Insulinoma differential diagnosis: Difference between revisions

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Revision as of 13:42, 22 September 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

Insulinoma must be differentiated from other diseases that cause features of hypoglycemia like altered mental status/confusion, profuse sweating and visual disturbances (blurring/diplopia). These are classified on the basis of laboratory findings into exogenous insulin, oral hypoglycemic agents (e.g. sulphonylureas), nesidioblastosis, insulin autoimmune hypoglycemia.

Differentiating insulinoma from other Diseases

Insulinoma must be differentiated from other diseases that cause features of hypoglycemia. These are classified on the basis of laboratory findings.

Differentials for Hypoglycemia on the basis of Laboratory findings^[1]:

Diagnoses	Laboratory Findings differentiating among causes of Hypoglycemia
Diagnoses	S.Glucose (mg/dL)	C Peptide (pmol/L)	S.Insulin (μU/mL)	S.Proinsulin (pmol/L)	S. Beta hydroxybutyrate	Glucose increase after glucagon(mg/dL)	Oral Hypoglycemic agent	Antibodies to Insulin
Normal/Fasting	<55	<200	<3	<5	>2.7	<25	-	-
Exogenous Insulin	<55	<200	>>3	<5	≤2.7	>25	-	-
Insulinoma/Nesidioblastosis/PGPH^†	<55	≥200	≥3	≥5	≤2.7	>25	-	-
Insulin autoimmune hypoglycemia	<55	>>200^‡	>>3	>>5^‡	≤2.7	>25	-	+
Oral hypoglycemic agent	<55	≥200	≥3	≥5	≤2.7	>25	+	-
IGF¤	<55	<200	<3	<5	≤2.7	>25	-	-

† PGPH= Post Gastric Bypass Hypoglycemia,
‡ Free C-peptide and proinsulin concentrations are low
¤ IGF= Insulin Growth Factor, Increased pro-IGF-2, free IGF-2, IGF-2/IGF-1 ratio

Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms (tachycardia, hypertension):


Disease	Clinical Manifestation					Investigations
	Symptoms				Signs
	Tachycardia	Fever	Sweating	Headache	Signs
Anxiety disorders	+	-	+	+	Patient looks irritable Rapid pulse and may be irregular	Normal investigations
Pheochromocytoma	+	+	+	+	Tachycardia Strong rapid pulse High pulse pressure	Plasma fractionated metanephrines, 24-hour urinary fractionated metanephrines, catecholamines.^[2] Computed tomography: Radiological evaluation should follow lab tests to locate site of the tumour.^[3]
Arrhythmia	+	-	-	-	Irregular pulse	ECG changes according to the cause
Hyperthyroidism	+	+	+	+	Hyperactive deep tendon reflexes Thyromegaly Exophthalmus	Level of thyroid-stimulating hormone (TSH) Levels of T4 and/or T3 in the blood Antibodies such as anti-TSH-receptor antibodies in Graves' disease

References

↑ Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
↑ Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P; et al. (2002). "Biochemical diagnosis of pheochromocytoma: which test is best?". JAMA. 287 (11): 1427–34. PMID 11903030.
↑ Bravo EL (1991). "Pheochromocytoma: new concepts and future trends". Kidney Int. 40 (3): 544–56. PMID 1787652.

Template:WH Template:WS

[pmid19088155-1] Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.

[pmid11903030-2] Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P; et al. (2002). "Biochemical diagnosis of pheochromocytoma: which test is best?". JAMA. 287 (11): 1427–34. PMID 11903030.

[pmid1787652-3] Bravo EL (1991). "Pheochromocytoma: new concepts and future trends". Kidney Int. 40 (3): 544–56. PMID 1787652.

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@@ Line 87: / Line 87: @@
 † PGPH= Post Gastric Bypass Hypoglycemia,<br>‡ Free C-peptide and proinsulin concentrations are low<br>
 ¤ [[IGF]]= Insulin Growth Factor, Increased pro-IGF-2, free [[Insulin-like growth factor 2|IGF]]-2, IGF-2/[[IGF-1]] ratio
+====Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms ([[tachycardia]], [[hypertension]]):====
+{| class="wikitable sortable"
+|+
+! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Disease
+! colspan="5" style="background: #4479BA; color: #FFFFFF; " |Clinical Manifestation
+! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Investigations
+|-
+! colspan="4" |Symptoms
+! rowspan="2" |Signs
+|-
+!Tachycardia
+!Fever
+!Sweating
+!Headache
+|-
+![[Anxiety disorders]]
+|<nowiki>+</nowiki>
+|<nowiki>-</nowiki>
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|
+*Patient looks irritable
+*Rapid [[pulse]] and may be irregular
+|
+*Normal investigations
+|-
+![[Pheochromocytoma]]
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|
+*[[Tachycardia]]
+*Strong rapid [[pulse]]
+*High [[pulse pressure]]
+|
+*Plasma fractionated [[Metanephrine|metanephrines]], 24-hour urinary fractionated [[Metanephrine|metanephrines]], [[catecholamines]].<ref name="pmid11903030">{{cite journal| author=Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al.| title=Biochemical diagnosis of pheochromocytoma: which test is best? | journal=JAMA | year= 2002 | volume= 287 | issue= 11 | pages= 1427-34 | pmid=11903030 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11903030  }}</ref>
+*[[Computed tomography]]: Radiological evaluation should follow lab tests to locate site of  the tumour.<ref name="pmid1787652">{{cite journal| author=Bravo EL| title=Pheochromocytoma: new concepts and future trends. | journal=Kidney Int | year= 1991 | volume= 40 | issue= 3 | pages= 544-56 | pmid=1787652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1787652  }}</ref>
+|-
+![[Arrhythmias|Arrhythmia]]
+| +
+|<nowiki>-</nowiki>
+|<nowiki>-</nowiki>
+|<nowiki>-</nowiki>
+|
+*Irregular pulse
+|
+*ECG changes according to the cause
+|-
+![[Hyperthyroidism]]
+| +
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|<nowiki>+</nowiki>
+|
+*Hyperactive [[Deep tendon reflex|deep tendon reflexes]]
+*[[Thyromegaly]]
+*[[Exophthalmus]]
+|
+*Level of [[thyroid-stimulating hormone]] ([[TSH]])
+*Levels of T4 and/or T3 in the blood
+*[[Antibody|Antibodies]] such as anti-[[TSH receptor|TSH-receptor antibodies]] in [[Graves' disease]]
+|}
 ==References==