Autori prezentujú kazuistiku 16-ročného chlapca s 1,5-ročnou anamnézou tonickoklonických kŕčov s bezvedomím podmienených hypoglykémiami pri inzulinóme. Pri prijatí chlapca na kliniku sa hladiny glykémie pohybovali v rozmedzí od 2,2–6,1 mmol/l, hodnoty C-peptidu a inzulínu (1948,9 pmol/l, 26,74 IU/ml) boli zvýšené. Pri orálnom glukózo-tolerančnom teste (oGTT) sa koncentrácie C-peptidu pohybovali v rozmedzí 1158–4526 pmol/l, hladina inzulínu 5,7–80,1 mU/l, koncentrácie glukózy boli v pásme poruchy glukózovej tolerancie, hladiny TSH boli zvýšené (6,31 mIU/l). Bolo vyslovené podozrenie na prítomnosť inzulinómu. CT vyšetrenie a oktreotidový scan boli negatívne v zmysle tumoróznych zmien. Realizované endoskopické ultrasonografické vyšetrenie potvrdilo nález dvoch ložísk v pankrease, z ktorých prvé bolo nepresne lokalizované v oblasti medzi hlavou a telom pankreasu s veľkosťou 19 x 20 mm, druhé ložisko bolo lokalizované v oblasti chvosta. U pacienta bola vykonaná distálna slezinu zachovávajúca pankreatektómia. Histologickým vyšetrením resekovanej časti pankreasu sa jednoznačne potvrdila diagnóza dobre diferencovaného endokrinného tumoru pankreasu veľkosti 16 mm. Imunohistochemicky bola v nádore okrem potvrdenia neuroendokrinnej diferenciácie dokázaná aj expresia inzulínu. Pacient bol prepustený po trojmesačnej hospitalizácii do domáceho ošetrenia. Po 9 mesiacoch od operácie sa u pacienta hladina glykémie pohybovala vo fyziologickom rozmedzí, koncentrácie inzulínu aj C-peptidu po oGTT boli tiež v norme. Hladina TSH bola vyššia (4,28 mIU/l). V klinickom obraze pacient schudol (súčasná hmotnosť 67 kg, pri prijatí hmotnosť 95 kg pri výške 170 cm), kŕče sa neopakovali.

The authors present the case of a 16-year boy with 1.5-year history of tonic-clonic seizures with unconsciousness caused by hypoglycemia associated with insulinoma. In admission of the patient to the clinic the glycemia levels were in the range of 2.2 – 6.1 mmol/l, values of C-peptide and insulin were increased (1948.9 pmol/l and 26.74 IU/ml, respectively). In oral glucose tolerance test (oGTT) the concentrations of C-peptide were in the range of 1158 – 4526 pmol/l, the level of insulin was 5.7 – 80.1 mU/l, glucose concentration was in the area of glucose tolerance disorder, the levels of TSH were elevated (6.3 mIU/l). The presence of insulinoma became suspected. CT examination and octreotide scan were negative as far as tumorous changes were concerned. The executed endoscopic ultrasonographic examination confirmed the finding of two foci in pancreas, of which the first one was not precisely localized in the region between head and body of pancreas with the size of 19 x 20 mm, the second focus was localized in the area in the area of tail (left extremity). In the patient distal spleen saving pancreatectomy was performed. Histological examination of the resected part of pancreas unambiguously confirmed the diagnosis of well differentiated endocrine tumor of pancreas of 16 mm size. Immunochemical examination of the tumor confirmed among others neuroendocrine differentiation confirmed by insulin expression as well. The patient was dismissed after three-month hospitalization into home treatment. Nine months after the operation the glucose levels were in the physiological range, the concentrations of insulin as well as C-peptide after oGTT were also normal. The level of TSH was higher than normal (4.28mIU/l). The clinical picture was characterized by loss of body weight from 95 kg upon admission to present 67kg body weight (stature of 170 cm).

Klinika detí a dorastu Jesseniova lekárska fakulta Univerzity Komenského Martinská fakultná nemocnica Martin

Insulinoma – the cause of relapsing hypoglycemia in a 16-year patient

Lit.: 13