Severe Refractory Hypoglycaemia in an Acutely Ill Elderly Man with Type 2 Diabetes Mellitus

Background: Hypoglycaemia in elderly Type 2 diabetes mellitus (T2DM) patients causes significant morbidity as the elderly are more prone to the effects of neuroglycopenia and are unable to mount a rapid and effective counter response. Rarely an insulinoma may occur in elderly T2DM subjects and may cause refactory hypoglycaemia. Case report and management: An octagenarian man with T2DM, Parkinson's disease and atrial fibrillation was admitted with leg cellulitis and was treated appropriately. He then developed Klebsiella pneumoniae pneumonia and septicaemia and an acute coronary syndrome. However his stay in hospital was characterized by multiple, frequent, symptomatic and distressing hypoglycaemia requiring ferquent intravenous glucose. Elevated serum insulin and C peptide levels during hypoglycaemia (plasma glucose 1.8 mmol/l), high chromogranin A, and a 2.5 cm low density lesion in the pancreatic head with a liver secondary confirmed a metastatic insulinoma. He was unsuitable for invasive investigations. His hypoglycaemia was refractory to high dose diazoxide, prednisolone and octereotide. Conclusions: We report a malignant insulinoma in an elderly, T2DM patient whose disease was punctuated by distressing hypoglycaemia. A palliative approach was adopted with close involvement of the patient and his family.