

laparotomies

, including

an exploration resulting

in postoperative

bleeding and

death , and five partial pancreatectomies . Evidence of surreptitious sulfonylurea usage was obtained from blood or urine assays in 16 cases , from a room or personal effects search in 6 cases , and from repeated questioning followed by a confession in 1 case.

Hypoglycemia Following Inadvertent and Factitious Sulfonylurea

Over dosages

, diabetes care 1995

eight

adult patients or their

spouses with

medical

jobs

seven

adult patients

with

a personal

history

of a

spouse

with

or a

close

friend

with sulfonylurea-treated diabetes mellitus, two teenage patients with a sulfonylurea-treated diabetic parent or guardian an unusual affect or history of psychiatric disease : seven patients an abrupt onset of symptoms without previous milder symptoms : nine

failure to

reproduce hypoglycemia by a 24-h fast : three patients The age of the factitious overdose patients 34.7± 14.1 years (mean ± SD), was significantly younger than that of insulinoma patients whose mean age has been reported to be at least 41.7 years , but the age distribution of these two groups overlapped

Hypoglycemia Following Inadvertent and Factitious Sulfonylurea Overdosages, diabetes care 1995

Features of patients with hypoglycemia after a factitiously self-administered sulfonylurea overdose included

Serious Hypoglycemia: Munchausen’s

Syndrome?

Diabetes

Care 2001 

the presence of a sulfonylurea-related oral hypoglycemic agent in

129 patients

who had

unexplained severe hypoglycemia

. during

a 35-month

period

were investigated using chromatographic

liquid method with UV detection.

In

22

patients (17%), a second generation of the sulfonylurea oral hypoglycemic agent was detected:

glibenclamide

was detected in 19 patients, and gliclazide was detected in 3 patients. The study population comprised 13 women (mean age ± SD 40 ± 18 years) and 9 men (64 ± 11 years). The plasmatic concentrations are usually superior to the therapeutic ones, and in seven cases, they were five times more, with a maximum of 18 times the therapeutic degrees. All of these patients had only

one hypoglycemic agent

.

an ICPR in excess of 1.0 in a

hypoglycemic patient

argues persuasively for surreptitious or inadvertent insulin administration and

against

insulinoma

(or sulfonylurea ingestion) as the cause of the hypoglycemia.

We report 2 cases of

factitious

hyperinsulinism

leading to partial pancreatectomy

.

Atypical histories of

hypoglycemia were

noted in both of our patients:

long

periods without

hypoglycemia, severe hypoglycemic

episodes, and

relapse after event-free periods

of

several days

after partial pancreatectomy

In the

primary evaluations

, insulinoma was suspected

considering the high plasma concentrations of insulin and C-peptide,

besides

negative

urine and plasma sulfonylureas

during hypoglycemic episodes. Considering the

normal imaging

studies and

refractory hypoglycemia

to medical therapy,

distal pancreatectomy

was

performed.

5 months later

, similar episodes recurred. Further investigations revealed different plasma concentrations of

insulin and C-peptide

in each hypoglycemic episode.

Int J Endocrinol Metab. 2018 January

It is suggested to suspect factitious hypoglycemia

in patients

with

diverse biochemical

patterns during

different hypoglycemic

episodes

After psychiatric and forensic pathology confirmation, he was discharged with quetiapine (25 mg/day) and outpatient psychiatric visits. However, four months later, he was found

unconsciousin

a hotel room and

died

Ann Intern Med

.

 1988

Factitious hypoglycemia due to surreptitious administration of insulin. Diagnosis, treatment, and long-term follow-up.

Grunberger

G

1

, 

Weiner JL

, 

Silverman R

, 

Taylor S

, 

Gorden

P

.

10

patients with factitious

hypoglycemia were followed-up for 15 years, only 3 returned to a productive life and 2 committed suicide

Several methods have been developed for the detection of antidiabetic drugs in the human plasma and urine. Some of these methods include micellar

electrokinetic

capillary chromatography,

highperformance

liquid chromatography (HPLC) with ultraviolet detection, HPLC with evaporative light scattering detection and HPLC with charged aerosol detection

.

The problem with most of these methods is their

timeconsuming

design and possibility of false positive results

it

can be seen that high-performance liquid

chromatography methods

have been used most extensively

For

all drugs

, assay validation showed good linearity (

r

2 >0.990

) and acceptable imprecision and recovery

based on

commonly used criteria of acceptance. The

mean extraction

recoveries were 63%–87% for 5

sulfonylureas but

<45% for 3 (

carbutamide

,

chlorpropamide

,

and

tolbutamide

).

The described assay method allows accurate, rapid identification and quantification of 8 sulfonylureas(glibenclamide, glipizide, gliclazide, glibornuride, glimepiride, carbutamide, chlorpropamide, and tolbutamide) in human plasma and can be used for specific diagnosis of factitious hypoglycemia caused by ingestion of these drugs.

this is the first reported case of surreptitious hypoglycemia secondary to

repaglinide

The

patient underwent a second supervised fast. He

remained asymptomatic

with normal plasma glucose concentrations

Repaglinide

serum concentrations

were determined with liquid

chromatography.

Repaglinide

was detectable (0.2

ngmL

) in six of seven

stored specimens

obtained by the referring endocrinologist

during the hypoglycemic episodes at home.

What should we do for this patient?

Refer to psychologist

Preventing harmful

surgery