Synopsis: Insulinoma is the most common cause of hyperinsulinemic hypoglycemia. We report a 23 year-old male with a five-year history of seizures, documented hyperinsulinemic hypoglycemia with negative imaging studies. Clinical Presentation: We report a 23- year old male nursing student with 5-year history of seizures. Five years prior to admission, patient was found unconscious and diaphoretic at dawn. Capillary blood glucose (CBG) was noted to be 28 mg/dl with reversal of symptoms after intravenous glucose administration. Subsequently, hypoglycemic episodes with glucose levels ranging between 20-30 mg/dl, which were unrelated to food intake. The episodes occurred thrice weekly (midnight - 6a.m.) predominantly after hospital duties, Which abated with carbonated drinks. He had three admissions for unconsciousness and seizures. Pancreatic insulinoma was considered. On the 10th hour of 72-hour fast, he was diaphoretic with blood glucose (28-35 mg/dl), and inappropriately elevated insulin 66.1 (NV < 7.1uU/ml) and C-peptide 6.68 (NV 1.1-5ng/ml). Abdominal ultrasound and magnetic resonance imaging (MRI) revealed normal pancreas. Physical Findings: Examined an obese patient with BMI 31.6 kg/m2, and waist-hip-ratio 0.97 with normal vital signs, unremarkable physical and neurologic findings. Diagnostics: Intra-arterial calcium gluconate stimulation test with hepatic venous sampling was performed stimulating the hepatic, gastroduodenal, superior mesenteric, proximal and distal splenic arteries with calcium gluconate (0.025mEq/kgBW). Baseline insulin levels in all arteries were 8.9 - 10.8 fold elevated (313.2 - 375.4 uIU/mL). A 1.4- fold increase at 60 seconds was noted in the superior mesenteric artery. Treatment: Patient underwent exploratory laparotomy where a 2 cm mass posterior to the pancreatic neck was palpated. Intraoperative ultrasonography revealed a 1.2x1.9cm sonolucent mass in the transverse and longitudinal planes. He underwent near-total pancreatectomy and splenectomy. Intraoperatively, CBGs ranged between 120-150 mg/dL with a linear rise to 200 mg/dL 60 minutes after resection of the pancreatic tumor. Serum insulin decreased to 51.1uIU/mL post-operatively. Histopathology revealed pancreatic islet cell tumor (insulinoma) confirmed by synaptophysin and chromogranin A staining. Outcome: One month post-surgery, he weighed 64kg and required 18 units of basal insulin to maintain euglycemia. He has had no recurrence of seizure since after surgery.

This is a case of a 7-year-old Filipino female who presented with undulating movements of the abdomen that occur only while awake, following the initiation of treatment for clinically diagnosed pulmonary tuberculosis. Systemic physical examination was normal. The neurological examination was also unremarkable. The 2-hr video EEG showed no electroencephalographic changes or ictal pattern correlating with the abdominal dyskinesia, highly suggesting a movement disorder. Craniospinal Magnetic Resonance Imaging (MRI) with Gadolinium showed typical results. The patient responded to the trial of carbamazepine after three weeks of treatment with complete resolution of abdominal dyskinesia.
Neurology ; Movement Disorders