Juan Carlos Ferrer-García

Everolimus resolving hypoglycemia, producing hyperglycemia, and necessitating insulin use in a patient with diabetes and nonresectable malignant insulinoma.

OBJECTIVE To present a case of management of refractory hypoglycemia due to malignant insulinoma with use of everolimus, resulting in recurrent insulin-requiring diabetes. METHODS This report describes a case of a nonresectable malignant insulinoma in a 78-year-old patient with long-standing type 2 diabetes mellitus. Endogenous hyperinsulinism was confirmed by a fasting test, which revealed a glucose level of 35 mg/dL and an insulin value of 23.7 μIU/mL. Endoscopic ultrasonography, magnetic resonance imaging, and computed tomography identified a pancreatic mass, infiltration of the superior mesenteric vein, and metastatic lesions in the liver. RESULTS After chemoembolization of the metastatic lesions, hypoglycemia recurred, despite combined treatment with somatostatin analogues, dexamethasone, and diazoxide. Everolimus, an orally administered mammalian target of rapamycin, was used at a daily dose of 5 mg. After 6 months, the hypoglycemia was controlled, and the patient presented with a C-peptide level of 0.2 ng/mL and secondary hyperglycemia that necessitated insulin treatment. CONCLUSION The orally administered drug everolimus controlled hypoglycemia due to a malignant insulinoma in a patient with prior insulin-requiring diabetes. Secondary hyperglycemia was an acceptable drug effect (to the patient and managing physicians), in light of the complex and often poorly tolerated treatments available for this rare condition.

Hemoglobin Glycosylation Index is not related with blood glucose

OBJECTIVE Accurate assessment of blood glucose control is essential to prevent chronic complications in diabetes. Hemoglobin Glycosylation Index (HGI) quantifies the degree to which individuals demonstrate a HbA(1C) higher or lower than average for the population. This study has aimed to assess the relationship between HGI and blood glucose. METHODS 25 type 1 diabetes subjects (12 men and 13 women), 22.0+/-5.2 (17-34) years old, were instructed to self-monitor glucose with the One Touch Profile capillary glucose meter. HbA(1C) was determined and self-monitored blood glucose levels were studied every 3 months. Diabetic patients were monitored for 3-9 months and 62 measurements of HbA(1C) were included. HbA(1C) was measured by HPLC. Mean blood glucose (MBG) was calculated from self-monitored blood glucose records. A linear regression was calculated between HbA(1C) and MBG during the 60 days before sampling to determine HbA(1C). For each diabetic patients MBG, a predicted HbA(1C) was calculated from the population regression equation. HGI was then calculated as HGI=observed HbA(1C)-predicted HbA(1C). Blood glucose was analyzed within target range (WTR), below target range (BTR) and above target range (ATR) according to The European Diabetes Policy Group Consensus for type 1 diabetes. RESULTS A good linear regression between HbA(1C) and MBG was observed (r=.71, r(2)=.497, P=.000). No correlation was found between HGI and the percentage of WTR, BTR or ATR values. Moreover, the percentage of self-monitored blood glucose ATR and BTR was the same for high glycosylators (HGI<0 and ATR: 56.2+/-20.9%; HGI<0 and BTR: 34.5+/-17.5%) as for low glycosylators (HGI>0 and ATR: 52.8+/-25.5%; HGI>0 and BTR: 25.1+/-15.0%). CONCLUSIONS HGI is determined for both physiological factors and blood glucose. A prospective study is necessary to assess whether HGI, together with HbA(1C), can predict the incidence and severity of chronic complications in diabetic patients.

Anorexia nerviosa como causa de fallo hepático agudo. A propósito de un caso

Caso clínico: presentamos una paciente de 33 años con anorexia nerviosa de 15 años de evolución con uno de los pocos casos reportados de fallo hepático agudo severo secundario a la desnutrición.Discusión: tras el soporte nutricional protocolizado para evitar el síndrome de realimentación y un adecuado manejo multidisciplinar, la paciente evoluciona favorablemente logrando normalizar los electrolitos, la función hepática y las alteraciones en la coagulación.