Insulinoma differential diagnosis: Difference between revisions

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| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Insulinoma]]/[[Nesidioblastosis]]/PGPH<sup>†</sup>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Insulinoma]]
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥200
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥200
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥3
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥3
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥5
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥5
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≤2.7
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≤2.7
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>25
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |>25
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Nesidioblastosis]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Post gastric bypass hypoglycemia (PGPH)
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Insulin autoimmune hypoglycemia  
| style="background: #DCDCDC; padding: 5px;text-align: center;" |Insulin autoimmune hypoglycemia  
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>>200<sup>‡</sup>
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>>200<sup>‡</sup>
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| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
| colspan="9" style="background: #DCDCDC; padding: 5px; |
‡ 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
|}
|}


† 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]]):
'''Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms ([[tachycardia]], [[hypertension]]):'''
{| class="wikitable sortable"
{|
|+
|+
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Disease
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Disease
Line 95: Line 102:
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Investigations
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Investigations
|-
|-
! colspan="4" |Symptoms
! colspan="4" style="background: #4479BA; color: #FFFFFF; " |Symptoms
! rowspan="2" |Signs
! rowspan="2" style="background: #4479BA; color: #FFFFFF; " |Signs
|-
|-
!Tachycardia
! style="background: #7d7d7d; color: #FFFFFF; "| Tachycardia
!Fever
! style="background: #7d7d7d; color: #FFFFFF; "|Fever
!Sweating
! style="background: #7d7d7d; color: #FFFFFF; "|Sweating
!Headache
! style="background: #7d7d7d; color: #FFFFFF; "|Headache
|-
|-
![[Anxiety disorders]]
! style="background: #DCDCDC; text-align: center;" |Insulinoma
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |
|
| style="background: #F5F5F5;" |
| style="background: #F5F5F5;" |
|-
! style="background: #DCDCDC; text-align: center;" |[[Anxiety disorders]]
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |
*Patient looks irritable
*Patient looks irritable
*Rapid [[pulse]] and may be irregular
*Rapid [[pulse]] and may be irregular
|
| style="background: #F5F5F5;" |
*Normal investigations
*Normal investigations
|-
|-
![[Pheochromocytoma]]
! style="background: #DCDCDC; text-align: center;" |[[Pheochromocytoma]]
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|
| style="background: #F5F5F5;" |
*[[Tachycardia]]
*[[Tachycardia]]
*Strong rapid [[pulse]]
*Strong rapid [[pulse]]
*High [[pulse pressure]]
*High [[pulse pressure]]
|
| style="background: #F5F5F5;" |
*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>
*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>
*[[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]]
! style="background: #DCDCDC; text-align: center;" |[[Arrhythmias|Arrhythmia]]
| +
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|
| style="background: #F5F5F5;" |
*Irregular pulse
*Irregular pulse
|
| style="background: #F5F5F5;" |
*ECG changes according to the cause
*ECG changes according to the cause
|-
|-
![[Hyperthyroidism]]
! style="background: #DCDCDC; text-align: center;" |[[Hyperthyroidism]]
| +
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|
| style="background: #F5F5F5;" |
*Hyperactive [[Deep tendon reflex|deep tendon reflexes]]
*Hyperactive [[Deep tendon reflex|deep tendon reflexes]]
*[[Thyromegaly]]
*[[Thyromegaly]]
*[[Exophthalmus]]
*[[Exophthalmus]]
|
| style="background: #F5F5F5;" |
*Level of [[thyroid-stimulating hormone]] ([[TSH]])
*Level of [[thyroid-stimulating hormone]] ([[TSH]])
*Levels of T4 and/or T3 in the blood
*Levels of T4 and/or T3 in the blood

Revision as of 16:07, 16 October 2017

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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
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 <55 ≥200 ≥3 ≥5 ≤2.7 >25 - -
Nesidioblastosis
Post gastric bypass hypoglycemia (PGPH)
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 - -

‡ 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
Insulinoma
Anxiety disorders + - + +
  • Patient looks irritable
  • Rapid pulse and may be irregular
  • Normal investigations
Pheochromocytoma + + + +
Arrhythmia + - - -
  • Irregular pulse
  • ECG changes according to the cause
Hyperthyroidism + + + +

References

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

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