Case of Insulinoma Misdiagnosed as a Psychiatric Condition for Five Months in Lattakia, Syria

Case Report

Austin J Clin Case Rep. 2018; 5(1): 1125.

Case of Insulinoma Misdiagnosed as a Psychiatric Condition for Five Months in Lattakia, Syria

Mansour M¹*, Salman R¹, Ahmad I² and Alloush A³

¹Department of Endocrinology, Faculty of Medicine, Tishreen University, Syria

²Department of Pathology, Faculty of Medicine, Tishreen University, Syria

³Department of Surgery, Faculty of Medicine, Tishreen University, Syria

*Corresponding author: Mansour M, Endocrinology Department, Tishreen University. Rabieh Square, Building 2200, Tartous, Syria

Received: December 03, 2017; Accepted: January 05, 2018; Published: January 25, 2018


Insulinomas are rare tumors of pancreas. These tumors produce insulin causing hypoglycemia which leads to severe asthenia, profuse diaphoresis and tremors. Occasionally they present with neurologic symptoms, therefore they are usually undiagnosed or misdiagnosed as behavior disturbances or psychiatric conditions. Many procedures can be used to localize the tumor and in most cases surgery is curative. Tumor enucleation is a procedure of choice, particularly in cases of small and isolated nodule that does not invade the pancreatic or bile ducts. Here we describe a case of a female patient with insulinoma presented with occasional loss of consciousness, depression, changes in personality and behavior for six months and barely responded to selective serotonin reuptake inhibitors. Once the diagnosis was made and the surgical therapy was carried out, our patient totally recovered and ended the psycho-drugs.

Keywords: Insulinoma; Psychiatric; Depression; Behavior; Personality changes


SSRIs: Selective Serotonin Reuptake Inhibitors; ER: Emergency Room; BP: Blood Pressure; RR: Respiratory Rate; HR: Heart Rate; TSH: Thyroid Stimulating Hormone; CT: Computerized Axial Tomography; H&E stain: Haematoxylin and Eosin stain


Insulinomas are rare tumors of pancreas. They are benign in more than 90% of cases [1]. Delays in diagnosis of insulinoma are common because there may be a misattribution of the symptoms to psychiatric, cardiac, or neurological disorders. Duration of symptoms before diagnosis can reach 12-18 months on average. Our patient waited 5 months for the proper diagnosis and recovered totally after surgery [1,2].

Case Presentation

A 51-year-old Syrian female had a history of episodic and repetitive symptoms of profuse diaphoresis, tremors, palpitations, behavior and personality changes and occasional loss of consciousness for 6 months. Those symptoms occurred mainly at night and early morning, not related to meals but were relieved with oral carbohydrates intake. She had no medical history of endocrine disease. She was not a smoker and had no alcohol intake. She presented to the emergency department with symptoms of confusion, profuse diaphoresis, palpitation, fatigue. She appeared anxious. On examination her BP105/60 mmHg, HR100 per minute, RR18 per minute, and Spo2 was 99% with ambient air. The rest of her examination was unremarkable. Her random blood glucose showed a severe hypoglycemia (42 mg/ dl). Blood samples were taken then she was treated with hypertonic glucose solution with an important resolution of symptoms. She was admitted to the endocrine department at Tishreen University hospital. On the ward, the Blood laboratory which were sampled in ER came and are shown in (Table 1). In the following morning a supervised fasting evaluation was performed and resulted in an episode of symptomatic hypoglycemia with hyperinsulinemia as shown in (Table 2). We decided to stop selective serotonin reuptake inhibitors (SSRIs). Urine for sulfonylurea screen was not preformed because it was not available in our institution, and the patient denied taking any medication. Abdominal echo revealed a kidney cyst measured 20 X 28 X 37 mm. Other hormonal studies were normal. Upper and lower gastric endoscopy were normal. During admission, the patient was on multiple meals daily, and strict glucose observation. The episodes were relieved by oral carbohydrate intake. Abdominal CT demonstrated a hyper-vascular lesion involving tail of pancreas, measuring 22 X 15 mm, with enhancement during the arterial phases of contrast bolus (Figure 1). Tumor enucleation was performed, the material was fixed in formalin 10%, then processed routinely using H&E, and immunohistochemistry. Macroscopically ill-demarcated mass, measuring 1.7 cm, cut sections were white showing micro cysts (Figure 2 and 3), microscopic picture exhibits invasive small, relatively uniform cuboidal cells with centrally located nuclei, nuclear enlargement, solid sheets or nest with Rosette-like gland formation, cystic spaces, mitotic figures are 2 mitoses/10 HPF (Figure 4). Chromogranin A +++, Ki-67+ cells < 2% (Figure 5 and 6). Complementary staining for insulin was not performed because it is not available. Therefore, a well differentiated insulinoma of pancreas was identified. Regarding to functional status and biological behavior, diagnosis of pancreatic insulinoma was confirmed. After surgical treatment, the glucose level increased to the normal range immediately. The patient was discharged after 3 days with no hypoglycemic symptoms. The patient remains asymptomatic during the five-month follow-up.