A Case of Insulinoma with Liver Metastasis, Terminating in Nonketotic Hyperosmolar Coma During Diazoxide Treatment

Abstract

A woman diagnosed as having insulinoma had a partial pancreatectomy at the age of 71 in 1973. One year later, she began to have hypoglycemia. At the age of 79, she went into a hypoglycemic coma and the I/G ratio of IRI (μU/ml) to glucose (mg/dl) was 3.0. Celiac angiography revealed multiple small masses in the liver. The diagnosis was insulinoma metastasizing to the liver. She was treated with 75 mg of diazoxide (DAX) per day. As a result her hypoglycemia was controlled. The I/G ratio was 0.2. At the age of 83, she became febrile and was not able to take DAX regularly. We expected her to remain hypoglycemic, but instead she became hyperglycemic. Subsequently, she went into a nonketotic hyperosmolar coma (NKHC) and shock. At autopsy, the liver showed numerous localized fatty areas measuring 1-2 cm in diameter. In the center of these localized fatty areas there were insulin-producing cell tumors up to 5 mm in diameter. The remaining pancreas was normal. It was concluded that insulin-producing lesions in the liver were the cause of the hypoglycemia. Although DAX could have been a causative factor of her NKHC, it was effective for controlling hypoglycemia for almost three years. This is the first report of localized fatty changes in the liver due to insulinoma metastasized to the liver.