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Insulinomas are rare pancreatic neuroendocrine tumors (NETs) characterized by autonomous insulin secretion leading to hypoglycemia. Malignant insulinomas are defined by the presence of metastases and present significant therapeutic challenges due to limited treatment options. We report the case of a 69-year-old woman with a two-month history of neuroglycopenic symptoms, including morning headaches, blurred vision, palpitations, and sweating, which were alleviated by sugar intake. An episode of severe hypoglycemia-induced unconsciousness necessitated intramuscular glucagon administration, resulting in regained consciousness. The combination of neuroglycopenic symptoms relieved by carbohydrate and documented hypoglycemia fulfilled Whipple's triad, prompting evaluation for an insulin-secreting tumor. Laboratory findings revealed elevated endogenous insulin and C-peptide levels, indicating hyperinsulinemia. Imaging studies, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), identified a 25 mm solid lesion in the pancreatic body and multiple hepatic metastases. A ⁶⁸Ga-DOTA-NOC positron emission tomography (PET) scan demonstrated high somatostatin receptor expression in both the pancreatic lesion and hepatic metastases. Ultrasound-guided liver biopsy revealed a high-grade (G3) neuroendocrine carcinoma with a Ki-67 proliferation index exceeding 30%, confirming the diagnosis of malignant insulinoma. Multidisciplinary consultation recommended initiation of systemic chemotherapy with cisplatin and etoposide. Despite optimized medical management, including dextrose infusion, diazoxide, octreotide, and corticosteroids, the patient experienced persistent severe hypoglycemia. Transarterial chemoembolization (TACE) of the tumor vasculature was performed to mitigate hypoglycemia by reducing tumor burden. Post-procedure, the patient developed a cerebellar hemorrhage leading to coma and subsequent death. This case underscores the aggressive nature and poor prognosis associated with malignant insulinomas, particularly those with high proliferative indices. It highlights the complexities of managing refractory hypoglycemia in the context of widespread metastatic disease and emphasizes the urgent need for effective therapeutic strategies to improve patient outcomes., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gonçalves et al.)

A 53-year-old, non-diabetic lady was evaluated for worsening breathlessness over the past 1 year. She was diagnosed with a lung lesion a year ago, but the prevailing COVID-19 situation prevented her from seeking further evaluation. She began to have early morning episodes of symptomatic hypoglycemia over the previous 4 months, which were relieved with dextrose infusions. The evaluation showed low insulin, low C-peptide, and high insulin-like growth factor-2 to insulin-like growth factor-1 ratio. High-resolution computed tomography scan of the thorax showed a 19.5 cm x 16.6 cm x 23.8 cm mass in the left hemithorax, and a microscopic examination of a biopsy specimen of which was consistent with the diagnosis of solitary fibrous tumor. The patient underwent sternotomy with left anterior thoracotomy with successful excision of the fibrous tumor. Post-operatively, histopathological diagnosis of solitary fibrous tumor was confirmed. There were no further episodes of hypoglycemia, and the patient was completely recovered. [ABSTRACT FROM AUTHOR]

Objective: To describe a rare case of pheochromocytoma presenting with hypoglycemia. Methods: We describe a rare case of pheochromocytoma presenting with a hypoglycemic seizure. Our article includes our differentials, work up, and management. Results: Our patient had non–islet-cell tumor hypoglycemia that was non-insulin mediated, as noted by low insulin levels. His hypoglycemia was likely multifactorial and mediated by different mechanisms. We describe the rare case and review the causes of tumor-induced hypoglycemia. Conclusion: Pheochromocytomas can rarely present with hypoglycemia and are associated with a poor prognosis.