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From eMedicine Case Presentations CME

Hypoglycemia: A Diagnostic Challenge CME

Peggy Nelson, MD; Ved V. Gossain, MD CME Released: 12/16/2 !; Valid "o# c#edi$ $%#o&g% 12/16/2 1

Hypoglycemia: A Diagnostic Challenge

Background
'Enla#ge (mage)

Figure 1.
'Enla#ge (mage)

Figure 2.
'Enla#ge (mage)

Figure 3.

* +!,yea#,old man -i$% a %is$o#y o" a$#ial "i.#illa$ion -%o is c&##en$ly $a/ing -a#"a#in is p#esen$ed $o $%e eme#gency depa#$men$ 'ED) "ollo-ing 2 syncopal episodes. Eac% episode -as -i$%o&$ any p#eceding p#od#omal symp$oms. 0is "i#s$ syncopal episode occ&##ed -%ile sea$ed in $%e .a$%#oom s%a1ing in $%e mo#ning. 0e a-a/ened on $%e .a$%#oom "loo# a"$e# an &nde$e#mined amo&n$ o" $ime and -as a.le $o c#a-l $o $%e /i$c%en and d#in/ a glass o" o#ange 2&ice, -%ic% led $o an imp#o1emen$ o" %is s$a$&s. 0e -as e1al&a$ed .y %is ca#diologis$ "ollo-ing $%is "i#s$ episode; $%e ca#diologis$ discon$in&ed %is an$i%ype#$ensi1e medica$ions 'amlodipine/.ena3ep#il and $#iam$e#ene/%yd#oc%lo#o$%ia3ide) .eca&se o" a conce#n $%a$ o#$%os$asis may %a1e .een #esponsi.le. 4%e ne5$ mo#ning, $%e pa$ien$ s&""e#ed a second syncopal episode, "o# -%ic% %e is no- in $%e ED. 4%is $ime, %e -as "o&nd &n#esponsi1e on %is .ed#oom "loo# .y "amily. 6n e1al&a$ion .y $%e eme#gency medical se#1ice 'EM7), $%e pa$ien$ -as no$ed $o %a1e a .lood gl&cose o" 2 mg/d8 '1.11 mmol/8), "o# -%ic% %e #ecei1ed 1 amp&le o" 9 : de5$#ose. 0e .ecame ale#$ and #esponsi1e immedia$ely a"$e# .eing $#ea$ed -i$% de5$#ose, and s$a$ed $%a$ %e -as &na-a#e o" $%e e1en$s leading &p $o %is loss o" conscio&sness. 4%e pa$ien$ %as no %is$o#y o" dia.e$es melli$&s, %epa$ic disease, o# #enal dys"&nc$ion. 0e denies any c&##en$ $o.acco o# alco%ol &se. 4%e pa$ien$ %as .een losing -eig%$ &nin$en$ionally. (n "ac$, %e s$a$es $%a$ %e %as .een ea$ing mo#e $%an p#e1io&sly .&$ is s$ill &na.le $o main$ain %is -eig%$. 0is c&##en$ medica$ions incl&de e3e$imi.e, p#opa"enone, lo1as$a$in, a$enolol, dia3epam, do5a3osin mesyla$e, ace$ylsalicylic acid, amlodipine/.ena3ep#il, $#iam$e#ene/%yd#oc%lo#o$%ia3ide, and -a#"a#in. 0e is also $a/ing "olic acid, "is% oil, 3inc, and 1i$amin E.

6n p%ysical e5amina$ion, $%e pa$ien$ is a -ell,de1eloped male -i$% a medi&m .&ild. E1al&a$ion o" %is 1i$al signs #e1eals an o#al $empe#a$&#e o" !;.6<= '>+. <C), p&lse o" ;> .pm, .lood p#ess&#e o" 12;/+ mm 0g '-i$%o&$ o#$%os$asis), #espi#a$o#y #a$e o" 2 .#ea$%s/min, and an o5ygen sa$&#a$ion o" 1 : -%ile .#ea$%ing #oom ai#. Diminis%ed .#ea$% so&nds a#e no$ed on a&sc&l$a$ion o" $%e l&ngs and $%e#e is d&llness $o pe#c&ssion in $%e le"$ lo-e# l&ng "ield. (##eg&la#ly i##eg&la# %ea#$ so&nds a#e p#esen$ on ca#diac e5amina$ion. * s/in s&#1ey #e1eals m&l$iple ecc%ymo$ic a#eas on $%e c%es$ and e5$#emi$ies. 0eme,posi$i1e .#o-n s$ool is no$ed on #ec$al e5amina$ion. 4%e #emainde# o" %is p%ysical e5amina$ion is no#mal. Plain,"ilm #adiog#ap%y o" $%e c%es$ demons$#a$es a mass in $%e lo-e# le"$ c%es$ 'see =ig&#e 1). Comp&$ed $omog#ap%y 'C4) scanning o" $%e c%es$ #e1eals a mass meas&#ing 6.9 ? @.9 ? @.1 in '16.@ ? 11.@ ? 1 .@ cm) in $%e le"$ lo-e# lo.e consis$en$ -i$% a %ema$oma 1e#s&s $&mo# 'see =ig&#e 2). Elec$#oca#diog#ap%y 'ECG) demons$#a$es a$#ial "i.#illa$ion a$ ++ .pm. Ec%oca#diog#ap%y #e1eals mild,$o,mode#a$e ao#$ic ins&""iciency, -i$% a le"$ 1en$#ic&la# e2ec$ion "#ac$ion o" A 6 : and no -all mo$ion a.no#mali$y. 8a.o#a$o#y in1es$iga$ions a#e pe#"o#med -%ile $%e pa$ien$ is "as$ing; $%e "indings a#e de$ailed .elo- 'a.no#mal 1al&es in old; no#mal #anges in pa#en$%esis): 0emoglo.in 0ema$oc#i$ Ca#diac En3ymes Elec$#oly$es =as$ing Clood Gl&cose (ns&lin C,pep$ide G#o-$% 0o#mone Co#$isol '.aseline) Co#$isol 'a"$e# ad#enoco#$ico$#opic %o#mone F*C40G s$im&la$ion) (ns&lin,li/e g#o-$% "ac$o# '(G=),( (G=,(( (G= Cinding p#o$ein, > =#ee 4%y#o5ine @ 4%y#oid 7$im&la$ing 0o#mone 4o$al $es$os$e#one 8&$eini3ing 0o#mone =ollicle 7$im&la$ing 0o#mone P#olac$in !." #/d$ '! g/8; no#mal #ange, 1>,1@ g/d8) %&.!: ' .26!; no#mal #ange, >@,@6:) Bi$%in no#mal limi$s Bi$%in no#mal limi$s '" m#/d$ '2.2 mmol/8; no#mal #ange, 6 ,12 mg/d8) ( %." )*+/m$ '1>.;! pmol/8; no#mal #ange, 6,2! D(E/m8) ".% n#/m$ ' . +nmol/8; no#mal #ange, .!,+.1 ng/m8) .22 ng/m8 ' .22 Dg/8; no#mal #ange, . 1, .!+ ng/m8) 1;.! Dg/d8 '921.@9 nmol/8; no#mal #ange, @,22 Dg/d8) @9 Dg/d8 '12@1 nmol/8; no#mal #esponse is a$ leas$ a 2, "old inc#ease) 3' n#/m$ '>@ Dg/8; no#mal #ange, 9!,1++ ng/m8) @1 ng/m8 'no#mal #ange, 2;;,+>6 ng/m8) 1.& )#/m$ 'no#mal #ange, 2.9, 9.1 Dg/m8) 1. 1 ng/d8 '1>. pmol/8; no#mal #ange, .;, 1.; ng/d8) >.>2 DE/m8 '>.>2 DE/8; no#mal #ange, .>9, 9.9 DE/m8) 9 ng/d8 '1+.>9 nmol/8; no#mal #ange, 1;1,+9; ng/m8)

2 .1 m(E/m8 '2 .1 (E/8; no#mal #ange, >.1,>@.6 m(E/m8) %".8 m*+/m$ '2 .; (E/8; no#mal #ange, 1.@, 1;.1 m(E/m8) 12.@ ng/m8 '12.@ Dg/8; no#mal #ange, 2.1, 1+.1 ng/m8)

4%e pa$ien$ is admi$$ed $o $%e medical se#1ice. D&#ing %is %ospi$ali3a$ion, %e #eH&i#es con$in&o&s in$#a1eno&s gl&cose $o main$ain e&glycemia 'see =ig&#e >).

B%a$ is $%e pa$ien$Is diagnosis and ca&se o" %is #ec&##en$ syncopal episodesJ Hint: Look closely at the glucose, insulin, and insulin-like growth factor (IGF) levels. (ns&linoma =i.#o&s soli$a#y $&mo# *d#enal ins&""iciency =ac$i$io&s %ypoglycemia
7a1e and P#oceed

Discussion
'Enla#ge (mage)

Figure 1.
'Enla#ge (mage)

Figure 2.
'Enla#ge (mage)

Figure 3.
'Enla#ge (mage)

Figure 4.
'Enla#ge (mage)

Figure

4%e di""e#en$ial diagnosis in pa$ien$s -%o p#esen$ -i$% syncope is $ypically H&i$e .#oad. 8a.o#a$o#y and o$%e# clinical $es$s, -%ile o"$en e5$ensi1e, &s&ally donK$ iden$i"y $%e ca&se. (n lo-,#is/ pa$ien$s -i$%o&$ a conce#ning p#esen$a$ion o" syncope, minimal $es$ing is accep$a.le and app#op#ia$e; %o-e1e#, gi1en $%is pa$ien$Ks &n&s&al p#esen$a$ion and &nde#lying medical condi$ions, an e5$ensi1e -o#/&p incl&ding e1al&a$ion o" ca#diac, me$a.olic, and ne&#ologic ca&ses o" syncope -as ini$ia$ed. * possi.le %ema$oma in $%e c%es$ -all as s&gges$ed .y in$e#p#e$a$ion o" $%e c%es$ C4 scan -as ini$ially en$e#$ained .eca&se $%is -o&ld %a1e e5plained $%e pa$ien$Ks anemia and possi.le ca#diop&lmona#y e""ec$s

'.eca&se o" $%e loca$ion); %o-e1e#, $%is s$ill did no$ e5plain $%e p#esence o" %ypoglycemia. 4%e pa$ien$Ks anemia -as mo#e li/ely $%e #es&l$ o" a c%#onic gas$#oin$es$inal 'G() .leed complica$ed .y an$icoag&la$ion. 6n ca#diac e1al&a$ion, %is ca#diac en3ymes, ECG, and ec%oca#diog#am did no$ #e1eal any ac&$e p#ocesses o# cond&c$ion a.no#mali$ies. B%ippleIs $#iad '%ypoglycemic symp$oms, lo- plasma gl&cose, and #elie" o" symp$oms -i$% $%e adminis$#a$ion o" de5$#ose) -as no$ed. D&#ing $%e %ospi$al co&#se, %is %emoglo.&lin and %ema$oc#i$ #emained #ela$i1ely s$a.le, -i$%o&$ any signs o" ac$i1e .leeding a"$e# -a#"a#in -as -i$%d#a-n. 6n #e1ie- o" $%e pa$ien$Ks endoc#ine da$a, $%e p#esence o" a lo- ins&lin le1el -as incompa$i.le -i$% a diagnosis o" ins&linoma. 4%e plasma ins&lin and C,pep$ide le1els -e#e app#op#ia$ely s&pp#essed in #esponse $o $%e lo"as$ing .lood gl&cose. 0is pi$&i$a#y "&nc$ion -as e1al&a$ed and #e1ealed a mildly ele1a$ed "ollicle,s$im&la$ing %o#mone, .&$ no#mal $%y#oid %o#mones, p#olac$in, and co#$isol le1els -e#e no$ed. *d#enal ins&""iciency -as also e5cl&ded gi1en $%e com.ina$ion o" a no#mal mo#ning co#$isol le1el and no#mal ad#enoco#$ico$#opin s$im&la$ion $es$. ($ -as also impo#$an$ $o e5cl&de $%e possi.ili$y o" %epa$ic and #enal dys"&nc$ion, -%ic% can .o$% lead $o #ec&##en$ %ypoglycemia. =ac$i$io&s %ypoglycemia -as no$ s&spec$ed in $%is pa$ien$ as i$ -as e5cl&ded .y $%e lo- le1els o" ins&lin and C,pep$ide. *ddi$ionally, %e -as no$ $a/ing any medica$ions -%ic% co&ld %a1e .een a so&#ce o" ia$#ogenically,ind&ced %ypoglycemia. 4%e mos$ li/ely diagnosis -as de$e#mined $o .e a non,isle$ cell $&mo# 'N(C4) p#od&cing %ypoglycemia. 4%e pa$ien$ p#esen$ed -i$% %ypoglycemic symp$oms and an a.no#mal c%es$ e5amina$ion, -%ic% co##ela$ed -i$% a c%es$ mass on C4 scanning. 7&#gical cons&l$a$ion -as o.$ained "o# a .iopsy o" $%e le"$,sided c%es$ mass. * C4 scan o" $%e a.domen and pel1is -as also o.$ained $o #&le o&$ me$as$a$ic disease; $%e #es&l$ o" $%e scan -as nega$i1e. Ciopsy o" $%e le"$ c%es$ mass 'see =ig&#e @) s%o-ed .land spindle cells -i$% a lacy o# #e$ic&la$ed appea#ance 'see =ig&#e 9) -%ic% led $o $%e diagnosis o" a soli$a#y "i.#o&s $&mo# o" mesenc%ymal o#igin. 4%e $&mo# -as no$ed $o .e 6.; ? 9.2 ? >.! in '1+.2 ? 1>.2 ? !.! cm) in si3e. 4%is la#ge mesenc%ymal $&mo# acco&n$ed "o# all o" $%e pa$ien$Ks symp$oms, incl&ding %is #ec&##en$ %ypoglycemia. F1,2G Non,isle$ cell $&mo#s 'N(C4s) a#e a #a#e .&$ -ell desc#i.ed e$iology o" c%#onic "as$ing %ypoglycemia. F>G 4%ese e5$#apanc#ea$ic $&mo#s a#e gene#ally o" mesenc%ymal o# epi$%elial o#igin. Mesenc%ymal $&mo#s #ep#esen$ 9 : o" all cases o" N(C4. 4%ey incl&de meso$%eliomas, "i.#osa#comas, #%a.domyosa#comas, leiomyosa#comas, and %emangiope#icy$omas. Ca#cinomas #ep#esen$ ano$%e# 29: o" N(C4s and incl&de %epa$omas, ad#enoco#$ical ca#cinomas, and ca#cinoid $&mo#s. 4%e #emaining 29: o" N(C4s associa$ed -i$% %ypoglycemia incl&de, .&$ a#e no$ limi$ed $o, %ype#nep%#omas, Bilms $&mo#s, p#os$a$e ca#cinomas, ce#1ical ca#cinomas, .#eas$ ca#cinomas, le&/emia, lymp%omas, and myelomas.F@G N(C4s a#e c%a#ac$e#is$ically la#ge in si3e, -eig%ing an a1e#age o" @.@, ;.; l. '2,@ /ilog#ams). 61e# one,$%i#d a#e #e$#ope#i$oneal in loca$ion, app#o5ima$ely one,$%i#d a#e in$#a, a.dominal, and $%e #emaining one,$%i#d a#e in$#a$%o#acic. F@G Ne&#oglycopenic symp$oms a#e $%e mos$ common clinical "ea$&#es associa$ed -i$% N(C4,ind&ced %ypoglycemia. 4%ese symp$oms incl&de o.$&nda$ion, con"&sion, and .e%a1io#al a.e##a$ions.F@G 4%e diagnos$ic s$&dy o" c%oice is C4 scanning o" $%e s&spec$ed $&mo# loca$ion, "ollo-ed .y a $iss&e .iopsy "o# iden$i"ica$ion. (n $%is pa$ien$, $%e la#ge mesenc%ymal $&mo# iden$i"ied in $%e in$#a$%o#acic a#ea #es&l$ed in $%e ne&#oglycopenic symp$om o" o.$&nda$ion. 0is o.$&nda$ion -as only a.a$ed .y con$in&o&s gl&cose adminis$#a$ion p#eope#a$i1ely, and .y s&#gical #emo1al o" $%e N(C4. ($ %as .een p#oposed $%a$ N(C4s media$e $%ei# e""ec$s $%#o&g% ins&lin,li/e g#o-$% "ac$o# '(G=)L((. (n no#mal ci#c&ms$ances, (G=,(( is p#od&ced .y $%e li1e# as a +.9,/ilodal$on '/D) molec&le. Mos$ (G=s s&.seH&en$ly "o#m

a 19 ,/D $e#$ia#y comple5 -i$% (G=,.inding p#o$ein '(G=CP)L> and acid,la.ile glycop#o$ein. 4%is la#ge comple5 is #e$ained in ci#c&la$ion and deli1e#s (G= $o $iss&es, -%e#e i$ in$e#ac$s -i$% speci"ic (G= #ecep$o#s "o# local g#o-$% p#omo$ion. No#mally, $%e ci#c&la$ing (G=,(( $e#$ia#y comple5 does no$ in$e#ac$ -i$% ins&lin #ecep$o#s and, $%e#e"o#e, is no$ associa$ed -i$% %ypoglycemia. F>,6G (n con$#as$ $o no#mal p%ysiology, N(C4s p#od&ce a pa#$ially p#ocessed, %ig% molec&la# -eig%$ 'MB) (G=,(( 'also /no-n as M.igN (G=,((). ($s MB %as .een demons$#a$ed $o .e 11,1; /D. ($ cons$i$&$es &p $o 9 ,+9: o" ci#c&la$ing (G=,(( in pa$ien$s -i$% N(C4s.F6G Cig (G=,(( does no$ "o#m a $e#$ia#y comple5, .&$ ins$ead "o#ms a .ina#y comple5 -i$% less #es$#ic$i1e (G=CPs, s&c% as (G=CP,2. 4%is smalle#, 9 ,/D .ina#y comple5 allo-s "o# capilla#y c#ossing and deli1e#y o" .ig (G=,(( $o ins&lin #ecep$o#s, p#ima#ily in s/ele$al m&scle, -%e#e inc#eased .ioa1aila.ili$y leads $o inc#eased gl&cose &$ili3a$ion and, $%e#e"o#e, %ypoglycemia. Cig (G=,(( also .inds $o ins&lin #ecep$o#s in $%e li1e#, -%e#e i$ s&pp#esses gl&coneogenesis and glycogenolysis, $%e#e.y en%ancing $%e %ypoglycemic #esponse.
F@G

4%e inc#ease in .ioa1aila.le (G=,(( also leads $o $%e s&pp#ession o" ins&lin and g#o-$% %o#mone, as -ell as a

dec#ease in $%e p#od&c$ion o" (G=,(, (G=CP,>, and acid la.ile s&.&ni$, -%ile inc#easing p#od&c$ion o" (G=CP,2. 4%e $#ea$men$ o" %ypoglycemia "o# pa$ien$s -i$% N(C4s is symp$oma$ic s&ppo#$ &n$il #esec$ion o" $%e $&mo# is pe#"o#med. D&#ing $%is pa$ien$Ks %ospi$al co&#se, %e #eH&i#ed con$in&o&s in"&sion o" de5$#ose along -i$% "#eH&en$ moni$o#ing o" %is .lood gl&cose. Comple$e #esol&$ion o" %is %ypoglycemic symp$oms a"$e# $&mo# #esec$ion s&ppo#$ed $%e diagnosis o" N(C4,ind&ced %ypoglycemia. 8o- le1els o" g#o-$% %o#mone, (G=,(, and (G=CP,> also s&ppo#$ed $%e %ypo$%esis $%a$ al$e#ed (G=,(( -as $%e media$o# o" %ypoglycemia. *l$%o&g% an ele1a$ed (G=,(( le1el -as no$ iden$i"ied, i$ is -ell /no-n $%a$ (G=,(( le1els may .e no#mal o# ele1a$ed. F+G (n N(C4, associa$ed %ypoglycemia, (G=,(( can ca&se %ypoglycemia a$ no#mal $o$al se#&m le1els as a #es&l$ o" al$e#ed p#ocessing and inc#eased .ioa1aila.ili$y o" (G=,((. F@G 4%e pa$ien$ -as "o#$&na$e $o %a1e a .enign $&mo# -%ic% did no$ #eH&i#e "&#$%e# c%emo$%e#apy o# #adia$ion. ($ s%o&ld also .e no$ed $%a$ $%is pa$ien$Ks p#esen$a$ion o" %ypoglycemia di""e#s s&.s$an$ially "#om classic %ypoglycemic episodes. 0ypoglycemic symp$oms $ypically incl&de %ype#ad#ene#gic and ne&#oglycopenic,$ype symp$oms; %o-e1e#, $%is pa$ien$ did no$ desc#i.e symp$oms s&c% as $%ese p#io# $o syncope. Pa$ien$s -i$% $&mo#,#ela$ed %ypoglycemia &s&ally %a1e g#ad&al slo- "alls in $%ei# .lood gl&cose. 4%is slo- "all does no$ $#igge# $%e %ype#ad#ene#gic #esponse, and ne&#oglycopenia can p#og#ess "#om con"&sion $o coma and possi.le sei3&#es -i$%o&$ .eing #ecogni3a.le $o $%e pa$ien$. *ddi$ionally, i$ is %ig%ly &n&s&al "o# a pa$ien$ -i$% %ypoglycemia $o spon$aneo&sly -a/e "#om an al$e#ed o# coma$ose s$a$e. Enli/e in $%e se$$ing o" %ypoglycemia seconda#y $o dia.e$es medica$ions, i$ is li/ely $%a$ in cases o" $&mo#,#ela$ed %ypoglycemia $%e .odyIs co&n$e#, #eg&la$o#y mec%anisms a#e a.le $o p#o1ide a s&""icien$ #esponse $o .#ing $%e se#&m gl&cose $o a #easona.le le1el and #es&l$ in #eco1e#y o" ale#$ness -i$%o&$ p%a#macologic in$e#1en$ion.

C!" #est

Oo& a#e e5amining a %ypoglycemic pa$ien$. C4 scanning o" $%e a.domen and pel1is is &l$ima$ely pe#"o#med d&#ing yo&# e1al&a$ion; i$ #e1eals a mass in $%e pa$ien$Is #e$#ope#i$one&m. (" $%is mass -e#e $o .e con"i#med as a non,isle$ cell $&mo# 'N(C4), -%ic% o" $%e "ollo-ing "indings -o&ld N64 .e seen in $%e la.o#a$o#y e5amina$ionsJ Dec#eased ins&lin le1el (nc#eased C,pep$ide le1el

No#mal o# ele1a$ed ins&lin,li/e g#o-$% "ac$o# '(G=)L(( le1el Dec#eased g#o-$% %o#mone le1el B%ic% o" $%e "ollo-ing symp$oms -o&ld .e mos$ li/ely $o occ&# in $%e a.o1e desc#i.ed pa$ien$J *l$e#ed men$al s$a$&s Gas$#oin$es$inal pain (nc#eased oc&la# p#ess&#e *$#ial "i.#illa$ion
7a1e and P#oceed

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$e%erences

1. 2.

C%ang PC, 7& QO, C%ao 7=, 0s& O0, Oang GG, C%ang C7. 0ypoglycemia in a pa$ien$ -i$% a %&ge malignan$ soli$a#y "i.#o&s $&mo# o" $%e ple&#a. Pa$%ol (n$. 2 +;9+:+!1,>. Go#den P, 0end#ic/s CM, Qa%n CR, Megyesi Q, Ro$% P. 0ypoglycemia associa$ed -i$% non,isle$,cell $&mo# and ins&lin,li/e g#o-$% "ac$o#s. N Engl P Med. 1!;1;> 9:1@92,9.

>.

0i3&/a N, =&/&da (, 4a/ano Q, *sa/a-a,Oas&mo$o Q, 6/&.o O, Dem&#a 0. 7e#&m %ig% molec&la# -eig%$ "o#m o" ins&lin,li/e g#o-$% "ac$o# (( "#om pa$ien$s -i$% non,isle$ cell $&mo# %ypoglycemia is 6, glycosyla$ed. P Clin Endoc#inol Me$a.. 1!!;;;>:2;+9,+.

@. 8a#sen PR, Q#onen.e#g 0M, Melmed 7, Polons/y Q7, eds Billiams 4e5$.oo/ o" Endoc#inology. 1
ed. P%iladelp%ia, P*:7a&nde#s;2 9. >:1++L2+!.

$%

7a$o R, 4s&2ino M, Nis%ida Q, e$ al. 0ig% molec&la# -eig%$ "o#m ins&lin,li/e g#o-$% "ac$o# ((,p#od&cing mesen$e#ic sa#coma ca&sing %ypoglycemia. (n$e#n Med. 2 @;@>:!6+,+1.

6.

7c%-eic%le# M, 0ennessey PV, Cole P, Pe#d&e P=, 8e Roi$% D. 0ypoglycemia in p#egnancy seconda#y $o a non,isle$ cell $&mo# o" $%e ple&#a and ec$opic ins&lin,li/e g#o-$% "ac$o# (( %o#mone p#od&c$ion. 6.s$e$ Gynecol. 1!!9;;9:;1 ,>.

+.

Ba/ami Q, 4a$eyama 0, Qa-as%ima 0, e$ al. 7oli$a#y "i.#o&s $&mo# o" $%e &$e#&s p#od&cing %ig%, molec&la#,-eig%$ ins&lin,li/e g#o-$% "ac$o# (( and associa$ed -i$% %ypoglycemia. (n$ P Gynecol Pa$%ol. 2 9;2@:+!,;@.

Authors and Disclosures

*s an o#gani3a$ion acc#edi$ed .y $%e *CCME, Medscape, 88C #eH&i#es e1e#yone -%o is in a posi$ion $o con$#ol $%e con$en$ o" an ed&ca$ion ac$i1i$y $o disclose all #ele1an$ "inancial #ela$ions%ips -i$% any comme#cial in$e#es$. 4%e *CCME de"ines R#ele1an$ "inancial #ela$ions%ipsR as "inancial #ela$ions%ips in any amo&n$, occ&##ing -i$%in $%e pas$ 12 mon$%s, incl&ding "inancial #ela$ions%ips o" a spo&se o# li"e pa#$ne#, $%a$ co&ld c#ea$e a con"lic$ o" in$e#es$.

Medscape, 88C enco&#ages *&$%o#s $o iden$i"y in1es$iga$ional p#od&c$s o# o"",la.el &ses o" p#od&c$s #eg&la$ed .y $%e E7 =ood and D#&g *dminis$#a$ion, a$ "i#s$ men$ion and -%e#e app#op#ia$e in $%e con$en$.

Author&s'
(eggy )elson* !D

Peggy Nelson, MD, =ello-, Endoc#inology, Mic%igan 7$a$e Eni1e#si$y; Residen$ P%ysician, Endoc#inology, 7pa##o- 0ospi$al, M( Disclos&#e: Peggy Nelson, MD, %as disclosed no #ele1an$ "inancial #ela$ions%ips.
+ed +. ,ossain* !D

Ved V. Gossain, MD, 7-a#$3 P#o"esso# o" Medicine, Depa#$men$ o" Medicine; C%ie", Di1ision o" Endoc#inology and Me$a.olism, Mic%igan 7$a$e Eni1e#si$y, Eas$ 8ansing, M( Disclos&#e: Ved V. Gossain, MD, %as disclosed #ele1an$ "inancial #ela$ions%ips -i$% GM,E*B, Eli 8illy S Co., Me$#i/a, (psen/4e#cica, 7ano"i,*1en$is, No1oNo#dis/, Me#c/ S Co., Gla5o7mi$%Qline, and P"i3e#.

"ditor&s'
"rik D. -chraga* !D

E#i/ D. 7c%#aga, MD, Di#ec$o#, eMedicine Case o" $%e Bee/; Clinical (ns$#&c$o# o" Eme#gency Medicine, 7$an"o#d/Qaise# Eme#gency Medicine Residency P#og#am, Depa#$men$ o" Eme#gency Medicine, Qaise# Pe#manen$e, 7an$a Cla#a Medical Cen$e#, 7an$a Cla#a, C* Disclos&#e: E#i/ D. 7c%#aga, MD, %as disclosed no #ele1an$ "inancial #ela$ions%ips.
.oel #. /e0is* !D* (hD* FAC"(* FAA"!

Poel 4. 8e1is, MD, P%D, =*CEP, =**EM, Clinical (ns$#&c$o# o" Eme#gency Medicine, 7$an"o#d/Qaise# Eme#gency Medicine Residency P#og#am; 7$a"" P%ysician, Depa#$men$ o" Eme#gency Medicine, Qaise# Pe#manen$e, 7an$a Cla#a Medical Cen$e#, 7an$a Cla#a, C* Disclos&#e: Poel 4. 8e1is, MD, P%D, =*CEP, =**EM, %as disclosed no #ele1an$ "inancial #ela$ions%ips.
,eorge #. ,ri%%ing* !D

Geo#ge 4. G#i""ing, MD, P#o"esso# o" Medicine, Depa#$men$ o" (n$e#nal Medicine, 7ain$ 8o&is Eni1e#si$y, 7ain$ 8o&is, M6 Disclos&#e: Geo#ge 4. G#i""ing, MD, %as disclosed no #ele1an$ "inancial #ela$ions%ips.
/uis !. -oler* BA

8&is M. 7ole#, C*, *ssocia$e Edi$o#, eMedicine/Medscape, Ne- Oo#/, NO Disclos&#e: 8&is M. 7ole#, C*, %as disclosed no #ele1an$ "inancial #ela$ions%ips.

C!" $e0ie1er&s'
/aurie ". -cudder* !-* )(

*cc#edi$a$ion Coo#dina$o#, Con$in&ing P#o"essional Ed&ca$ion Depa#$men$, MedscapeCME; Clinical *ssis$an$ P#o"esso#, 7c%ool o" N&#sing and *llied 0eal$%, Geo#ge Bas%ing$on Eni1e#si$y, Bas%ing$on, DC; N&#se P#ac$i$ione#, 7c%ool,Cased 0eal$% Cen$e#s, Cal$imo#e Ci$y P&.lic 7c%ools, Cal$imo#e, Ma#yland Disclos&#e: 8a&#ie E. 7c&dde#, M7, NP, %as disclosed no #ele1an$ "inancial #ela$ions%ips.
,isclaimer 4%e ma$e#ial p#esen$ed %e#e does no$ necessa#ily #e"lec$ $%e 1ie-s o" Medscape, 88C o# companies $%a$ s&ppo#$ ed&ca$ional p#og#amming on ---.medscapecme.com. 4%ese ma$e#ials may disc&ss $%e#ape&$ic p#od&c$s $%a$ %a1e no$ .een app#o1ed .y $%e E7 =ood and D#&g *dminis$#a$ion and o"",la.el &ses o" app#o1ed p#od&c$s. * H&ali"ied %eal$%ca#e p#o"essional s%o&ld .e cons&l$ed .e"o#e &sing any $%e#ape&$ic p#od&c$ disc&ssed. Reade#s s%o&ld 1e#i"y all in"o#ma$ion and da$a .e"o#e $#ea$ing pa$ien$s o# employing any $%e#apies desc#i.ed in $%is ed&ca$ional ac$i1i$y. eMedicine Case P#esen$a$ions CME T 2 ! MedscapeCME

This article is a CME certified activity. To earn credit for this activity visit: http://cme.medscape.com/viewarticle/713851 C!" 2n%ormation
CME -eleased: 1%/1&/%""!. /alid for credit thro0#h 1%/1&/%"1"

#arget Audience
4%is ac$i1i$y is in$ended "o# clinicians in p#ima#y ca#e, eme#gency ca#e, oncology, and endoc#inology.

,oal
4%e goal o" $%is ac$i1i$y is $o #ein"o#ce and %ig%lig%$ common concep$s, si$&a$ions, and p#esen$a$ions $%a$ clinicians -ill enco&n$e# on a #eg&la# .asis in o#de# $o p#o1ide s&ppo#$i1e con$in&ing ed&ca$ion $%a$ ill&s$#a$es #eal,-o#ld condi$ions and si$&a$ions.

/earning 345ecti0es
Epon comple$ion o" $%is ac$i1i$y, pa#$icipan$s -ill .e a.le $o: 1. Desc#i.e $%e $ypical p#esen$a$ion and managemen$ o" a commonly enco&n$e#ed medical condi$ion in clinical p#ac$ice.

Credits A0aila4le
1hysicians , ma5im&m o" .29 ! "# $ategory % $redit(s)&

*ll o$%e# %eal$%ca#e p#o"essionals comple$ing con$in&ing ed&ca$ion c#edi$ "o# $%is ac$i1i$y -ill .e iss&ed a ce#$i"ica$e o" pa#$icipa$ion. P%ysicians s%o&ld only claim c#edi$ commens&#a$e -i$% $%e e5$en$ o" $%ei# pa#$icipa$ion in $%e ac$i1i$y.

Accreditation -tatements
For (hysicians

Medscape, 88C is acc#edi$ed .y $%e *cc#edi$a$ion Co&ncil "o# Con$in&ing Medical Ed&ca$ion '*CCME) $o p#o1ide con$in&ing medical ed&ca$ion "o# p%ysicians. Medscape, 88C designa$es $%is ed&ca$ional ac$i1i$y "o# a ma5im&m o" .29 AMA PRA Category 1 Credit(s) . P%ysicians s%o&ld only claim c#edi$ commens&#a$e -i$% $%e e5$en$ o" $%ei# pa#$icipa$ion in $%e ac$i1i$y. Medscape, 88C s$a"" %a1e disclosed $%a$ $%ey %a1e no #ele1an$ "inancial #ela$ions%ips. Con$ac$ 4%is P#o1ide# =o# H&es$ions #ega#ding $%e con$en$ o" $%is ac$i1i$y, con$ac$ $%e acc#edi$ed p#o1ide# "o# $%is CME/CE ac$i1i$y no$ed a.o1e. =o# $ec%nical assis$ance, con$ac$ CMEUmedscape.ne$

2nstructions %or (articipation and Credit

4%e#e a#e no "ees "o# pa#$icipa$ing in o# #ecei1ing c#edi$ "o# $%is online ed&ca$ional ac$i1i$y. =o# in"o#ma$ion on applica.ili$y and accep$ance o" con$in&ing ed&ca$ion c#edi$ "o# $%is ac$i1i$y, please cons&l$ yo&# p#o"essional licensing .oa#d. 4%is ac$i1i$y is designed $o .e comple$ed -i$%in $%e $ime designa$ed on $%e $i$le page; p%ysicians s%o&ld claim only $%ose c#edi$s $%a$ #e"lec$ $%e $ime ac$&ally spen$ in $%e ac$i1i$y. 4o s&ccess"&lly ea#n c#edi$, pa#$icipan$s m&s$ comple$e $%e ac$i1i$y online d&#ing $%e 1alid c#edi$ pe#iod $%a$ is no$ed on $%e $i$le page. =ollo- $%ese s$eps $o ea#n CME/CE c#edi$V: 1. 2. >. Read $%e $a#ge$ a&dience, lea#ning o.2ec$i1es, and a&$%o# disclos&#es. 7$&dy $%e ed&ca$ional con$en$ online o# p#in$ed o&$. 6nline, c%oose $%e .es$ ans-e# $o eac% $es$ H&es$ion. 4o #ecei1e a ce#$i"ica$e, yo& m&s$ #ecei1e a passing sco#e as designa$ed a$ $%e $op o" $%e $es$. MedscapeCME enco&#ages yo& $o comple$e $%e *c$i1i$y E1al&a$ion $o p#o1ide "eed.ac/ "o# "&$&#e p#og#amming.

Oo& may no- 1ie- o# p#in$ $%e ce#$i"ica$e "#om yo&# CME/CE 4#ac/e#. Oo& may p#in$ $%e ce#$i"ica$e .&$ yo& canno$ al$e# i$. C#edi$s -ill .e $allied in yo&# CME/CE 4#ac/e# and a#c%i1ed "o# 6 yea#s; a$ any poin$ -i$%in $%is $ime pe#iod yo& can p#in$ o&$ $%e $ally as -ell as $%e ce#$i"ica$es .y accessing REdi$ Oo&# P#o"ileR a$ $%e $op o" yo&# Medscape %omepage. V4%e c#edi$ $%a$ yo& #ecei1e is .ased on yo&# &se# p#o"ile.

Hard1are6-o%t1are $e7uirements

MedscapeCME is accessi.le &sing $%e "ollo-ing .#o-se#s: (n$e#ne$ E5plo#e# 6.5 o# %ig%e#, =i#e"o5 2.5 o# %ig%e#, 7a"a#i 2.5 o# %ig%e#. Ce#$ain ed&ca$ional ac$i1i$ies may #eH&i#e addi$ional so"$-a#e $o 1ie- m&l$imedia, p#esen$a$ion o# p#in$a.le 1e#sions o" $%ei# con$en$. 4%ese ac$i1i$ies -ill .e ma#/ed as s&c% and -ill p#o1ide lin/s $o $%e #eH&i#ed so"$-a#e. 4%a$ so"$-a#e may .e: Mac#omedia =las%, *do.e *c#o.a$, o# Mic#oso"$ Po-e#Poin$.